contracts being set up are not done in a discriminatory way. you're not only with certain kinds of providers so certain consumers can't get their care. you want to make sure they're not basically giving inducements to providers to make sure they're not providing certain medically necessary care or there's some kind of gag rules, they can't discuss certain types of care. all those are all rolled together into our model act. about ten states have taken and adopted our model verbatim. taken it just as it is. another ten have some kind of similar -- i just want to point out, even beyond those 20, states through guidance and through other regulatory have adopted these concepts. they work with the carriers. the carriers do use a lot of these standards in developing their networks. if you want a copy of it, you can go to the naic model, go to store and go to free. a whole section of free materials you can get including all of our models. we also have a white paper that we did on this going back a

couple of years. you can get that as well which kind of looks at the issues that we are now going to be looking at as we look to revise our model. we have set up a subgroup which is currently doing regular phone calls. they are open phone calls, anybody, anybody in this room can sit in on them if you have nothing else better to do with your life. i always picture a 40-year-old man in his mother's basement. i don't know why. you can provide comments -- anybody and everybody can provide comments, suggested changes, however you want to do it. we've gone through a series of calls now where we've had all the stakeholders, the carriers, provide providers, consumers, of course, others that have come in and brought us their ideas. we're going to soon start the process of updating it. there are a couple of areas we are clear we need to update. one is essential community

provider. that's not something we were really looking at before. are those now included in your networks? there's also issues in the new environment of are we applying it to all manner of managed care. some states only did what you would call your old managed care, closed network type of plans. now do you go out to ppos, to others as well, to make sure everybody is doing what they need to do. we're having weekly calls. in fact, our next one is thursday, july 24th at 1:30 p.m. mark it on your calenders. be there, as we start looking at amendments. we've received comments from about 30 different groups so far. we're going to start going through those and seeing where we need to update our model. if you want information, the website is there. you can go and get the exact call-in information. one of the issues -- one is the flexibility to reflect state needs. this is always going to be our

number one point. we don't want a one size fits all federal government comes in and says this is exactly the time and distance for each type of provider. we don't think that will work. i don't know about you. but wyoming is a tad different than los angeles. so what are the standards? how do people get there? there are good examples brought up as well. what about certain populations in maybe very pop lugs areas but maybe transportation issues. states have been looking at these issues and are best to address these issues given all their needs. but then we do, as has been brought up, we need to balance. there's no sense in going here and saying we need to get rid of all these, no narrow networks. we need to balance quality. we need to balance affordability and we need to balance access. and how do you do that and -- how you do that in the model and make sure everybody is protected is our number one concern. some of the key issues we're going to be looking at.

tiered networks and narrow networks. tier networks are, if you go to this group, you pay this much, this group, this much, and they're tiered up. especially in formularies which we're looking at more than in the past for prescription drugs. how are those set up? narrow networks. one issue in particular we'll be looking at is in a couple of states, carriers said if you purchase in the state, we will cover you either in network or out of network. if you go to any provider outside the state, we will pay nothing. it's not even like a higher cost sharing. it's just we will pay nothing not covered. we're going to have to look at that. we'll also have to look at provider directories and updates. i think that was already addressed here. this is probably the most critical issue. you can't have a free market when people cannot get access to information. we had that this year. i'm not placing blame on anybody. it was a rough year just trying to get plans on, getting things

up and running and get it out there. we've got to do better in 2015 open enrollment period. consumers need to know if they purchase that plan, is their provider in the network or not? they have to have clear access to the website to make sure they can know which ones are in and which are out. to tell you the truth, providers do, too. i had so many provider groups calling us and saying, i had no idea, i got the call from the provider. i said i'm in. i have a contract with that company, then i find out i don't have a contract for that particular plan. we need to make sure everybody has the information they need, and if there are updates, that those notifications are going out so the consumer is well aware what their options are. we do want options. there are many plans and we're going to have more plans on the exchanges next year across the country. are some of them narrow? some of them not narrow? do people know the difference and do they have the options available to them. so the directories are they

accurate, updates accurate consumer education, do they have the right choices before them. another issue we'll be looking at is the surprise bills. how many of you like surprises? i like surprises but not when it's a bill. this is where you go in for a procedure, your doctor is in the network, your hospital is in the network and your anesthesiologist is not. that's called surprise. you're going to be charged higher for that. make sure everybody is educated. the federal government has looked at this. it's something to make sure, again, everybody is educated. it's okay if she is not or he is not. what's not okay is nobody knows and no choice was given. i'll leave you with this last slide, if you have any questions, please call jolie. she was supposed to be here and i'm not taking the questions. she is the staffer in charge.

she's writing and updating the model. if you have any questions, please call her. she'll be able to help you out. if you're interested in this, please join the calls. we hope to be done by november of this year with a brand new model that states can use to update their procedures. if you want to be part of that or just know what's going on, jump on the calls. we'd love to have you. thanks. >> terrific, thank you so much, brian. brian has agreed in the course of the q&a session to channel his inner jolie. so you now have a chance to join the conversation, and i'm going to exercise a little prerogative just to clarify some things. at the appropriate time you can fill out a question card that's in your packet. you can also repair to one of the microphones that are in the room, and you can tweet a question using the hash tag

network adequacy. so you've got all sorts of channels, and the first thing i want to do is sort of a factual clarification. we've heard a lot of talk about in network and out of network. how many people don't know the difference between in network and out of network for purposes of this discussion? the question is, is there a typical pricing pattern? in other words, what's the penalty, maybe not out of state being zero, but in a typical plan. if you are in a narrow network and have to go out for some reason or think you do, is there a substantial differential or is it fairly nominal? so how important is this is what i'm asking? dan, do you have any sense of that? >> sure.

again, i think it's critical from the point of view providing value to consumers that we allow these high value networks to be a choice. as many of you heard from a number of speakers today, many consumers are buying based on premiums. and to get that premium point down to an affordable level, plans are offering narrow networks. it's not the only option. you broad networks as you can see in the mackenzie poll for 90% of the population. so it's a choice there. if you're in a plan that does have a specific network, then there are certain requirements to go outside that network, plans don't say you can't do that, but they'll work with the individual on their specific needs. so if there's a particular type of specialist that simply is not in the network, then the plan has an obligation to work with that customer to find someone out of network that can provide

that medically necessary service. >> if i can add something, part of it depends on the type of plan you have. if you have -- are in an hmo that does not have out-of-network coverage, then it's far more restrictive that you won't get anything out of the network than if you're an hmo with preferred service coverage. i would say the differences are substantial. i think they have to be for the narrow network approach to work, because it's not just that you'll pay a higher, say, co-insurance rates with the out of network but you won't be able to negotiate a network price so you'll be liable for the amount beyond what the insurer allows for out of network in addition to the extra co-insurance. >> paul, is it typical that if

that happens, whatever the out-of-pocket expense is, it doesn't count toward the deductible in the plan. >> the co-insurance counts, but not what we call the balance billing. >> you want to identify yourself? >> my name is daniel davis with the administration for community living and hhs. >> one of the considerations that we're looking at quite a bit right now is the access to providers for people with disabilities in narrow networks, specifically there are considerations where there's been a number of studies on subspecialties where there's 20 or 40% of providers, according to some secret shopper tests that don't serve patients with

mobility disabilities. to what extent are naic and the private insurance industry taking that into consideration and making sure that there isn't inadvertent health status discrimination. >> with the naic that is something raised as an issue, something that we need to look at, state regulators need to look at when reviewing the various plans. not just that. but especially with mental impairity and things coming on, new requirements on behavioral health, et cetera, there's a lot of issues there that we need to make sure everybody is taking into consideration. so we would agree. >> i'll just add that health plans work very hard to comply with all the federal laws, state laws, rules and regulations.

and they submit their plans for review and they're approved in the state. if they're a qualified health plan, also, by the federal government and they're certified. so they have to meet the standards set in statute and in regulation to be able to compete in the marketplace. we take that very seriously. if you don't meet those requirements, then you're not certified to be in the market. >> having the gentleman from the administration asking that question reminds me of a question that was submitted in advance that is related. it makes reference to the fact that the administration had communicated with plans not so long ago that they were going to focus on areas that have, and the question actually quotes, historically raised network adequacy concerns including, among others, mental health providers. i wonder if we have any other

elaboration of how the current discussions or the current controversies for that matter deal with behavioral health issues. katherine, do you have anything to add on that? >> i will just add that clearly that's a consideration. we focus so much on first what are the physicians and the hospitals in those networks, and that becomes the bulk. as brian pointed out, then you have the anesthesiologist. my point is there is outpatient access that needs to be considered, mental health, home health, all the care continuum for clinically integrated network to be successful. that entire network has to be considered. i don't have any specific examples. but i absolutely agree with your point.

>> i'm dr. caroline poplyn, i'm a primary care physician. i have two questions for ahib. one n the satisfaction surveys that you presented, did they break out people with chronic illnesses or people who have had a serious illness in the last year versus healthy people? most people are healthy most of the time. if they don't use their network, they'll be satisfied with it. my second question has to do with choice. it sounds like each insurance company in an exchange will present a variety of plans. maybe they're required to present bronze, silver, gold, platinum. and if experience with part d shows people get very confused when they have too many choices, five insurance companies offering 50 plans, that's hard to deal with, especially if you have to do it every year. and in part d, i think there was

a study that showed, in fact, most people didn't change their primary plan. they just kept the same plan year after year even though it wasn't the best plan for them. so two questions. >> thank you for those. first, on the poll, the commonwealth fund survey that i mentioned in my slides was very comprehensive. i don't have the actual sample data in front of me to answer your specific question, but if you go to the website, they provide a very thorough explanation of where their sample is drawn from so you can find whether or not it covered the specific populations that you mentioned. >> whether it separated the specific populations because you're going to get a different answer from people who have to use the plan versus people who just think it's going to be great because they don't really know, they've never had to use it. >> right. that survey also included those that actually have used their plan, too. there's data on that as well. i encourage you to go to their

website and pull up their survey. it is comprehensive and very informative. with regard to your second question, if you could repeat that. >> choice. do you worry about the fact that people are going to get confused by having too many choices and each one has a lot of information? the part d experience hasn't been all that reassuring on the question of whether people can make a good choice. >> that's a very good question. it really depends on the individual. some are very savvy and sophisticated about looking through the websites and finding what's best for them. others need a lot of help. that's why the aca provides for navigators, assisters, brokers as well and others that can help, individual review plans and make the choice that's best for them and their families.

health plans are doing a lot, too, in terms of basic education and putting as much information as they can on their websites to help individuals make the best choice, including things like cost calculators. if you know you're going to have a specific procedure, what your out-of-pocket cost would be for that and the like. >> if i can add something to the proliferation of choices, i think the structuring of offerings being being grouped into tiers probably helps consumers a lot going through this. i suspect that most consumers first decide what tier -- what medal they want to get and the numbers of plans aren't as great. >> i actually wanted to follow up a little bit because one of the questions that has been raised at least in the materials

that our staff has assembled is the question of how a consumer in trying to make the choice can distinguish between the narrow network and a broader one. presumably those aren't two different things. there is a blend, there is a range of narrowness, if you will. are there standard formulations that are being used either on the marketplace websites or among the plans that can help people who don't deal with kind of terminology every day to understand which of the choices they're making along that spectrum. >> in reading the mackenzie study, i'm presuming there is nothing out there, as you were saying. since they came up with their own definitions of whether it was ultra narrow or just narrow. it was clearly based on what proportion of the hospitals were

in the network, and i probably would be a good idea going forward in the same way that we have four tiers of plans to also -- they'll be arbitrary, they'll say a plan with which has below a certain threshold of providers is called a narrow network plan, and consumers -- in a sense, consumers can put some aside and then they won't be standardization like actuarial values, but at least they would help the consumer simplify their search. >> brian, any talk of something like that in the revisions that naic group is considering? >> no, not at this time as far as in our model. it is something that, as far as choices and information, i think states would like to look at. we don't -- in the past we've seen carriers try to hide things like that, they want the information, they want to

distinguish between one plan and the other. so how that's done and how clear it is, we'll work toward that. it's probably not something to be in our model specifically, trying to standardize it anyway. i'll just add that plans do provide a summary of benefit in coverage on healthcare.gov and that provides important information to shop around. there's other information on healthcare.gov. new information will be coming in the future, specifically with regard to quality and consumer satisfaction. they're currently building that in and working to produce that. i think just with part d, it will take a while for the website, healthcare.gov to get where it needs to be to provide all the information that consumers want. you have to walk before you can run. so we're still in the first year, and i think we find from the experience in state-based exchanges those states have tried to do too much on their

websites, rab into some real challenges and lessoned learned there, but health plans are committed to providing the necessary information so consumers can make the best choice for their families. >> yes, ma'am. >> lauren kennedy with the national partnership for women and families. my question follows nicely on your last comments which is, i was wondering if any of the panelists could speak to what have been successful strategies for ensuring consumer access to this type of information specifically with regard to quality and performance data. i think it was in everybody's presentation that this is a key criteria not just for provider selection, performance on quality and value metrics, but also the consumers' ability to access the information, understand it and use it to make informed choices. specifically with regards to exchanges, how do we support consumer access, not just to

planned performance on quality metrics, being able to rate plans by quality data, but also consumer access to how providers themselves are performing on quality metrics? we would make the case that if we're looking at narrow choice through narrowed networks or high value networks, however they're referred to, that consumers have a distinct interest in understanding how individual providers in the network or facilities are performing on quality networks. in a way that's consumer friendly and understandable to them. >> no one disagrees apparently. >> it's not an argument. i was wondering if you're able to share some strategies you've seen successful or you might be contemplating or policy changes that might be necessary in order to sort of compel this type of consumer access to provider data. >> can you do it directly or do

you have to do it by -- in effect, requiring the plans to collect the information in some way? >> i think this is a direction we want to go. i think the first thing is to get more meaningful quality data on providers. i did notice two of our panelist organizations together were promoting the idea of standardizing quality measurements. i think as we get better at measuring quality and as we get some consistency, then it's going to be far more possible for plans to really advise or inform about the quality of the providers in their network because ultimately, as you said, i think what matters most to many people is the quality of the providers. >> paul, is it a fair assessment of the state of the art that the people who measure quality aren't very happy with the state of quality measurement at this

point? >> yes, yes. i think there's a consensus on the direction of a lot of the quality measures. now we have the ability to do more in the way of outcome measures. >> i do believe we would advocate for collaboration to make it more universal, as i stated earlier. having so many different ways of measuring quality. that's where we are today in our health care delivery. with so many different ways you get completely contradictory conclusions. you read magazine coverages of who's the best hospitals. they're in, they're out. you don't get any real conclusion as to who is providing the best quality. i think this area has to be improved, needs to be universal. we advocate working with

insurers, employers and patients to come up with the right quality metrics. >> can i ask just one followup? do you feel that's best done in the private sector, the public sector or in collaboration with both if we're aiming toward better alignment and standardization? >> with as far as we have to go, it's going to start in multiple areas, public and private. i think our point is that the ultimate goal could be single. it should be something universal that we're all accustomed to and understand. i think in the interim we'll work with insurers, work with hhs. we're interested in pursuing this to help, not narrow the number of quality indicators but make them more understandable and comprehensive. >> let me digress for 30 seconds and tell you that jim talon who is on the alliance board and runs the united hospital fund of new york city once observed that because of all these rating systems, new york city contained

40 of the top 25 hospitals in the united states. >> that's right. >> gary? >> stewart gordon with the national association of state mental health program directors. in the mental health field a lot of services are provided through peer support, both in mental health and substance use. brian is in an aligned area. despite scope of practice laws in the state, it can be provided by nurse practitioners and physician assistants. is that something -- i guess it's two factions of the same issue. is that something naic is looking at? >> not currently on the table as an issue we'll be looking at. we've tended in the past not to get much involved and who provides the care and those kind of certifications. if it's something you'd like us to look at, you know the number.

but it's not something in the past we've dealt with. >> we've received several questions on cards about the role of nurse practitioners and other non-physician providers in these circumstances. i wonder, are there states that have taken steps to define adequacy to include some of these non-physician providers? anybody know? there's a crowd source question for you. if anybody knows, send it to us at allhealth.org, we'll put it on the website. go right ahead. >> my name is chandler why land. i'm a consumer and caregiver. katherine, you come across conveying caring for the consumer and yet lamenting that

your narrow network lacked an outpatient laboratory, that the narrow network included a hospital laboratory, but it didn't seem easy for the consumer related to parking issues which i totally understand. but it would seem that they have all their information, that that little parking ticket can be validated at the lab, so it would not necessitate hiring or contracting with an outside lab, just a similar thought bubble i had. >> appreciate the thought. i would, if you allow me to add, we would be happy to serve all outpatients for their lab testing and make the access into that garage or that parking lot as easy as possible, whether

it's getting a stikt validated. but even just getting them from the garage in, some folks have trouble walking from that parking lot up to the entry. i'm saying folks may not want to come to that big hospital campus. they may want to go to the accessible quest lab that's sitting there a half mile from their home. >> most of the parking lots that i've been there for hospitals, they have a button as you enter the parking if you need assistance. >> sure. again, we'd be happy to provide that. >> i'm mary tyranny, a pediatrician. my background is i ran epsdt in the office of child health working fon a man by the name of leonard schaeffer. obviously my question is going to be on pediatrics. what are we really doing for

kids that absolutely must have tertiary care, children's hospitals and so on? i just talked to a man the other day who had -- talked him again who had a child born with at the time rolling of flow, very complex heart disease, that wanted to send his child to a surgeon who hadn't donny heart surgery on kids in about ten years. and luckily got him into a children's hospital. how are you addressing these things, especially with kids with very complex needs? >> i think that's where choice comes in. in this current marketplace there's a lot of choice, whether you want to choose a very broad network or a very narrowed network or someplace in between. it's important that consumers have the right information so they can make the best choice for their families to get the care they need. >> i have an answer to the

question. this sounded like a case for the need for a very speedy appeals process to provide access for very specialized care to those providers who really are experienced in it. in the various work i've done over the years in health care markets, one of the observations is often the pediatric hospitals are by far the highest priced hospitals in the area. so the inclination to create a network without some of them i can fully understand that. but if you're going to do that comes the obligation of providing access for those that cannot be served in the general academic medical centers that are in the network. >> i'd just add consumer education and involvement. >> if i can just add to that,

tauchb department of insurance, insurance commissioners get involved and work with the insurance companies and consumers to try to make sure, if it's determined to be insufficient, to resolve the issue, to say you've got to cover everybody, let's deal with situation by situation. that's why the grievance procedure is there. that's why there's regulation just to make sure everybody can resolve the issue. and it most often does. >> if i can ask you to forebear for just a second, i wanted to follow up on something with a question on a card, and i should say that we have enough cards to carry us through tuesday of next week. you might want to use the microphones if you absolutely, positively have to get your question answered or at least addressed. this one actually is also directed to you, brian. what's the naic position, if

there is one, on midyear network removals as we're seeing with the medicare advantage plans. and i want to come back to the medicare advantage part. but what happens when you sign up for a plan that has the physician you want and she or he drops out halfway through? >> our current model deals with that by making sure everybody is notified of those changes and then also makes sure if there's an issue of continuity of care, that is taken care of. it's something we're looking at, especially since again, there's been a drastic change in the marketplace, especially individual market. we do have a policy -- we really didn't have that before. we are going year over year. we're looking at how that can be resolved if something needs to be done there. we have no position yet on whether it should or shouldn't. it's something we're looking at given the new environment. >> dan, you want to comment on that? is there a general industry practice for that kind of

situation? >> you managed medicare advantage. their plans are under extraordinary pressure. you know the aca produced payments by over $200 billion for over ten years of ma plans. the administration added additional cost reduction on top of that through the regulatory process. so plans have to find a way to provide value to consumers. some of that is by taking a closer look at their networks to see if there are ways that they can tailer their networks. >> there's been adequate notification to consumers and the like and we feel that is important and we're working towards that goal. >> i'm not sure how we get there, but i think to the degree that limited narrow networks are going to be an important part of the landscape for a long time, we should start thinking about how to move the system so all

network agreements between plans and providers conform to the daelts of the plan, so if they're on a calendar year, so then this issue of provider dropping out of the network would be very limited to a provider that got out of practice or something like that. >> i'll add, too, which is an important part of this debate, there have been numerous studies out there that show tremendous price variation with little or no correlation to quality. so that is something that we have to take a close look at and plans are trying to deal with that by saying let's focus on those providers that provide value given the tremendous price variation in this country, you can provide good quality service to consumers by finding those providers that provide valuable services, high quality services at a lower price. and that's the premise behind

doing networks in a way that's focused on value. if we don't -- if we just open it up to everyone including then we're stuck back in this fee-for-volume system which we all agree we have to move away from. this is one of the ways that plans are helping to move us towards a value-based system. >> that was actually my tweet and you've answered all my followup questions now. i'll sit down. >> let the record show we respond to tweeted questions. yes, go right ahead. >> this question is for brian, but for anybody on the panel that feels like chiming in. brian, going back a couple questions when you mentioned stepping in in that pediatric example when a network was determined to be inadequate, what other tools do you haveality your disposal when networks are determined to be inadequate? are there fines on plans that

don't offer enough coverage, bans on them offering -- continuing to sell insurance in the state or do they have to promise to get better and improve the problem? >> it defended on the state and whether it's actually in the law or in the regulation as to what the standards are. they're going to file their plan at the beginning of the year when they're saying we want this plan, they will file their access plan. the state will look at that. if they don't approve it, they will ask the company to refile it. you have to get that approved first. then if during the year there are a lot of grievances and a lot of issues, then the state as the regulator can step in, can talk to the company, can ask them to make some changes to fix issues and then with the market conduct review, you could fine them, you could withdraw their license. you have all of those at your disposal. we're not going to get there on this kind of issue, but you talk to the company and usually you can resolve the issue that way.

you have all of that as your background. you're the regulator. you said that company can sell that product in that state. if they're not actually fulfilling their access plan which they filed with you, then you can take action against them to fix it. >> thank you. >> bob. >> bob griss with the institution of social medicine and community health. there are two issues that i haven't heard addressed so far and yet they are trends in a sense in the health care marketplace. one of them is concierge medicine. how will this focus on network adequacy deal with doctors who want to collect a special fee just for the privilege of going to them? secondly, the subject of conscience clauses, since we have a representative of the catholic hospital systems.

when providers choose not to provide certain fda approved medical services, how -- what obligations does the health plan or provider have to insure that that patient is able to get the medically necessary treatment that they want. >> i'm not sure that the prider has the sole responsibility here. there is a matter of disclosure up front about what providers are providing what services: people do sign agreements and waivers. i may be wrong on this, and i'd be interested in dan's comment about this. but if you're a plan, you have the responsibility for making sure the services are available through one or another of the

provide providers. >> it depends on the state. there's a lot of variation on state law on this particular issue. >> i'll comment generally that being our mission base, we would not provide ethically -- we follow ethical religious directives. but as patients and families access these plans and are wanting other services it's expected through the plan to get them the access they need. it's determined at the plan level. >> how do you do that if -- let's say you're a hospital, let's say you're the only hospital in a geographical area, and a provider -- you decide that something is not consistent with your religious -- with the providers' or the owners' religious beliefs, how does the

patient get the medically necessary treatment? >> i can't comment on all. ki tell you in our markets we're not the sole provider in our markets. >> i don't want to belabor it, but we are getting a little bit off the question of adequate networks at the plan level and i want to make sure that we don't miss out on the opportunity to get to these questions. that means calling on you at the moment. >> my name is camille bonta with summit health care consulting. i represent a number of provider organizations. this has been a terrific panel discussion. i'm glad the topic of network adequacy has been brought up with respect to medicare advantage plans. i think some of the same issues regarding transparency to patients about who is in their network at any given time due to midyear contract terminations at no cause are very concerning and

whether subsequently there is adequate networks of providers, i'll add that senator shared brown and congresswoman delore row introduced legislation pertaining to those midyear terminations. on the topic of network adequacy, i know the question was raised of what do you do if you determine that a network is inadequate. but i think, also importantly, what are the tools being used to ascertain whether or not a network is adequate. mr. ginsburg, you raised a very important point at the very beginning of this conversation. i would welcome a response from either mr. durham or mr. webb. but if a plan looks at its network and says we have 30 ophthalmologists in our network and they're looking at the

specialty designation, but they're not looking at sub specialists for which there may not be a medicare subspecialty designation, should they be doing a little bit more of a deeper dive if, for example, someone notes to see a retina specialist, but that ophthalmologist doesn't provide a lot of retina services, should they be taking it down to the cbt level to find out do we have an adequate number of et rhett /* retina specialists to be caring for patients with very specific needs? i think that's a really important point. i've heard health plans using the g.o. access reports to help determine network adequacy. that does not go down to the subspecialty level. it may just look at the specialty designation. i'd welcome any thoughts that mr. webb or mr. durham have or even mr. ginsburg on ascertaining whether truly there is network adequacy. >> well, let me say something

quickly about the subspecialties and move on to the other questions. i would say we're in a learning process about how to regulate and have transparency for limited network plans because they've just arisen. i'm familiar with some anecdotes where say in ophthalmology that i know fairly well where the issue of the retina specialist was raised, and through the academy of ophthalmology it went to the insurer who i think just responded, oh, we didn't know that. we will make sure to put some retina specialists in the plan. so i think it's just discovering that this is an issue. i will say, yes, the detail that's going to be needed in some specialties probably will have to go by subspecialty. it's going to make it more complex. but this is going to be a big

part of our environment so we might as well just do that. anybody else? brian? >> it does vary by state. some do a deep dive and they go down to specialists, sub specialists, not at medicare advantage, we don't get to regulate that. we're excluded. >> yes, go right ahead. >> my name is jesse bushman, i work with the american college of nurse midwives. we've been doing a survey of the plans, calling them and asking about inclusion of nurse midwives in their services in the plan's provider network. what we discovered of those who responded to our survey which is about a third of the plans, 15% of them flat out do not include a nurse midwife in the network at all. about 40% of them don't cover birth centers either. about 35% of them don't pay the

nurse midwives the same rate as the physicians providing the same service. in the regulation, cmf stayed away from dictating what type of providers should be included in the plan so insurers could have the flexibility to do exactly what we're talking about and maintain lower levels of premiums. that's understandable. my question is, the cnns are attending 8% of the births in the country. it's part of the essential health benefits package. i think i could argue reasonably that's a provider type that shoush included in a plan's network. i'm wondering how you make decisions about what types of providers are and are not going to be in your network and what's the criteria? i think if i was to argue that a plan could include a few family practice docs doing deliveries and, therefore, did not need to

include any obs, i think people would say that was unreasonable. my question is where is the line and how do you decide when is a certain provider type necessary for inclusion in your network. >> is that an niac question, brian? >> no. we check to see if all the ones required by law are in there. >> dan, you're the default second place answerer. >> we've talk about this previously. to be a qualified health plan, plans have to be certified and part of that certification process is review of how they meet the network adequacy standards. if you don't meet those standards, you're not a qualified health plan to participate on the exchange. ocms is looking at this. this year they required health plans to submit a lot more

information in terms of who is in their provider networks, the names of the doctors, the hospitals and the like. so they had all this data now. the plans have supplied it so they can do a test using software that they have to make a determination whether or not they believe the network is adequate based on their standards. if it's not, they can work with the plan to get it to a place where it needs to be to get certified. so it really depends largely upon the rules and regulations that are applied to meet certification. i'd also add that there's a measure of choice here. some plans go beyond what other plans are doing, and they may have a higher price level because of that, broader networks, lower out-of-pocket maximums, lower deductibles, but it comes usually with a higher prum yum in a platinum plan or gold plan. there are tradeoffs here that consumers need to look at before

buying a plan. >> i'd offer just one followup to that, and that is from an insurer's standpoint, i'm not so much complaining about them as wanting to say that there's this huge the insurer to take advantage of because the practice pattern of the nurse midwife is something that reduces levels of interventions and therefore reduces costs. i don't see it so much as a complaint against the insurance companies as something we can do to educate them to say here is an opportunity for savings and i think it would result in savings for your members as well. >> i agree with you. a lot depends, too, on state laws. we'd like to see states go to a place where nurse practitioners can practice to the top of their license and for other providers as well so we could take advantage of those type of cost savings while preserving quality. >> thank you. >> if i could ask you to suspend for just a moment. i wanted to take just a couple of the questions that have come

in on cards which actually dove tails very nicely with a couple questions we received in advance, and it has to do with the question of essential community providers. first of all, i want to make sure that everybody knows what an essential community provider is, and so i'd like one of our expert panelists to take a crack at that. but the aca requires plans to include substantial numbers of them, whatever they are, and they are particularly important to the lower and moderate income folks and isolated populations that katherine was talking about. how effective is the regulatory device, which i think is a threshold of saying that you need to have 20% of all of essential community providers with a change pending to raise that to 30%. is that the appropriate way to assure that folks can provide --

that they can find the providers they need? >> as far as the naic and our work on the model, we're just going to have to put in what that requirement is. as far as the regulation, we're looking at it, especially when it comes to some of the native american and alaska natives and what they have to do there, have to at least try to get a contract with them, whether they can get one or not is a question, and there's a lot of things involved in that. that's going to have to be something that kind of evolves over time. we have the thresholds in place. now we're going to have to look at how we can enforce that, what's necessary, and that's something we're looking at with our model is get the thresholds in there, but then from there how do we move forward and how do we regulate and make sure that they are contracting with them and reaching to them and what those things mean. so it will take time, but we're working on it. >> katherine? >> yeah. i couldn't comment on this 20%, the right number, or 30%.

obviously it depends on market success, access, et cetera, but i will say that we are supportive of essential provider requirements. you know sha, given our history our footprint we do a lot of work and partner with federally qualified health clinics as well as we're the safety net provider in many of our communities, certainly right here in washington, d.c., we do a lot of work with unity, the fqhc here. so we are just proponents for making sure that's coverage there to serve the poor and the vulnerable. >> i'll just add the threshold has increased for 2015, so in 2014 plans participating in the exchange had to include 20% of essential community providers in their area. now it's 30% for 2015 so plans are meeting that regulation, but again it comes at a trade-off in

terms of price to the extent you continue to expand the network access requirements and health plans, that in turn will lead to higher premiums, so we have to be cognizant of that trade-off as we look to further regulate and restrict a plan's ability to provide that kind of high value to consumers. >> we have just a few minutes left. we're going to get this question and maybe a couple from cards before we finish, but i'd ask you to fill out the blue evaluation forms while we're finishing up the conversation so we can get some feedback from you about this program and others that we might do. yes, sir. thank you. >> hi, i'm doug jacobs a medical student and also an intern with hhs, and i understand that health insurance companies, they're using value as a way to select physicians. my concern is that they would also exclude physicians who treat sicker patients because

those physicianins would be mor costly to include in the network. i was wondering is this happening, and also if anything is being done to prevent it from happening. >> i have seen no evidence of that. >> i would say that when insurers are trying to look at value, which to me has two dimensions besides price. they're looking at broader measures of costs to see, you know, for an episode of care or for a period of time which provider is less expensive, and then there's a quality dimension. i would think that insurers would want to adjust for different patient populations, but what they can effectively do is an open question, and so, you know, it's probably not ideal now. hopefully it will get better. >> and i would just note that in our model and something states look for is that nondiscrimination, that you're not contracting with people just because -- or providers because they happen to care for certain types of diseases or groups of

people. so that is something that we look for and will continue to kind of look at that as we move forward. >> thank you. >> we've got a question here, i guess, that would go initially anyway to dan. providers listed on planetwor networks may not be accepting new patients. how do plans inform potential enrollees about which providers are truly available? >> well, that's an important question, and that's one thing that plans are committed to, to provide up to date provider networks on their website but i'll add it's a two-way street. if a provider is no longer taking new patients and they fail to communicate that to the plan, then the plan tries to make it very easy for them to do so through special call-in lines and the like, but part of this rests on the provider to let the plan know when they're no longer taking new patients. so, you know, we have to work on this collaboratively to make sure that consumers have the

latest information. >> katherine? >> that's a fair comment. the providers need to be in contact with the plans for sure. i can tell you in our hill system if someone is calling for an appointment and that physician has reached capacity, cannot take the patient, we'll ensure that they get referred to someone who can within the area, but that's our practice. i don't know that that's any regulation or requirement. >> i'm sorry, brian, anything? if i can go back to the related question of the maybe -- not completely accurate directories or midyear cancellations as opposed to physicians who aren't taking new patients, who bears the burden of the lag in information? is it the patient? is it the provider? is it the plan?

what happens when that surprise bill shows up? whose surprise is it? >> it depends on the circumstance. we think it's important that, for example, hospitals that are in the network employ anesthesiologists or pathologists or other specialists in their hospital that are not in the plan. you know, they have a responsibility to notify the patient before they go under surgery to say, well, you know, this particular anesthesiologist is not participating in the plan that the hospital is, and so it could result in higher out of pocket costs. we think there is some responsibility there on the hospital side in that type of situation. >> you know, one thing i can add is that outside of this issue of networks, that a number of states have put restrictions as

to how much these out of network physicians can charge just because, you know, these anesthesiologists and other hospital-based physicians where consumers are just not in a position to be able to make those judgments. >> you know, i'd like to add just one comment to this point, and i do believe that, yes, the providers are standing in the relationship with the patient, and as we've done, we're educated, we're working with them to know which providers are in their networks and not, but i do come back to as the patient or family is signing up for a network, they're entitled to know who's in, who's not, and we do see that education requirement needs to be provided by the plans and probably something in much more robust than just directories. probably something more like examples, scenarios, things to ask so that, again, the patient can be more informed.

>> okay. i think that probably is a very good note on which to bring our discussion to a close. we didn't get -- i really apologize to those of you who spent the time to write some very good questions on the green cards, but it's a subject that we are not letting go. obviously there is a high level of interest in it. there are a lot of complex pieces of it, and so we plan on revisiting this issue in the fall, probably with a briefing, perhaps with a webinar. keep tuned, and we'll try to explore this question of network adequacy as it develops. thanks to our friends at wellpoint for helping us put this program together. thanks to our emergency panelists who filled in so greatly, i think, and thanks to you for asking all the questions that we have tried to address.

so if you'd join me in thanking our panel, i would very much appreciate it. [ applause ] and we take you live now also on capitol hill where the middle east policy council holding a conference today on president obama's foreign policy and the future of the middle east. the panel includes former government officials with a range of experiences within middle east policy. the event should get under way in just a few moments. live coverage here on c-span3.

we're ready to begin. i'm the executive director of the middle east policy council. like to welcome you here. this is the 77th capitol hill conference, and it is about president obama's policies in the middle east. we are live streaming this event and c-span is here, so i would like to say a few words about the council before we begin. the middle east policy council is now 33 years old.

it has three major programs. one is the publication of our journal, middle east policy. it's been published now for 32 years, and for 30 of these years it's been edited by ann joyce. this is her 30th anniversary as our editor. would you stand up, please, ann? [ applause ] so ann has taken the journal from its infancy to its current status, and it is the most frequently cited journal in the field of contemporary politics in the middle east. our second program is these capitol hill conferences. as i said, we have done 77 of them, and we publish them in the journal. we live stream them and we have

the video on our website so you can watch them later. and our third program is an outreach program in which we provide content for secondary school educators and community college educators and workshops for them and their students. you can see all of that on our website at www.mepc.org. and i hope you visit, it is a very rich website. now, i'd like to say just some brief words about the topic before i introduce the speakers. we chose this topic when we heard president obama's speech at west point late in may this year. he did say that the united states would use force unilaterally if our core interests were directly threatened, but he emphasized a

counterterrorism strategy which would rely upon supporting and training and working with security partners and announced a $5 billion program to support security partners in the middle east having identified terrorism as the most direct threat to the united states. not long after that the islamic state of iraq and syria moved down the tigris river and the iraqi security forces retreated, raising the question of how we -- how much we can depend upon a strategy like that in iraq or even in afghanistan where we will be leaving soon, and he said that syria would be a major focus of this strategy, and we know that we've had a difficult time finding security partners there because it's a very fragmented opposition and hard to vet and find moderates.

our panelists will be discussing that today. another point that he emphasized in his speech was our commitment to upholding international order through support for international institutions and international law. and he spoke about our multilateral sanctions against iran and our multilateral diplomacy with iran in that context, and we know that the p-5 plus 1 negotiations with iran were scheduled to conclude yesterday, and they didn't. so they were extended for four months because everyone feels that some progress was made, enough progress was made to go forward and continue trying. we will discuss that today. what terms ought to be in the final agreement and what the united states would have to consider doing if we don't get a

solution we consider satisfactory. i was struck in the speech by the fact that when he talked about international order, international institutions, and international law he never mentioned israeli/palestinian issues, but his support for kerry's peacemaking was well-known and, unfortunately, did not succeed, and he is said to be willing to try again before his term is over but wanted the failure to really sink into the minds of the parties and hope that they would come back to him with better ideas, and now instead of that we have the third escalation of the conflict in the gaza strip in the past five years. we know how they go, and we know how they end, and they don't produce agreements, they produce casualties, so that is another situation that we should try to explore today.

and i know the panelists are ready to do that. i will introduce the panelists very briefly all at the same time, and they'll speak in the order in which they're listed, and i ask each of them to come to the podium because we do have tv cameras here and speak into the microphone, which i hope i have been doing. our first speaker is -- and, by the way, each of these speakers has a bio that would take all tay to rea day to read, and you will find them on the back of the invitation, so i'm only going to give you the highlights. but our first speaker is kenneth pollack, a senior fellow from the brookings institution. and before that he was the director of the center and before that he was the director of research at the center, and he also has been at the council of foreign relations and had a career as an analyst at the cia

and is a very well-known author who has a recent book out called "unthinkable," which is about the iranian nuclear program. our second speaker is paul pillar who is a nonresident senior fellow at the center for security studies at georgetown university and a nonresident senior fellow at the center for 21st century security and intelligence at the brookings institution, contributing editor to "the national interest." i recommend you look up his articles there. and a former cia analyst. the third speaker is amin tarzi, who is the director of middle eastern studies at the marine corps university and a senior fellow at the program on the middle east at the foreign policy research institute.

and, finally, our fourth speaker with chaz freeman, chairman of projects international, former assistant secretary of defense for international security affairs, former united states ambassador to saudi arabia, and also a former president of the middle east policy council. so with that i conclude and turn the mic over to kenneth pollack. [ applause ] >> good afternoon. thank you, tom, for that kind introduction. thank you to the middle east policy council for inviting me up here today. when the obama administration first took office, i had the occasion to talk on any number of different instances with different members of the administration about their middle east policy, and, of course, that interaction has

gone on ever since, and what i consistently heard from the president's team, the president's middle east team, was a proposition that the united states had consistently over invested in the middle east. that was their perspective on u.s. policy toward the region, that the u.s. had needlessly squandered resources, time, energy, et cetera, on the region and that they were determined to fix that. and i pressed them to explain their rationale, what i heard back consistently from them was a three-point argument. the first one was that we middle east experts and many other people beyond that had greatly exaggerated the importance of the middle east and in particular had greatly exaggerated its capacity for things to go wrong there. as part of that, they argued that the region really didn't need the united states to the extent that we middle east analysts and other people seemed

to believe, and what's more some would go beyond that to argue that, in fact, the united states was a major source of the problems in the region and not only could the united states afford to disengage from the reason but that, in fact, it would be better for the region if we had less to do with it, and then they went on to argue that the middle east simply wasn't that important and that even if bad things happened there, they really wouldn't affect core american interests and that, therefore, for all of these reasons they felt that it was not just possible, but, in fact, necessary for the united states to pay less attention, devote fewer resources to the middle east, and, instead, pivot to other things, to asia and in particular to dealing with the american economy which, of course, and i think that the president was right about, but the president believed that was what the american people had elected him to deal with first and foremost. at the time i questioned many of these assumptions, but i think that we can see very clearly the

underlying foundation of how the obama administration at least in its first four or five years approached the middle east in this basic philosophy, this basic set of sentiments about the region. up fortunately, of course, this policy has run into some significant problems since then, and certainly the first set of assumptions, that the middle east wouldn't go to hell, that the united states wasn't necessary to keep it from going to hell, and that the united states was, in fact, part of the problem rather than part of the solution, i think that that has been proven demonstrably false by the events of the last few years. the region has gone to hell, and i say this as someone who wasn't exactly fond of george w. bush's approach to the middle east either. i never thought that in 2014 i would be looking at a middle east that could somehow be worse than the middle east of 2006,

the nadir of george w. bush's approach. yet that's what i see. iraq and syria are in civil war. yemen is on the brink of civil war. probably is in civil war. lebanon has experienced all kinds of problem. the arab spring is dead. egypt has returned to a dictatorship, at least temporarily. any number of other problems are spreading all across the region. it is a deeply troubled region, not to mention the point that tom just made about having yet another israeli/palestinian war in gaza. this is not a good situation. this is not a good region. and while i don't think that everything that the obama administration argued was wrong, i do think that the united states has certainly made its share of mistakes in the middle east, and not only under the george w. bush administration, although they certainly had more than their fair share of those mistakes.

but it certainly is the case that the united states has made mistakes in the region, that we have often contributed to the problems of the region, but nevertheless, i think the weight of evidence on the whole is that the united states has helped the problems in the region more than we have hurt them. especially if you accept the obvious examples, obvious contrary examples of the bush administration's handling of iraq and certain other issues. and i think that, in fact, the best proof that even the obama administration now recognizes this is how they've been handling the middle east in the last year or so. we've seen a very significant change in the obama administration's approach to many different issues in the region. it started with the selection of senator kerry as the -- as our secretary of state, our foreign minister, and his decision to pursue a new peace process between arabs and israelis, between arabs and palestinians, and while that effort seems to

have failed badly, the fact that he wanted to do that i think was the first indication that the administration was beginning, just beginning, to question some of those basic assumptions, was recognizing that the region was not headed in a good direction and was even threatening the last and most important of their assumptions, which is that problems in the region really weren't problematic for the united states. but i think we have seen since then a number of important course corrections. the president's recent decision to a lot money in support of the syrian moderate operation. that represents a dramatic departure from their prior position on syria, and now the recent efforts since the fall of mosul on the part of secretary kerry and other obama administration officials to become much more actively involved in iraq's politics, to try as best they can to pull it back out of the civil war into

which it has once again descended. i will say that i applaud those efforts and i think they are the right ones. i only wish they had come quite a bit earlier. and in a piece in foreign affairs, i talked about this, and i talked about the fact that i had these strong sense that it was my perception that while the united states had swung too far in one direction under george w. bush, toward unilateralism, toward the militarization of its middle east policy, toward a war on terrorism that encompassed and overwhelmed everything else going on in the region, that i felt that the obama administration, unfortunately, had pushed the pendulum too far in the other way, toward disengaging, towards simply walking away from the region and believing that whatever happened there wouldn't be too bad and wouldn't be able to hurt us. and, again, i think that the administration is even recognizing that their position, that that early position has become unsustainable and is already tacking back in the other direction. but what i take away from that in particular is obviously not just that we need to do better

with some of the crises at hand, we do, i'm glad to talk about them. i will say actually that in a number of those cases, while i dislike how the obama administration handled them before we got here, in some of those cases i actually largely am in agreement with how they've been dealing with them since we got there, and iraq is a perfect example. i think the administration's iraq policy was an unmitigated disaster. i think it helped cause the civil war in iraq, but since the fall of mosul with some tactical tweaks here or there, i think they have been by and large following the right policy toward iraq. but i think that iraq in particular illustrates what we have to think about moving forward, and what the obama administration failed to recognize in its first four to five years, which is that especially in the middle east, the old afroism that an ounce of prevention is worth a pound of cure is the best motto for the united states to take. i think there were any number of occasions when the united states could have had an impact on iraq that could have allowed it to

avoid the current impasse at a much, much lower cost with much fewer resources, with much less commitment of time, energy, effort, et cetera than what we may now have to sink into it if we are going to try to help them pull themselves out of civil war. i think that we missed important opportunities early on with syria. i think we missed some tremendous opportunities with libya after the fall of gadhafi. i think that we missed some tremendous opportunities in egypt, especially after the fall of mubarak where i think that had we made a greater effort with the government then, we might have helped then prime minister morsi avoid some of his worst mistakes -- excuse me, president morsi, avoid some of his worst mistakes and perhaps even headed off the military coup that overthrew him and that replaced him with yet another egyptian dictatorship. i think that around the region we can find other instances of that. and, again, what it brings me back to is this essential focus

that the middle east does need some help from the united states, but that the more that we are engaged on a regular basis in the regular processes of diplomacy, of trade, of public diplomacy, of military assistance in a whole variety of ways, the better we will be able to head off the great problems of the region to prevent the kind of crises that we are now facing all around the region and the better able we will be, the more influence and leverage we will have when the inevitable middle east crisis does break out. just looking forward briefly, i want to comment on a few other things. again, i'm glad in the q & a to focus on whichever specific parts you folks are interested in, but i want to say a few words about a couple of issues that i think are lying out there that we need to think harder about again in this same context of an ounce of prevention being worth a pound of cure. the first of these is the arab spring. the arab spring is not what any of us hoped it would be.

it's not what most arabs hoped it would be. there's good reasons for that. there are a lot of different reasons for that, but what i think we need to recognize moving forward is that the desire for change on the part of a great many arabs has not gone away. it has been frightened in many cases by fear of what happened in syria and yemen and libya and elsewhere, but that basic unhappiness that gave rise to these protests movement all across the middle east, they haven't gone away, and chances are they will reappear, they will resurface at some point in the not too distant future, and we need to be thinking about what form they will take and how best to head off the potentially very negative man fasttatiifest that pressure, and in my mind it goes back to an idea that i and a number of other people were advocating for long before the arab spring which is the idea of reform rather than revolution.

okay? and here i would actually suggest we take a look at ambassador freeman's former stomping grounds in saudi arabia. we don't see saudi arabia as a great beacon of reform. from my experience, the saudis do, and that's been a critical element in allowing the royal family and allowing the saudi system to negotiate the arab spring without the same kind of unrest that we saw in other countries. i can remember speaking to saudis at the time and having them say, but, yes, while we have the same problems as egypt, we don't need to do what the egyptians did because we have abdullah, not mubarak, and abdullah is moving us in the right direction, and for me that's one thing to think about is even in the face of all of this chaos and all of this anarchy, the impetus for change is still there, and one useful role that we can play is in helping the remaining governments of the region, those that have not fallen into civil war, to think about how they can

begin programs of reform that will at least begin to let off the pressure, that will defuse the anger that led to the movements in 2011, and that's a very important one. and the last point i wanted to make was on iran. i am still hopeful that we will get a deal with the iranians. if we do, that would be by far the best outcome for us, for the iranians, for our allies in the region, but obviously that hope has got to be tempered by the realities that we faced certainly over the past six months, but arguably of the prior 35 years. it is going to be difficult, and i think that we need to start thinking now about what we might do if we don't get a deal with the iranians. we also, by the way, have to be thinking about what we do if we do get a deal with the iranians. that will be equally important, but i have been struck by how many people around town are already focused on that. i think that we also need to be thinking about the other side,

and i think there's going to be a very important debate to be had because if we don't get that deal, many people are going to take that as a sign that the iranians are now bound and determined to acquire nuclear weapons. they may be right. we probably won't know. but there's going to be a critical question of how we handle the iranians and the rest of the world going forward. from my perspective, i think war is not a good option. i think war could be the worst of all options. but if we don't start to explore the alternatives, if we don't start to put in place the policy mechanisms and the pathway that is we might follow when that time comes upon us, i fear that we will have no other good alternatives and we will find ourselves pushed into another middle eastern war that we don't need. just because i don't think that obama has gotten it right, that he pushed too far too disengagement means that going to war with iran is the right way to center that pendulum either. thank you all very much. [ applause ]

jo thank y >>thank you, ken. i should have said there are cards on your seat. if this think of questions, please write them down. it may be hard to take questions from the floor because we didn't get the standing mic that we asked for, so, please. paul, thank you. >> thanks very much, tom, and good afternoon. the title of this event is obama's foreign policy vision and the future of the middle east. in my judgment the vision thing as the elder george bush referred to it is overrated. it tends to be a thing that people like us, pundits and critics such as those of us sitting in the front of the room, like to deal with as a way to encapsulate and get our conceptual hands around policy, but any themes that would

satisfy us in that respect would almost by definition be too simple, i would say simplistic, to be the basis for sound and successful u.s. foreign policy. the challenges out there are simply too complex, and the u.s. interests at stake in facing those challenges are too multifaceted to boil everything down to a single vision in a bumper sticker kind of way, and that's certainly at least true in the middle east as elsewhere. successful foreign policies, including u.s. foreign policy in the middle east i would suggest are necessarily more ad hoc, at least as much a matter of avoiding losses as scoring gains than the sort of vision that would score high in the estimation of most critics. foreign policy strategy does not tend to get high marks for not

doing certain things as opposed to doing certain things in response to a positive vision. but i would suggest that not doing certain things or to put it differently not screwing up is at least as important in advancing and protecting u.s. interests in this region as doing things. ken suggested a motto, the thing about the ounce of prevention. let me throw out an alternative motto, not to be conflicted with it but i think you should consider it as well, that's the hippocratic principle of first do no harm. if you look back over the last few decades of u.s. involvement in the middle east and the u.s. interests that have been affected by it and ask yourself what particular things where the u.s. had some control over it have had the biggest impact positively or negatively in terms of american lives, resources, distraction from other interests, legacy problems we're dealing with today, and i would have to put squarely at

the top of the list and squarely at the top of the list the launching of the iraq war in 2003. as that example would indicate, not doing certain things and not doing harm i think is an important part of judging anyone's foreign policy even though it doesn't get high marks from the vision people. mr. obama's west point speech did not get especially high marks from most of the critics, and it probably did not deserve them in terms of the usual criterion for assessing these things as opposed to my criteria. the one stab that the president seemed to take at a theoretical framework in the speech was a pretty bad one in my view. he seemed to equate realism with isolationism, which was rather wrong. much of the rest of what he did say was consistent, however, with at least implicitly with what i would consider more of a realist view and that's sound. the president articulated several important principles i

think we ought to bear very much in mind. he talked about distinguishing our core interests from other lesser interests and explicitly made the point that that distinction is important in weighing what measures and what means we should use to pursue those interests. he also made very clearly the point that not every problem has a military solution, and i think this particular point is one on which we see the sharpest difference or the greatest daylight between mr. obama and his most vocal critics here in washington. i expect that mr. obama himself probably privately regrets as he looks at the current mess in libya the role that the u.s. played in the use of military force there. i might be wrong, but that's just a guess in terms of private thoughts. the president appropriately

acknowledged the many trade-offs between different u.s. objectives even when dealing with a single middle eastern country, and he specifically used the example of egypt, which is as good an example as anyone. in which we have interests having to do with dem mock ra at thisization and human rights but he also quite frankly said we have morva strategic interests. he did not mention i could also add the egyptian role in the current tragedy that we're reading about over the last week. but the point is he's correct that there are conflicting objectives and it can't be all boiled down to one vision even with a single country like egypt. the president made a good case, i thought, for collective action. the need to rely on what other countries and not just the u.s. do in this region even when we're pursuing u.s. interests. and i think this is another major difference with some of

his chief critics who seem to believe that if there is a problem out there, not only can it be solved, but the u.s. can and should be the one to solve it. the president did not explicitly address, but i think we might, i think we should, the basic criteria in determining cooperation or lack of cooperation with particular states in the region. we americans have an unfortunate manichaean te manichaean tend si to divide the world in allies and adversaries on the other, a very rigid division, and to take that as the sole guide for determining whom we're going to cooperate with and whom we're going to oppose. the label gets slapped on some as ally as if that were a substitute for careful thinking about what the government of that country is doing that may conflict with or may advance

u.s. interests. and conversely, we look at those who are traditionally labeled as adversaries and we consider any influence that they might have as bad without taking the trouble to ask ourselves how will they use that influence and to what purpose which may or may not be consistent with or in conflict with our own interests. there are a variety of conflicting and converging interests with different states across the region, including ones that are traditionally labeled allies and other that is are traditionally labeled adversaries. mr. obama in that west point speech voiced some pretty conventional themes that didn't really distinguish himself clear

ri fr clearly from his critics, although some of them may carry the hazard of trapping him into acting against some of his own principles or at least increasing the pressure on him to act contrary to his own principles. he identified terrorism as the biggest threat to u.s. interests. we could debate that. the counter terrorist aid initiative he announced is a worthwhile recognition of the principle i mentioned earlier of how what other countries can do can be at least as effective as what we do ourselves in advancing our own interests. and speaking from an old counter terrorist hand, on that particular issue, terrorism, the u.s. must rely at least as much on the actions of others who are closer to the front line of dealing with terrorist threats and groups as on any other issue. but the enshrinement of terrorism as the prime threat with the natural focus on the

ogre of the day, in this case the group that's called itself isis, increases the pressure to act in a place like iraq along the lines who believe that every problem can be solved by the u.s. and every problem has a military solution, which, again, goes back against what the president was trying to arct articulate elsewhere in his address. we see some of the same nings in syria always there the ogre is on the same side as the overall civil war as those that we would be assisting. still on terrorism, mr. obama mentioned in his speech what i thought were a very sound set of criteria in determining when to pull the trigger on a drone strike. but it still comes down to those individual decisions, and there probably is, i would guess, with this administration at least as much as the last one, you can just count the number of strikes that we've had, a bias in pulling that trigger maybe more

often than a careful consideration of the criteria the president voiced would dictate because of the pressure to do something about terrorism. a few closing thoughts. i think the best approach to u.s. policy in this region is somewhat akin to steering, to use another cliche, the stip of state carefully to avoid the rocks and shoals where it might crash. and if we're thinking just about long-term vision, we may miss the rocks that are right in front of us, and, my goodness, there are plenty of them right in front of us in this region. now, that sounds a little bit like straight lining. it's not imaginative, how can we change things for the better and i'll grant that, and i would identified two particular things that would be most likely to more fundamentally change what will we're looking at in the middle east and change it, in my view, for the better. one is very unlikely because the political courage here in

washington will not be mustered. the other is much more likely. the first one is the courage to do something about the israeli/palestinian conflict, to get that story off the tragic course, the tragedy of which has been emphasized by the events of the last week more than anything i can say. that requires not so much vision as it does at conscience and the political courage. the other thing that's happily much more likely is the one that ken finished his thoughts on and i agree with almost everything ken said about this, and that's completing the nuclear deal with iran, which besides being the best way to preclude any iranian nuclear weapon would also by opening the door to a more normal relationship with iran unshackle an important aspect of u.s. diplomacy in the middle east, enable us as i suggested earlier to do business with

anyone labeled as an adversary or an ally where it serves our own interests. and the fact is the iranians are major players in a lot of places of high concern to us, even where we wish they weren't like syria. and there are other places where they are not only a major player, but their interests actually are quite parallel to ours in major respects, even though in other respects they would still conflict. i'm thinking of iraq. i'm thinking of afghanistan to go a little bit farther east, as areas where neither we nor the islamic republic have an interest in endless conflict and instability which is on their borders and not on ours. and finally, that kind of world in which we did have a more normal relationship with iran or we're edging closer to it, i'm not suggesting any embassies are going to be opened up in the foreseeable future, but it would bring us closer to a system where we had more flexibility and leverage in dealing with anyone else in the region who is

troublesome whether they're labeled as an ally or an adversary. thank you very much. [ applause ] >> dr. tarzi. >> thank you. thank you very much. i want to just put one caveat. unlike my esteemed colleagues, i still work for the united states government, and i will be speaking here wearing my fbi hat and not my marine corps hat, so whatever i say is amin tarzi speaking and not the defense department or any branch thereof. while i agree on some of the main points, the invasion of iraq. before i was a government person i wrote about the greatest strategic mistakes of our country's history and i still stick to that, and the iran issue but i will dwell on that

later. maybe i'm an idealist, maybe i just go to middle east too often, i'll be there in three days again, i do understand the fact that we should look at ad hoc avoiding the rocks and sailing straight but at the same time i think unlike any area in the world, you pick any area in this world, and that includes now even sub-saharan africa which at one point was not doing so well, there is no place that has the problems that middle east has. people are talking about even why. this has been going on for a long time. it's not new. the psyche of the arabs and the muslim problem, is it colonialism, you name it. is it arab/israeli affairs. this has been going on for so long. students of middle east studied it last century literally, but the question that i have is that unless we address those in some form or fashion, i think we go from crisis to crisis.

it becomes more of a crisis management rather than trying to at least find a way as a reliable partner, not that the united states can fix everything. i don't believe in that. i am a former marine. i think everybody thinks that we can fix everything. i tell you we cannot fix everything. but as we heard before, yes, we are a partner. yes, we have interests there for the foreseeable future despite fracking and all that that we need to be in that region, and the interests are interwoven with other countries in the region as well. so i think a little bit of consistency is important. when you talk to colleagues in the region, they are confused. the word i get, if we are putting a policy forward to confuse them as part of an implementation of a policy, we are doing a fantastic job. friend and foe are confused to the point they have no idea what to do anymore, and in my view

where the leadership of our country is no longer -- and maybe that's not a bad thing, we are no longer a unilateral situation right after the cold war where the united states was the sole power by all means, and there are rising powers, and that kind of environment if you don't have a reliable partner as still the most strongest power in the world, still as the most looked up to power, then you have a state where i think the middle east will be. we have to avoid rocks, if i may use that cliche, rather than have some smooth sailing at one point to have some predictability, and i think if you talk about the foreign policy of president obama, if i think -- again, you may say after the first two speakers that i am very ideological. one of the issues that i look at and say we have made not only

inconsistencies but we actually have made the situation worse is let's say the promotion of democracy. this is not new in the united states, promotion of democracy came in, but when you look at the numbers, at the fiscal year 2009, the united states put more money on democracy than the entire decade between 1991 to 2001. so we spent more money in one year than the entire ten years. but look at the outcome. look at the input and the outcome. if you put this in a mathematical format or an investment, you say this was an amazing loss. and the other aspect is do we -- are we looking for partners in the region beyond these temporary ad hoc friends or foes for that matter, iran is now, i agree, bopartially. are we looking at something that is a bit more stable. again, is it possible? yes. look at latin america a few

years ago and look at what's happening. they're not all friendly. we have the bolivias of the world and venezuelas, but there's still a process that is a much better process to deal with than what we have in the middle east. i'm not saying democracy is the panacea of all of this, but the inconsistencies that we have had with democracy going back to the cairo speech 2009, then the speech at 2010 with first west point speech, and what has happened afterwards post-arab uprisings, if you want to call it spring. i like spring a little better than what's going on there, but with the exception of tu nae sha, that is one exception, it's struggling but it's still an exception, things have gotten worse in every case if you look at it as a "new york times" a while ago an editorial called egypt exhibit a, and failing to support a democratic movement. even we called the ouster of morsi, not that morsi was any

great person, the restoration of democracy. if that goes on and if year looking at the basic idea of this new generation coming in whether it be in afghanistan in the east or all the way to morocco in the west, where are they going to look at because it becomes almost -- in the cold war we always stated that, you know, we have supported regimes because of security or, you know, regimes are against communism and later on after 9/11 who were against terrorism and we have lost on democracy and supporting -- and gaining these allies for long term. i think we have to have a balance of expedient, ad hoc missing the dangers in front of us, but also have a vision and balance it. you always have to have a balance. i agree policy has to be a balanced policy. i think when you look at the

past few years, that is the missing issue. when you sit down, as i said, and talk to either the military side or the civilian side or -- i'm not even talking about grass root, there is an utter -- a lot of regions there blame everything on the united states, including the weather condition. i have gotten used to that, but that's not what i'm talking about. there are fundamental issues they look at, and they look where are you 1257ndistanding o? if we removed every president because they mismanaged it and called them a terrorist, the world will be without leaders. i'm not saying morsi was a good president but the events that went on there was very, very in the face of this democratic movement. now, i would use the remaining time if i could on two countries, iran and i go all the way to the eastern and touch a little bit on afghanistan as i was asked.

i agree that an agreement with iran, and again i'm speaking on my own behalf, an agreement on iran is a wonderful thing. an agreement whereby iran stops using or stops trying to procure nuclear weapons. that is a great thing and it's applaudable. it is wonderful. nobody is against that, at least i am not. the question i want to ask, and this is something that we for t forget, that iranians, why they were pursuing a nuclear potential, if anybody thinks they were not pursuing a weapons, i would argue against that. they were. at least they were trying to tell us that they were. that's the whole thing. if they weren't, they were going a great job of telling the outside world they were trying to get a weapons system. why they went through basically mortgaging their country and coming very close to having themselves be targeted either by

us or by some other regional states, but yet in the same time they went through all of that. why? this is a question. to my view there's only one answer. the iranians fundamentally did and still do even after president obama's u.n. general assembly speech of last september where he said the united states was not interested in regime change but change of behavior, the iranians by and large, that includes ayatollah and includes also the smiling mr. rouhani believed the united states objective is regime change and not behavior change. and they also believe, and this is where i become worried as somebody who once in my past life dealt with nonproliferation. they believe that fundamentally having or pursuing weapons of mass destruction, nuclear weapons specifically, will alter america's activities towards

you. and here we have iran, a country that is one of four countries that the state department recognizes as state upon sers of terrorists, only four of them. the oldest before cuba, '84 i believe. human rights just did a report about them or what comes out of this building. yet they sit down with the six top leaders of the world, four top democracies, two of them are not democracies, but you know china and russia excluded. why are they there? how did they get that seat at the table? because they are nice guys? no. because they cheated and they're being rerewarded, and they may t to keep their regime, a regime that kills more people today than ahmadinejad did, and this is where we need to look at, yes, it's an expedient, it's a great thing to do. the question is why iran was going for nuclear and why are they delaying it? who is rouhani?

mr. rouhani is ni a regime savior. rouhani is there for one specific issue. the regime was hurting from within. number one, there was a structural problem. the whole aspect of the rule of the jurisprudence which is the basis of the iranian regime was crumbling mainly because the ayatollah's support of ahmadinejad where he became part of politics. secondly the sanctions were working. there was a lot of things that made the sanctions work, and here we have to praise the president's policies. the coalition building, the fact that ahmadinejad was so easy to go against calling the holocaust is fable, saying that we're going to destroy everybody. it was easy to dislike him.

rouhani is sending greetings to jews around the world in his twitter, but the aspect is this man -- i am not saying iran is goin raasch rashashanah greetings. i don't think they will invade anybody. however, the aspect is not that iran has just become a good guy. this is what somebody said before. we have to be looking -- let's say tomorrow at november this year, we have a solution. we have an agreement. then what? does that's include iran will have delivery systems? the question will be why. i cannot say that anybody who talks about their missiles or any other platforms is idiotic and crazy. so if a country is building weapons that only are usable for delivery of specific type of warhead, i.e., nuclear warhead,

why are they having it? we have to balance this. and the second thing is that some people say iran with nuclear weapons will become a domino effect. i will even tell you if iran gets an amazing deal, that will push a lot of countries in the region. i think it involves united states policy towards them. and they are always -- khomeini keeps pointing at libya. he always says that. he's quoted that a few times. look, after gadhafi was killed. look at you fool. the westerners gave you something, and then they killed you like a dog. so this is the idea -- the promotion of nuclear weapons as something that gets your seat at the table with the big boys. i think it is dangerous and it's going to bite us you know where if we don't follow it. and another line on syria. i believe that the chemical weapons use and then the agreement which in itself is

good. please, don't get me wrong. has given bashar al assad the lifeline. in a way he may have saved his regime by using chemical weapons. this is a dangerous precedent. if we don't take leadership on it, i don't believe in iran being attacked at all. please, all i have to say is that because of an ed pedeient agreement that could be nice because of whatever, i'm not going to go there because i want to keep my job. because of that, we have to make sure we have an agreement that is solid and that does not portray us as somebody that comes in because it's what's expedient at the moment. afghanistan became a -- it's the longest war we've ever fought inner history. in the history of the united states, that's the longest war. 80 something countries tried to democratize this country. we can discuss its merits, good

or bad, constitutional, good or bad. the question is right now, there was an election in april that was applauded. we all looked at least with one place, things are going a little bit further in a good way. the elections were actually pretty open. fingers were cut and all that, but people actually -- great. well, nobody -- doesn't matter who, nobody wanted 50% plus one vote. so we went back to square one. the second time it was pretty much everybody agrees it was a very fraudulent election. secretary kerry did a miracle to at least have them talk. but we speak today as nobody has agreed an the mechanics of what -- how you count these votes. so, yes there was an agreement as an expedeience issue but the details were missing. i think for the last ten years or so what we have done is built

these villages, these walls that look very good, but they have no foundation. and all i'm saying is if we are not careful, they look good for picture taking and send them back home, but if you aren't careful, these walls will fall and sometimes they fall not only on intended people but they fall on something bigger. thank you very much. >> thank you. i think those were three very interesting and stimulating presentations. a while back, the united states set out to reconfigure the middle east. and the result is the region and our position in it are both in shambles. much of what has happened seems irreversible. in the short time allotted to me, i just want to talk about the region's dynamics and i'll conclude with a few thoughts

about what might be done but probably won't be. to begin, if we're at all honest, we must admit the deplorable state of affairs in the middle east, in egypt, iraq, israel, jordan, lebanon, palestine, syria, the persian gulf and arabian peninsula and libya, afghanistan. it's a product not only of the dynamics of the region, but also of a lapse in our capacity to think and act strategically. we have answered the end of the bipolar cold war order with a mixture of denial, strategic incoherence and inconstancy. false american assumptions and unrealistic objectives have helped create the current mess in the middle east. it's not news to anybody that american politics is uncivil and dysfunctional.

we have a foreign policy that has its head up its media bubble. prefers narratives to analysis. and imagines that the best way to deal with hateful foreigners is to use airborne robots to kill them, their friends and their families. we have leaders who can't lead. and a legislature that can't legislate. in short, we have a government that can't make relevant decisions, fund their implementation and list allies to support them or see them through. until we get our act together at home, those looking for american leadership abroad will be disappointed. at west point, president obama accurately pointed out that our military has no pier. he then sensibly added that,

quote, u.s. military actions cannot be the only or even primary ona of our leader. every instance. just because we have the best hammer does not mean that every problem is a nail. true enough. experience is justified hesitancy about the use of force. our hammer blows in the middle east were intended to showcase our power. instead, they convincingly demonstrated its limitations. these interventions worsened, not improved the region's stability, politics and prospects. our unmatched military prowess has not enabled us to impose our will in west asia and north africa, eastern europe or elsewhere. the record of covert action in solving political problems in all of these regions has been no better. the question then is, what alternatives to the military

hammer and related kinetic instrument does the u.s. presidency now have? normally, the answer would be the political screwdriver of diplomacy or other nonpercussive means such as subsidies and subventions. but there's a reason the department of state is the smallest and weakest executive department of our government. the united states seldom goresos to diplomacy. gladiators trump diplomats any time. in terms of the spectacle they provide. even if they don't work, coercive measures like sanctions and bombing are much more immediately satisfying emotionally than the long slog of diplomacy. then aside from our reflexive militaryism, we're broke. our military commanders have walking around money, our

diplomats do not. and the amateurism inherent in the spoil system further reduces the effectiveness of our diplomacy. jet-propelled seat of the pants drop-byes with secretaries of state have proven to be no substitute for either strategy or the patient cultivation of influence with those leaders who are in their capitals. it's hard to think of any american project in the middle east that is not now at or near a dead end. this includes our policies toward israel and palestine, democracy promotion, egypt, islamist terrorism, stability in the fertile crescent, iran and the gulf. let me quickly run through that list. in april our four-decade long effort to broker a secure and accepted place for a jewish state in the middle east sputtered to a disgraceful end.

in the tragic comic final phase of the so-called peace process, instead of mediating, the united states negotiated with israel in terms of palestinian capitulation. not with the palestinians about self-determination. the u.s. effort to broker peace for israel is now not just dead but so putrid, it isn't fit to show at a wake. israel didn't believe in it, so it killed it. may it rest in peace. from the outset, israel used the peace process as a distraction while it created facts on the ground in the form of illegal settlements. israeli expansionism and related policies have now made israel's peaceful co-existence with the palestinians and israel's arab neighbors impossible. the united states created the moral hazard that enabled israel to put itself in this ultimately