there's a belief that something will materialize that allows them to pay for this. it will be something and done slap dash right before they leave. >> a lot of hearings. walk us through what's going on in the senate and house. >> i don't have my list of hearings in front of me. i know the big one that's coming this week for sure is the veterans committee where they will be having a new confirmation for the new secretary. that will be closely watched to see how the new leadership team can carry out matters in the wake of the scandal going on there. that will be closely watched. beyond that you said you have a list in front of you. we will be covering the senate finance committee. looking at the u.s. tax code.

the house and senate taking up a hearing on u.s. policy in iraq. iraq continues to be a big concern in addition to the other conflicts. i know there were some concerns over the webbing end with jordan and iraq' situation with them. >> beyond hearings and there are -- not that i have my list in front of me. beyond hearings i think again the probably one of the markka one twz of the webbing. we will have to keep watching for reactions in russia and ukraine and the middle east.

at some point i think we will see calls for the u.s. to help ukraine ukraine. as i scan this hearing list, there is at least in the senate -- it specks to a lack of accountability. accountability. they are also looking at flood insurance issues but appropriations was supposed to be big success of the month. that there was going to be big deals done before the recess happens. >> we may get some sense this week whether it will move at

all. >> i just want to get your reaction to your colleague who was a story this morning leadership war stimies the mission. senators say they are increasingly felling like upons catch between the democratic and republican leader. the senate going for three months this spring without voting on a single legislative a amendment. >> this isn't even a partisan issue versus republican anymore. it has become a reed versus mcon el mconle issue. reed very sensitive to do anything that happens mcon el's

re-election campaign. the fact that these two men cannot sit in a room together and tack to each other. the fact that at times he will ask a helper to talk to reed. >> ed quick sidebar note because you posted this story late last week but the press secretary for congressman moreno of pennsylvania put on unpaid leave bringing a smith and weson gun inside the office. what happened. >> as far as we know he walked into the canon house building on friday. he had his magazine or clip in a

bag. they were apart from each other. it was the acommunition climmmunition clip. they pulled him aside and arrested him because it is against federal law and there are restrictions on with a you can carry in the district of columbia. i was told that it was a mistake. that he didn't mean to bring this with him. this stuff happens all the time not only at the capital but other places as well. he spent one night in the jail and remains on unpaid leave as the investigation continues. >> ed oe keith thanks for setting up the lead for us. >> associated correspondent matthew lee joins us to discuss

the palestine conflict. we'll talk with ed bingle a former customs and border protection official but minors crossing the border. piece c piece. every morning on cspan at 7:00 eastern. >> president obama on monday awarded the medal of honor to formal active duty sergeant ryan pits. he held off the taliban during an attack on his unit. he the ninth recipient to be

award ed awarded for the war in iraq or afghanistan. >> he is of the chosen few to receive this honor today as the nation pauses to recognize him. our hearts are touched by staff sergeant ryan pits. he humbly insisted that his remarkable actions were simply was his duty it will always be on his loyalty to his unit. we acknowledge that devotion came from a faithful family who prayed for and supported him. we join our hearts together as we honor him today. we honor the courage and

commitment of all who serve in harms way. this we pray in your holy same, amen. >> good afternoon everybody. welcome to the white house. please be seated. please be seated. forces in afghanistan, the battle of wanat was one of the most fierce of this entire war. 48 americans, along with their afghan partners were manning their small base deep in a valley when they were attacked by some 200 insurgents.

soon, under the relentless fire all nine of these men were wounded or owe killed. insurgents broke through the wire. medal post was on thefalling. against that onslaught, one american held the line. just 22 years old, nearly surrounded. bloodied the soldier we recognize today with our nation's highest millary declaration. the medal of honor. staff sergeant ryan pits. i don't want to embarrass ryan but the character he dismayed was cheerily forged early. >> when he was in fifth grade

his teacher sent home a note who saying ryan is a very special human being. you see the loyalty that defines america's men in uniform. he says it's not mine alone. it belongs everybody there that day because we did it together. i want to welcome those who were there that day or those who will be welcoming him into their ranks. we are very proud of them. we welcome ryan's family many from new hampshire including his wonderful wife amy. i have to tick a pause because they are actually celebrating their second anniversary today.

as ryan put it it will be tough topping this one as anniversaries go. let me give you a piece of advice from someone married over 20 years, you should try. i'm just saying don't rest after just two years. >> we welcome their gorgeous son one one-year-old lucas. of course the red sox and bruins and the pats. i want you to try to imagine the circumstances in which rye april and his team served. this was 2008 wrm our troops were deployed. they had just arrived in wana just days before.

they still building a small base. wanat one report later included that it had significant vulnerabilities. >> parts of village sat on higher ground. >> every heavy equipment was delayed. in 100 degree heat they ran out of water. early that morning in the predawn darkness they spotted several men at the mountains. before ryan and his team could take action the entire valley erupted. machine gun fire poured down from every direction. the insurge entnts were firing from trees and valleys.

it was hell on earth. up at their post ryan and his team were being pounded. almost instantly every one of them was wounded. he was hit by shrapnel in the league. if as the insurgents moved in ryan picked up a grenade and pulled the pin and held them back again and again. unable to stand ryan pulled himself up on his knees and mans a machine gun. soldiers below made a daring run dodging skploes explosions. eight american soldiers had now fallen and ryan pits was the

only living soldier at that post. the enemy was so close he could hear their voices up close. i was going to die and made my piece with it. bleeding and barely conscious. one insurgent was now right on top of the post shooting down until another team of americans showed up and drove him back. as one of his teammates said had it not been for ryan pits, that post would have been overrun. even with reenforcements that battle was not over. nine americans were now gone. still the fighting raged. ryan worked the radio helping to target the air strikes that were

hitting. the tide began to turn. eventually the insurgents fell back. ryan and his fellow soldiers had held their ground. this medal ryan says is an opportunity to tell our storiment there was valor everywhere so today we also play tribute to all who served with such value that day shielding their wounded buddies with their own bodies. running through the gun fire to reinforce that post. fieging through their injuries and never giving up. helicopters and crews who came under 5y rain. never in my career have i seep such bravery and sacrifice. i want those who served that day

to please stand. [ applause ] >> most of all ryan says he considers this a memorial for the guys who did not come home. today we honor the nine american soldiers who made sacrifices for us all. the expected father whose dream would later come true. specialist sergio abad. the boy who dominated the soccer fields. fell in love with motor cycles and there in that outpost took a

direct hit in the helmet and kept fighting. the photographer whose pictures and wrote afghanistan is exactly where i wanted to be. >> the father who loved surfing with his son. first lieutenant. an immigrant from mexico who became a proud american soldier whose final thoughts were of his beloved wife lessly. a man of faith who could always get a laugh out of his commander. the husband who wouldn't wait to opinioning an uncle. the adventure corporal matthew

phillips. the big guy with a big heart whew best was cleaning up at the poker table with his dad and buddies. the youngest just 20 years old, the little brother of the platoon who loved to play guitar corporal gunner swilling. these american patriots live to serve us all. their hearts live on in the hearts of those who live them still. brothers and sisters,s sons and daughters. to you they are families but please know this nation will honor your soldiers now and forever. i would ask the gold star families to please stand. please stand.

[ applause ] >> this is the story ryan wants us to remember. soldiers who lived each other like brothers and who fought for each other. families who made a sacrifice that our nation must never forget. ryan says, i think we owe it to them to live lives worthy of their sacrifice. as commander in chief i think one of the ways we can do that is heeding the lessons of that battle when this nation sends

our troops into harms way they deserve a if well defined mission and serve the support to get the job done. that's why we owe soldiers like ryan and the comrades who were lost that's how we can truly honor those who gave their live that's day. as how as a nation we can remain worthy of their sacrifice. i know that's shared by our secretary of defense and joint chiefs of staff. it is remarkable that we have young men serving nur military who die in die out are able to perform with so much integrity, so much humility and och courage.

ryan represents the very best of that tradition. we are proud of them as they are of you. god bless you ryan. may god continue to bless the united states of america. with that, i would like our military aid to please complete the ceremony. >> the president of the united states of america authored by acts of congress march 3rd 1863 has awarded in the name of congress, the medal of honor to sergeant ryan m. pits, united states army for conspeck uous gallant ri and risking his life above and beyond the call of duty. he distinguished himself by

extraordinary acts of heroism beyond the call of duty. chosen company second battalion air born. 503 air regiment in the vicinity of wanar village on july 13th 2008. early that morning while he was providing perimeter security a well organized anti-afghan force consisting by over 200 members ip ish initiated a complex assault using rocket propelled grenade, machine gun and small arms fire on the base. in a immediate prepare of rounds engulfed the observation

post. he had been knocked to the ground and was bleeding from slap they will wounds to his arms and legs. he subsequently took control of the observation post and returned fire on the enemy. as they grew nearer, he threw grenades to allow a immediately detonation on the hostile forces. unable to stand on his own and near death sergeant pits continued to lay suppressive fire into a two men reinforcement team arrived. he assisted them by gaernling up his main weapon. at this point sergeant pits crawled to the radio and described the situation to the command post as the enemy tried to isolate the observation post

from the control post. with total disregard for his own life. sergeant pit it's whispered in a radio information report sergeant pits courage and stead fast commitment to the defense of his unit prevented the enemy from overrunning the osksbservation most. sergeant ryan m. pits extraordinary heroism and selflessness are in keeping with the highest traditions of military service. second battalion air born 503 infantry regiment 173rd brigade in the united states army.

[ applause ] [ applause ] >> that's not bad to stand up on this one. >> let us pray.

god we knew in our hearts and faith in you to live with humility, confidence. sergeant pits exemplary service bravery and devotion. may our nation remain strong and safe. a free land. may soldiers defend her even today. regardless we might remain worthy of our trust and respect even as they remain faithful in their service. all of this we pray in your blessed and holy name. amen. >> well that includes the official part of the ceremony but we still have a big anniversary party. the white house i understand has prepared some pretty good edibles some befr anlverages.

i hope everybody enjoys the reception. i want to thank you and the families of those who serve. you make us proud everyday. we wish you all the best because what an extraordinary family you have. the pleasures of family were hard earned by this family. thank you very much everybody. god bless you. god bless america. [ applause ] some live events to tell you about here on cspan three. at 9:45 a.m. eastern the senate finance committee holds a hearing to examine the u.s. tax code. witnesses will include economist and the treasury department's

deputy secretary for tax reforms. the confirmation mr. mcdonald will be before the senate finance committee at 3:00 p.m. eastern. next the british ambassador to the u.s. talks about nato and transatlantic security issues. the ambassador also spoke about the recent downing of malaysia airlines flight. this is one hour. >> welcome. this is a special event. it's a pleasure to have the

british ambassador here to talk about nato and the changing face of transatlantic security. it could not have come at a more timely quick. he became the ambassador to the u.s. in january of 2012. this is his second posting this washington. he was previously the mc's downs lore for public and private apairs. prior tore that was ambassador to turkey starting in 2002. peter his career in the diplomatic service have included postings in toronto there's a lot more to it. it's just too distinguished for

me. let's welcome the ambassador. don't forget you can follow online as twitter as well. #def1live. if you want to get to more questions. [ applause ] >> thank you. thanks jimmy. thank you so much. thank you all very much for copping down this afternoon it is quite a time will me emt. i think as we survey the rather dramatic events going around world recently it's important to talk about the human dynamic going on and to remember the people who lost their lives when theed airplane was shot down

last week. people are dying in gaza. all types of things are not in the headlines that are bigger issues. >> in my introduction how many important an vrsaries there are going on. what a hiftor rick time it is. it's 200 years since the end of the last conflict between britain and the united states. the beginning of the closest military alliance we've ever seen. seven decades since the trauma and heroism of the d-day landings. twooif years since the falling of the berlin wall. >> 70 years ago this week british and american forces were embroiled in heavy fighting

around a french town as they battled to break out of a normandy breach head. those landings involved 175,000 british service men fighting across their u.s. comrades. the brits and americans joined by canadians, new zu landealanderszealanders, dutch, it was a partnership to defeat fascism. after the war britain were instrumental in the creation of nato which has proved vital in facing down soviet aggression. the fall of the berlin wall 25 years ago as i was saying this november marked the beginning of

soef yoet dom. britain and america have come together again and again to lead coalitions in national security. as we did on land in the balkans and the sea of the horn of africa and the skies over libya. the september 11 attacks sparked the alliances longest mission to date in afghanistan and throughout nato's military operations, british and u.s. personnel made up the two largest contingents fighting in afghanistan. today we face fresh challenges. the contours of the conflict in gaza are depressingly familiar.

it doesn't lessen the urgency of finding a resolution. of course israel has a right to defend itself against the rocket attacks but we believe it does it appropriately to take on measures measures to keep the loss of civilian life. i'm very pleased this morning john kerry is on his way back to the region to see if he can deliver that objective. in other parts the world the nature of the challenges is changing constantly almost by the day. in ukraine we find ourselves in new and dangerous territory. the shooting down of a civilian airline is an intolerable out rage. it's being compounded by russian separatists to block access to

the crash site. tragically others are still on the side of the accident of the crash. >> the separatists grant immediate access to the side so those who are still there can be identified and it areturned to their families f. owe the international community can have the facts behind whose responsible for this atroegs crime. those who took the lives 298 lives can be held responsible for their actions. it looks like it was fired from a separatist controlled area of eastern ukraine. whatever the outcome of the investigation, it's already clear that russia has fermented a conflict. president putin has the power to bring an edge to the bloodshed. we believe he must do you so without delay. the eyes of the world are behind

him. today's threats come from regional terism, cyber attacks and so on. some states seek to use the cyber domain. increasing we're seeing threats from nonstate actors. none can no longer be seen as fringe groups. al qaeda's core has been deteriorated. we can't dismiss the challenge these developments pose to our national security because the rise of isis threatens to destabilize the region. we can add a third grouping. we might call them quasi state

actors. we see them in ukraine. this should be a source of american for all countries. any threat to the principal of national sovereign nations. first we've got to look to stop the conflicts before they occur. whether we like it or not, that requires some discreet intelligence gathering sometimes necessarily secret sow that we can find terrorisms before they kill innocent people not afterwards. another is our efforts to remedy the societial ills. this is aimed at changing the

culture of impunity for those who commit these terrible acts. smams we have sometimes we have to take a firmer line. until the kremlin decides to bring an end to this conflict nato will have to continue to take action to reassure its partners. we will continue to ratchet up sanctions and continue towe must remember economically russia needs the west at least as much as we do russia. real sanctions can have real bite. the uk has pushed for international piece and national security. meanwhile, we will carry on working through the mf to help

stabilize ukraine's economy and through the osce to monitor conditions on the ground. >> through sanctions diplomacy, negotiation, we've made progress and enough to make extending the negotiations for another four months. these are good examples of handling problems without force. it's clear that each time our efforts to keep arm forces. our militaries must be nimble and flexible. we brits are investing heavily

in new capabilities to make our equipment fit for purpose. working more seamlessly with our american allies. we're upgreating to more traditional war capabilities. we will be spending $250 billion in the next two years. david cameron announced a 1 $1/2 billion in surveillance and intelligent capabilities. >> over the next few years we have a rejuvenated air craft carriers and a fleet of f fighters to fly from them. a couple of months ago i visited the queen elizabeth with my american counterpart in jumpsuits and goggles.

the queen elizabeth ceremony with her majesty, and our most most capability is our fighting men and women. our troops we believe remain among the pest in the world. we ask a lot of them and they deliver year in year out to an it a astonishing high level. with so many people now returning from afghanistan, we've got to take more seriously than ever the pastural obligations that we have toward veterans and their families. we're funding projects like homes for veterans and mental health lines for personnel and their families. just after the nato submit in

south wails, london will host the games for wounded warriors in the u.s./uk for a dozen countries. it will be a major celebration of their troops from and their major why major major celebrations. >> in his recent speech at west point president obama emphasized the importance of partnerships. weigh gree with him. for as good as our efforts may be they will fall short. britain seeks partnerships beyond for example. we have strong historical ties with hong kong and australia and

new zealand and singapore. where i should add even the smallest contact is valuable because it does lessen the risk of miscommunication or miscalculation in a region where territorial pursuits exists even as military powers mature. these are at. it's in evaneryone's tre to try to stabilize the nations before they become a great threat. libya is an example of a state that we can't afford to let slide into anarchy. the g 8 agreed to train more than 7,000 militias to reintegrate them in society. there's another efforts to help

libya, the uk is playing a major role elsewhere. we've got experts within the eu's trading mission in molly. with other governments we're actively engaged in training un peace keepers for stabilizing missions around the world. the most important partnerships however are those we enjoy with our close allies. with the u.s. cooperation has become routine almost operation. we've joined to the hip but it does not stop there. across our arounded forces we enjoy a unique level of integration. hundreds are positioned in the united states along with their

american comrades. the same is true the other way around with u.s. personnel in the uk. as we approach the end of combat operations in afghanistan. we're also looking seriously when we no longer have to fight side by side. last month the joint chiefs met their mettish equivalents where peace was at the top of the agenda. we're developing a combined joint expeditionary force with france which we expect to be fully operational to 2069. which brings me to the nato summit in october. just a few months ago we were asked why we even need a summit.

well in one is saying that anymore. on the contrary, there's pretty much universal acceptness of the importance of the alliance today and in the past p. the summit will focus on threats rent and tuture and will resolve around three key things. first afghanistan. afghanistan today is not perfect but it is far from the terrorist launchpad it was back in 201. afghan troops are providing security across the country. unprecedented numbers of girls are going to school. 40% of afghans use mobile phones. none of this would have been even thinkable under the taliban. all of it contributes to a afghanistan that is for more secure today than any time since

the taliban took the turn out in afghanistan's residential elections showed that afghanistans wanted a constitutional peaceful transfer of power which we hope leads to the formation of a government of national unit. nato will go on supporting afghanistan. thanks to the pledges we made two years ago in chicago the funding is there. second seem for the summit is going to be european security and the longer term implications implications. we have hybrid warfare that russia has been engaging in.

crucially we must consider how to further deter russian aggression. last week's events underscore how urgent the situation is becoming. >> finally we will be able to future proof the alliance. we need to make sure nato has everything we need. as well as modernization, we needed to develop than that. a system in which allies share the burden of security by pooling resources in a coordinated manner. clearly this requires all allies to pull their weight that includes states that's spending falls below 2% of gdp. we believe that security is well worth the price tag.

of one of only four countries to have met the nato target. we will continue nato's efforts to building the largest partnership. almost half of the nation's participating in afghanistan. we owe it to them to look for new ways of integrating them into the alliance decision making process. nato acted as a deterrent against depression but the alliance needs to know hae it can be equally effective in its new role as an active player on a constantly changing global security change. together the united states and europe have played a leading

role in designing international system since the world war. the system has been a great prosperous than ever before. more countries are democratic than ever before. around the globe more and more societies are emerging from poverty. at the same time security picture is more complex that at any time in recent memory. the brits, americans and other who landed in normandy 70 years ago did so to combat a clear unified state-based anniversary. the next two generations face similarly ugly threat. today, it's far more fragmented and complex. not only nation states but also terrorists, extremists, insurgents, all pose a threat to our national security. to deal with it we need strong traditional military, and we're working to achieve that, as i have been trying to explain. we also need a subtle array of

alternatives. we need hard power and soft power, we need intelligence democracy, sanctions. we need development and military partnerships. nato is the world's preeminent alliance but again adapts to new realities as it has done over the last quarter century. i'm confident that come september, come the nato summit in south wales world leaders will be able to show that nato remains strong united, ready to meet and defeat any threat. as we continue to adapt we could do a lot worse than bear in mind the important words of abraham lincoln who wrote 150 years ago the struggle today is not all together of today. it's also for the vast future. thank you very much for your attention. [ applause ] and for your applause. i'm very happy now to look forward to sitting down with you and discussing your questions and discussing whatever else you want to raise.

>> thank you. you have no idea what just happened. excellent address, and raised lot of good points and sets up an interesting and complex landscape, and i want to go through a lot of them including the state of affairs and debate in britain right now about defense and the military. relationship to the u.s. nato but where to start? i think defense one, we discuss the future of military power. and what comes next where we're going. and part of that big question right now is the use of power, the limits of it, and the purposes of our militaries. that's a debate going on in this country. i know in the united kingdom, there is a new kind of recommitment to a future with a major funding announcement, as

you said. explain to us and the viewers a little bit about the background there of the debate in britain of how much to spend what kind of military to have, and how it should be used. >> i think in the u.k. we are very conscious about nato is a very precious alliance, but it is not reasonable to expect the united states to continue to bear more than its fair share of the costs. when i last looked at the numbers, it was something like 75% of the cost of nato fell to the united states. we believe the other partners have to do their bit as well. that's why we're firm believers in the target of 2% of gdp from each member of the alienls in order to assure that we are pulling our weight. united kingdom is somewhat above that figure at the moment. there are not many of our european partners who are. as i mentioned in my remarks we believe just four countries. so it's very important in terms

of equality of burden sharing, but it is also very important in terms of capabilities. and it's not just about what is the amount of money you spend. it's what you do with it. it is, are you willing to use the equipment you've got? and it's asking yourself to question of whether the equipment you've got for your brave fighting men and women of the armed services is the right stuff to deal with the current or future threats. of course, it's a long lead time with military equipment you design and manufacture, and threats have a nasty habit of evolving very rapidly, more quickly than we sometimes can do in terms of design and manufacture. nevertheless nevertheless, we believe it's important to keep an eye on what the threats are, what to do with them, and what we can expect to do. hence, what i said about having a 10000 deployment capeability we can sustain. hence the reason to project a long way from home. two new 60,000 ton aircraft

carriers, both under construction. one recently launched, one to be completed soon. together with state of the art f-35s, and a whole bunch of other cutting-edge technologies are an indication of what we believe we need to do. we were maintain our territory. we will spend more on cyber defenses. we will spend more on new technologies in a number of different areas. so we're trying to insure that what we do is not just fair burden sharing but it's also relevant and capable in terms of a threat that lies ahead. we believe that's an important part of the debate at home for nato not just on the u.k., so that's why it's on the agenda for the summit that will be taking place. >> you mentioned the capability capabilities and the f-35s. are you so sure about the f-35s? they just made a no show, and they're constantly delayed. is there a plan b for your country, as has been discussed in this country for carriers

that need aircraft that can launch off them? >> we won't be disappointed that we didn't have the f-35 at two air shows in the u.k. last week. it was because there was an engine fire in one of those aircraft. new products, unfortunately, have troubles, but i have to say that we remain confident in the product, convinced that it's what we need, proud of the partnership the u.k. has with the united states as a pretty much prime contractor in this project, and we're sure to come out in the end. we're a bit concerned some people talk about the price. we would like, of course, the best possible value for money but we're absolutely not wavering in our commitment to this aircraft. >> you mentioned burden sharing. this is high-end capabilities committing to the nuclear deterrents. in a world where we have these low-end threats, as you also describe. how has either the budget or what's happening now with russia

changed either great britain and nato's commitment to both defending the homeland of europe farther out from its actual borders or changed its calculus of how far around the world the united kingdom can be or should be involved in global security? >> i think one of the results of what's been going on in ukraine lately has been a reconfirmation, if you like, within the alliance of the importance of the commitments we have given each other and in particular of the commitment of article 5. article 5, which means that an armed attack against one is an armed attack against all. it's only been used once i think, in afghanistan in the context of 9/11, but it is there. it is a commitment, and because of its importance, we have seen a number of rotations and deployments of nato armed capabilities into some of the nato countries which are closer

to ukraine. we have reminded people through reassurance programs of the importance of the alliance and of the seriousness with which we take our commitments. we have also been trying to engage with non-nato partners to try to insure them we care about their security as well. we need to be clear that article 5 applies to nato allies and not others, and that's one reason why the united states government, my own government have made clear in terms of dealing with ukraine we need to look at a number of different means of insuring that our security is protected that what's been going on in ukraine is regarded as unacceptable and there is a price to pay for what the russians have been up to but which stops short of military deployment, boots on the ground in non-nato countries. that's not on the agenda, but we have to include some of the things i mentioned of different policy responses. >> isn't that the criticism of

ukraine, simply because there is no article 5 requiring it ukraine is going to suffer? that even with an airplane shootdown, what really can the west do or is the west willing to do? you mentioned eded holding them accountable. is accountability going to be stronger sanctions with every one of these events there seems there's more and more of a clamor for actual military response, a strike, some sort of punishment, some show of force. >> i believe i heard the president say when he spoke to president putin late last week, there was a strong complaint about the sanctions which had been ratcheted up by the united states last week. it's much more than possible probable in the event that the russians do not change their tack. the president does not meet the requirements which have been spelled out by the president and my own prime minister, by a number of people in the last few days, that there will be further

pressure through sanctions and other measures. there are already a lot of individuals and entities on the sanction list. more can be done in different sectors. we think it is not reasonable that a russia which destabilizes its next door neighbor in the way it has been in ukraine should continue to have access to high technology and finance and financial services and the means to maximize its energy resources, for example, on all of which it depends on the west, without being any response from us to say, no, we're not prepared to play that game if you're going to carry on behaving in this unacceptable way. there are a number of leavers we have, we are by no means at the end of the road and i think one of the consequences of the terrible event of the shooting down of the malaysian airlines aircraft is a number of european governments which have been a little wary of going down the sanctions route will now be more robust. >> i want to remind everybody watching, we'll get to questions

shortly from the viewers and from here in the room. we'll pass around a microphone. on european collective defense you mentioned the 2% number again, which is one we have heard for a long time now, and there's been a lot of succession of american defense secretaries that go to nato and usually in their final speech, wrap nato of the knuckles for not meeting that goal. it seems to me there's a divide here about what level of security for europe needs that washington thinks versus what european capitals either believe they need or are willing to spend. and that is if the europeans don't step up the number, that's either the 2% or the number that makes the pentagon happy either the pentagon is going to stay there and do the job for them or have to accept a lesser european defense. is there -- is there any real reason to believe that the other members of nato are going to reach that number, and is that

number even needed anymore or is this 2% thing a red herring by now? >> the 2% thing is an agreed target of the alliance. we think it has a value. we are proud of the fact that we exceed it. we would like to see our fellow members of the alliance do as much. as i said the business of insuring that nato is capable, fit for purpose, ready to respond, is not just about numbers and the amount of money you can spend. there are countries which spend quite a lot of money on defense but don't actually do anything with what they get for that money. so this is one reason why we want to have a really adult debate about this when the nato summit gets together in just under two months' time. we think it's important to look at all this. we feel in the light of recent developments european security has rarely been more important.

i know on television, senator feinstein, when asked when we're back in the cold war era, she said yes. >> do you believe that? >> well, i'm going to leave senator feinstein to speak for herself, but i think we are in new and dangerous territory. and i think one of the unhappy consequences of recent events is that we are now more and more focused on the importance of insuring that european security and mutual defense is robust and credible. so that's a debate we're going to have in south wales it's very important. >> let's move from nato into the middle east and israel. i guess we'll get into iraq after. in your remarks with lots of the other world leaders have mentioned frequently israel has its right to defend itself, yet calling for a proportionate response. does that mean you believe israel's response is not portionate? >> i think we are united with many other governments, including many, many people in

israel in being very distressed to see the number of civilian casualties in gaza rising above the 500 mark. this is a very high level. there are horrific stories each day of children in schools and cafes and so on children on the beach losing their lives. we would very much hope that this ground incursion comes to an end quickly. we would very much hope to see a cease-fire. that's why i'm very pleased to see secretary kerry on his way there at the moment to see whether he can build on the initiative that's been taken by the egyptians and see whether we can bring the fighting to a stop. >> is there -- in thinking of hamas, hezbollah and other groups, all the way into isis it's been on our minds, we have the u.s./mexican border as an existential crisis. you were talking about the

border. what's the difference between that and calling these groups flatty an existential threat to britain, to the united states, to nato? if they're an existential threat to order, is that enough to send troops to get military involved or realistically, are all our countries going to sit back in this defensive posture after the fatigue of the last 12 years of war and allow a lot of violence, a lot of destabilization, a lot of power control shifts to occur without real military-led types of reactions? >> the conclusions of these two very lengthy very costly conflicts, both of which lasted longer than the first or second world war in iraq and afghanistan, has been the public opinion has become very wary in most western democracies of the use of military action. people can see how you get into wars. they are not so good at seeing

how you get out of them. the question that we hear so much more often now than used to be the case is what's the exit strategy? or put another way, i can see how we get in there, but how can we be sure we're going to make things better rather than make things worse? and what about the cost at a time of considerable economic difficulty in many countries? i have seen estimates that iraq and afghanistan cost the american taxpayers between $5 trillion and $6 trillion. my own country has taken a lot of sacrifices as well, a lot of lives lost, a lot of blood and treasure. if you look at the polling in britain, france, the united states for example what does public opinion think about the use of military action the use of boots on the ground to deal with another country mfs internal turmoil even a humanitarian disaster let alone an existential threat to international order? people are wary. they have become more conscious about whether the use of armed force is necessarily the right

answer. they want to be very sure that it is going to make things better. sometimes it does. in the united kingdom for example, i went to sierra leone about three times in one of my previous responsibilities. there was a brief war, it lasted about six weeks, we were able to turn back a brutal campaign from a bunch of drug-crazed kids chopping off the arms and legs of civilians in that country restore a form of government and make things better. it isn't always that straightforward. sometimes it's more difficult. we need to be very sure before you're going to take military action that you're comfortable with the thought that there's a strategy there, a plan in place that means you will be able to go in and you will be able to come out and that you will be leaving things in better shape. and i think the answer to those questions are necessary for the public opinion increasingly sasing to governments we need you to be sure before you commit more blood and treasure. >> with that i'll open to question, and keep in mind the

thought of talking about a group going in leaving things better than they were than coming out is not something i think a military might be designed to do. these are instruments of destruction. we have been asking to do a lot of different things in the counter insurgency era. >> they need to be part of a strategy that makes sense. with other measures in place that do make a difference. at the same time as i was saying george shulschultz again democracy is not backed by use of force is ineffecttual, and we need to bear that in mind, too. >> in the room, we'll start. we have a microphone to pass around. i think we'll go up there to sir george. he's from our building. >> sir george? >> national journal. >> george condon national journal. mr. ambassador, if i can take you back to the summit you said the second theme of the summit would be how to deter further

aggression by russia, and just looking at the situation in ukraine, do you see the summit discussion as more planning for the future or assessing what has been done in ukraine and how the alliance could respond? >> i think we're talking about a bit of both. that is to say we want to have in place credible defense arrangements which mean that there is going to be no threat to members of the alliance. that is the fundamental purpose for which nato exists. but we're also conscious that we have got a broader responsibility, which goes outside of the territory of the member states, and that's why nato has been involved in many other places, including, as i mentioned, the balkans and the waters of somalia and so on trying to make things for the better. but i think also that unless we have a change of heart on the part of the crimea in the coming days and weeks, we're going to

have to be looking seriously at how we're going to deal with the specific issue of the way russia is treating its neighbors in europe. it will be a little bit of both. i don't want to anticipate in detail what heads will be saying to each other or indeed what the situation will be by the time we get to the beginning of september, but i suspect it will be a bit of both. >> from the department of state i have a question about kind of these two themes that often seem to reoccur in european security. one is the burden sharing between the united states and europe and wib europe, and the other is within europe, nato versus the eu you mentioned this new and dangerous territory, that might have impacts on the burden sharing debate. i'm curious what impact you think that this new environment might have on the respective roles of the european union and nato and european security.

>> thank you. the respective roles of europe and nato, as you know probably better than i, it's complicated. and it gets tied up in a number of different issues including questions of sovereignty and the question of how far and nato as opposed to the european union are responsible for collective defense. that said, we have got some pretty good examples of how the european union and nato have been working together. either offshore or onshore in trying to make a difference in africa, in the balkans, and in dealing with somali piracy for example. so we've got some good examples of working together, but from our point of view, we think it is important that we don't either undermine or dilute the nato command structures and the way the alliance functions by mixing things up too much. and it's important that we remain also clear where

competence falls defense policy lies, but i think as threats evolve, as the importance of working together becomes more and more apparent, the scope for the eu and for nato to work together will grow. it should grow. there are now increasing number of capabilities within both organizations, and there is also growing evidence of individual members of nato which are also members of eu doing stuff together. so i think that's an important area of future capability as well. >> youwhen it comes to the burden sharing, it's also inclusive of nato, but the u.s. is not thought of as part of that. is the u.s. helping in line with the burden sharing conversation or is it considered the u.s. is going to take care of itself no matter what. this is for the rest of the members sort out? >> well, the united states pays the share for a long way by the

moment. i don't think anyone thinks the united states should be doing more. but what the united states can do is engage with the rest of us in a number of different ways. one of the opinions that i happen to hold is that if we are to continue to persuade public opinion across the alliance that their valuable taxes should be spent on defense, that there's got to be an extent to which they see this contributing to their own industrial defense, employment prosperity objective. that is to say, if you're going to spend lots of money, it can't always be buying stuff from somebody else and where you've got a defense capability, where you've got defense industries of your own, it's got to be possible for those industries to be credible and to be able to sell elsewhere in the alienls. we need to have something more than a kind of two-way street, if you like, so we're not all buying off the shelf from one or

two suppliers and that everybody feels that there is something for the tax dollars, the tax euros, the tax pounds that we spend on defense, which also strengthens your own defense and industrial capabilities. that's important if you're going to keep public opinion firmly on board and believe it's a good use of public money. >> i like that. move on next. question here. >> harry blaney from the center for national policy and a former diplomat, served in nato. the question i'm asking is kind of a more difficult element focusing more on both nato and the ukraine and sanctions. today, prime minister cameron in the house of commons discussed basically three different levels of possible sanctions. on the so-called third level, which is sectorial sanctions he

mention ed mentioned that the problem that seemed to be at work is that europe, including britain, was not fave rblgorableeorable until now in support of the third tier particularly on the financial side of things which perhaps the city of london would have interest in. and there's a memo that some people have distributed about that issue. i was wondering in the larger sense that this relates to a subject you did not get a lot into. that is the membership with the eu. it seems to me that if one is going to have an influence on some very crucial decisions of both defense and security and economics, that britain within the eu would be more a stronger and a better voice and that

outside with possible decision zombies at some point and a more isolated britain might not be an example you have now going to the summit, including the eu will not have that influence, and that has an impact on your relationship with not only europe but also, i might add, with the united states. i would appreciate very much your thoughts about that. >> let me make two comments in reply. first of all, we very much recognize that if we are going to have to ratchet up sanctions in the direction of tier 3 or tier 2 or whatever you want to call it doing more, this is not going to be cost free. we know it's going to be difficult. we know that for us it will be difficult, for the financial service industry. we know the sum of our partners it will be more difficult if there's an arms embargo. we know for those with energy

technology or purchases will be painful, but my government, anyway, has taken the decision that if that's what it takes that's what we've got to do. we've got to make a stand on this point of principal that you cannot allow the playground bully to carry on beating up all the children, to put it in a rather simplistic form. so don't be under any illusion that we are firm or robust in that area and i think answering your first point a little bit we have played quite an important role, much of it behind the scenes, in trying to stiffen the backbone of some of our other european partners who weren't quite sure whenif this was the right path to go down in response to what we all now, i think, increasingly regard as unacceptable behavior in ukraine, so we're going that way knowing full well that it's going to be costly and it's going to be difficult. we hope very much, i was struck by both the president and secretary kerry making this point in our recent interventions. we hope very much the off-ramp

that is available to putin to de-escalate this will be taken. but if not, there will have to be a ratcheting up of the pressure and of the sanctions. on your second point we do not intend in the british government to see the united kingdom becoming more isolated or less a part of the european union. my primary strategy i hope i get it right is that he wishes to secure a better functioning european union and improved terms of membership with the united kingdom and then if he's given fresh consent himself, if given a fresh mandate in the general election next may, to take the issue to the british people, maybe in the end of 2017, to get the british people themselves to give fresh consent to the question of u.k. membership of the european union. that's the strategy. it's not a strategy designed to take us out of the european union. it's a strategy designed to help

europe work better and improve the terms of our relationship with the european union, but we do believe in the british government that there are improvements which are necessary, not just to keep the brits happy but because there are an awful lot of areas where it could be working better, and there are a number of european union governments which agree with us, even if some of them don't say so quite as loudly as we do. >> there's a couple on this side. move around, we'll get to sydney and perhaps a question or two from the internet. >> sydney freedberg, breaking defense.com. good afternoon. >> good afternoon. >> i wanted to ask you, you mentioned the special relationship, as it were. in the u.k. has long played this bridging role in some ways between the european continental partners, especially france and germany, and the united states.

accused sometimes of being air strip one or a poodle but generally, i think, providing a helpful intermediary and translator between american english and brussels. how has that role changed? does it come under strain, you know, despite this commitment the uk forces have suffered a lot of cuts in recent years. there's a very strong dependence, especially in germany, on russian energy resources. there is a lot of backlash against revelations of nsa and now cia penetration in germany in particular. faced with this common crisis in ukraine made horrifically obvious by the shootdown of a malaysian airliner. how does britain play that role

in face of all those strains? including your own domestic discontent with the eu rising? how do you stay the intermediary as opposed to being pulled between the two to no good effect? >> it's an eye sore that we have the kablt of playing a bridging role across the atlantic but we shouldn't get too pleased with ourselves in this area. i learned from my friend last week when germany just sort of in parenthesis wrote america's strongsest ally in europe so france has got a very important relationship, interest, equity history in the relationship here. a lot of european nations go back a very long way with the united states, and are themselves fundamental partners allies, friends in lots of different ways. sometimes, perhaps we are able to play a role.

we do have a shared language or what sometimes looks like a shared language, with the united states and maybe that facilitates a degree of interpretation or persuasion. certainly, there have been moments in the past when the u.k. has been shoulder to shoulder with the united states when some of our other european partners have not been. that is indeed true. i think for the u.k. we would like to continue to play that role where our own interests and values, which so frequently coincide with those of the united states, i think, that we would continue to do that. but i think as i said, different approach towards europe, to answer the question really, we're not aiming to move away from europe. we're aiming to remain a key player at the heart but reformed, outward looking to the european union. that's what we would like to be in the years to come. so i think that is not a source of tension. that is a source of strength.

and i believe that is in the interest of our other european union partners, particularly those who believe that the european union should have a role in global security and foreign policy issues. that is a role that with cathy ashton in charge has become stronger in stronger in my view in regards to what the european union does for the community. she's been the point person on negotiations with iran for example. she's been deeply involved in a number of other global foreign policy issues. so i think we're all, if you like, bringing a little bit of something different to the table. i think we're all much of the time putting in the same direction. occasionally, we may be able to act as a bridge, if you like, but if you like, when we are trying to persuade some of our european partners to be more robust in their response to russian behavior in eastern ukraine, it is not simply

because the white house has said to us please beat up on your european allies. it is actually because we think it is the right thing to do and that the international community must make that stand. so frequently, it comes from, as i was saying just now, an identity of interest and values but you've also got to have the capability to do it. that's where some of the things that we bring to the party like permanent membership of the security council and the role we can play within nato and the european union in other respects, these are hard to come about, sometimes an important part of trying to conduct conflict resolution in certain parts of the world. those are all different things we would like to think we can do to help move the international situation in the right direction. >> final five minutes here. not looking at our twitter questions, i think we have answered them already, so i am going to ask one of my own, which is on our pivot to asia, as we call it here in the united states. if the u.k. is truly going to be

america's closest partner and reliable ally what role is there for the u.k. in the pivot? i have been around the building saying are we going to see british brigts steaming through the sea and providing hardware and troops to go along with it because we tend to hear measures besides the pivot based on the number of ships and people we send that way. how far is the british military willing to go toward global security again specifically with the asia pivot? why aren't we seeing or hearing more about more british assets alongside america that far away? >> i think there are two things. one is a global foreign policy, and global interest in east asia. the other is defense capabilities. on the first point, if you look at the evidence and the number of times that we have the prime

ministers, foreign secretaries and so on engaging with the powers, also southeast asia, william hague visited southeast ash asia in a way no british foreign secretary has done because of the importance of the aleaguance, because of the importance to our interests, but we also like to tap into historic relationships with those countries, with china with singapore, with malaysia. we've got a very strong business relationship with south korea and japan. we have a historic responsibility for hong kong. there are a number of different reasons why we remain seriously engaged and why we've got a great deal of competence, language and other skills within our diplomatic service on what is going on in that part of the world, and we see that in the context of our prosperity agenda, that is to say one of the three legs of the stool of british foreign policy, prosperity, security, protection

of british interests and abroad, but our prosperity agenda does depend on developmenting our links with east asia to a certain extent that it does. it does in a limited way similar to the united states so priority for diplomacy economic political foreign policy for sure. we also pay close attention to the instabilities, which are out there. that does worry us. that is a part of the diplomatic dialogue we're having with our friends here in washington and also with the governments concerned out there in the region. are you going to see lots of vessels steaming up and down the sea? probably not, but are you seeing the united kingdom now equipping itself with a capability in the years to come to deploy firepower and highly qualified, highly skilled soldiers a very long way away from home on aircraft carriers which we

really haven't had that capability for a number of years? yes, i think you are. because as the world changes as the cold war ends and as the risk of different conflicts here and there arising where we might be able to make a contribution, we wish to be able to project ourselves a long way away. that's why we have invested heavily in long range transport aircraft as well as aircraft carriers. it's not the same for the united states. it's not going to be but i would like to leave you with the impression that asia east asia for reasons of foreign policy diplomacy, security and prosperity, are of great importance to us, too. >> good place to end, and i think a reminder of a former empire to the current united states which has at least when it comes to security a very large global to-do list, and a list of responsibilities of the importance of burden sharing as you said, both within the alliance and externally and

figuring out how to deal with such a wide variety of threats facing all of us today. ambassador, thank you very much for coming here to deliver your address and take our questions and for the great conversation. appreciate it. >> thank you for having me. thank you, everybody. the british ambassador to the u.s. spoke some about the ongoing situation in ukraine and russia's role in the matter. that same issue was addressed monday by british prime minister david cameron at the house of commons. here's some of what he had to say. >> this is a defining moment for russia. the world is watching, and president putin faces a clear choice in how he decides to respond to this appalling tragedy. i hope that he will use this moment to find a path out of this festering and dangerous crisis by ending russia's support for the separatists, but

if he does not change his approach to ukraine in this way, then europe and the west must fundamentally change our approach to russia. those of us in europe should not need to be reminded of the consequences of turning a blind eye when big countries bully smaller countries. we should not shrink from standing up for the principles that govern conduct between independent nations in europe in which ultimately keep the peace on our continent. for too long, there has been a reluctance on the part of too many european countries to face up to the implications of what is happening in eastern ukraine. it's time to make our power, influence, and resources felt. over the weekend i agreed with chancellor merkel and president hollande that we should push our partners to consider a new range of hard-hitting economic sanctions against russia. we should take the first step at the foreign ministers meeting in brussels tomorrow, and if russia does not change course, we must be clear that europe must keep increasing the pressure. russia cannot expect to continue enjoying access to european

markets, european capital, european knowledge and technical expertise while she feels conflict in one of europe's nations. we must do what is necessary to stand up to russia and put an end to the conflicts in ukraine before any more innocent lives are lost. >> you can find all of british prime minister david cameron's remarks at the house of commons online at c-span.org. next a discussion on the state of health care provider networks under the health care law. topics include the cost, access and overall quality of the networks. hosted by the alliance for health reform, this is an hour and a half. i always enjoy speaking at alliance for health reform events. and so today i'm going to talk about -- i have been using the term limited networks.

it's less charged. and really about why we have these -- these plans have really been around for a long time, but with the development of the public exchanges became far more prominent than just put the issue on the radar screen of a lot more policymakers. and i want to start with the economists saying limited networks have the potential to substantially lower costs. basically, they do this, the beginning is identifying which providers are lower cost or higher value. and insurers in developing these networks do have the opportunity to use broader measures of cost than just unit prices. and one of the ironic things is that some of the measurements of providers to assess who to invite into a limited network are very parallel to some of the payment reforms that you've

heard about, like episode funneling patient centers medical homes and the like so quietly they're moving in the same direction. so where does the savings come from? they come from steering volume to lower-cost providers. and that's a direct thing. in addition, if you're successfully steering patients or have a good prospect of it you can negotiate lower unit prices with some of the providers in a market. when enough plans do this in a market, enough people are involved, this will strengthen provider incentives to lower costs. limited networks can also support integration in delivery. this is fairly new. if we're going to have provider-led plans playing a bigger role, whether the provider is the insurer or in partnership with an insurer

limit markets are credible to their being viable because it's really important to steer enroll enrollees to the delivery system's providers. this approach through our work at the center for studying health system change since the mid-'90s we saw provider-led plans develop in the mid-1990s and the whole purpose was the expectation that they could offer plans with networks limited to the systems providers. and these were abandoned for the most part when limited networks disappeared back then. i want to briefly mention the highlights of the mckenzie work about the experience in public exchanges, and they estimated that narrow network plans were available to 92% of consumers using the exchanges and that broad network plans were available to 90%. that narrow network plans accounted for 48% of the

offerings and 60% in metropolitan areas. and the key thing was that broad network offerings had premium increases 13% to 17% greater than the narrow network offerings. so what's behind the rapid growth in limited networks? i think a big basic reason is that health spending now is increasingly higher in relation to income. and we all know about that from advancing technology and higher unit prices and it's led to a situation where broad provider choice is a luxury that fewer people can afford. but the key break with the past really was the development of public and private health insurance exchanges. i would say that there are two key things. one is that the freedom from one size fits all requirements, you

know, if you're an employer and you're offering your employees a plan there's strong pressure to make it a plan that almost everybody is going to find attractive. that's not the environment for a limited network plan, but with exchanges, you're freed from that because there are a lot of competitors in most exchanges and a plan can be very successful on an exchange if it appeals to just half or even less of the population. this would be a disaster in employer-based coverage unless that employer was offering a wide variety. the other aspect is the fact that the subsidies to consumers are fixed. you know they're based on the second lowest silver plan premium in a marketplace in the affordable care act or in private exchanges. they're also fixed. so it means that consumers are spending their own money for the marginal cost of a more

expensive plan. okay, now, to do this, some basic tasks need to be done well. and they haven't always been done well over the past year. or this year to date. one is accurate and accessible consumer information on the network status of providers. and there are roles for both plans and exchanges. and i'm often you know, surprised that we don't see more products on exchanges like what the federal employees health benefits plan uses. it's a tool from consumer checkbook where people click on a plan, they put the names of their providers in, and they see which plans those providers are in the network of. there's a need to monitor the network provider capacity. you know there's the possibility that a lot of plans have the same providers in the network, and those providers are

overwhelmed. this will straighten out over time, i'm sure. and also, there needs to be recognition of some of the sub-specialties and the attention to physicians hospital admitting privileges and specialties like opthulmology and orthopedics they're pretty specialized and someone who has a problem with a retina or a problem with their foot probably doesn't want to just go to any old ophthalmologist or orthopedist. there needs to be a speedy exception mechanism to allow a patient with highly specialized needs to meet them at network pricing and also something that perhaps a responsibility of exchanges is insuring that broad network plans are also available. just a few comments on regulation of network adequacy. there clearly is a need for regulation, but there's a very high cost if the regulation goes too far. the key needs are the basics

the transparency needs and the basic tasks i mentioned. also, a need to prevent risk selection strategies based on poor coverage of some specialties. and a consumer protection needs which i would describe as basically if there are some networks that very few informed consumers would find acceptable it's probably best that they shouldn't be on the market. i think some of the dangers is disarming the most powerful market tool that's available to address the effects of increasing provider leverage in negotiating with insurers. you know prices have been going up rapidly. they explain most of the rise in spending. so you know, the success with limited network plans is going to be important for health spending, especially for lower income consumers. and also i'm concerned about interfering with some of the steps towards clinical integration.

let me just talk about the politics. it's inevitable that pressure from providers to be included in narrow networks will happen. we have seen it now particularly from pediatric hospitals being particularly outspoken, and we've had any willing provider laws in a number of states that actually have been around since the 1980s which seem to be a particularly misguided response to this issue, but in contrast with 1990s, consumers see much more a mistake of having lower-cost products available as a choice. federal government also has a stake in how high silver-plan premiums are, and i'm suspecting we'll have a much more new aunlsuanced reaction to these issues. thank you. >> there we go.

well, good afternoon, everyone. it's a pleasure to be with you today. i plan to briefly cover five topics in my presentation. i'll start with some of the latest consumer satisfaction polling. and then i'll turn to how networks are focused on delivering value to consumers. and then a little bit about the importance of increased choice and how those choices enhance the value proposition. and then a little bit about how networks are built based on a recent study that we commissioned and then finally i'll wrap it up with our commitment to consumers which really focuses on accessibility. the commonwealth fund recently examined attitudes about satisfaction of coverage in

exchange s exchanges and found that nearly 3 out of 4 are satisfied. this is consistent with a recent poll that showed that 74% are satisfied with their health plan. and directionally, this matches with what we have seen in private polling showing that more than 9 out of 10 registered voters are satisfied with their private health insurance coverage. consumers preferences for balancing provider access with cost is another very important consideration. a recent poll indicated that 50% -- 57% of small employers would choose a smaller provider network if it resulted in a 5% reduction in their premium. and this increased to 82% if the result were a 20% reduction in premium. in another mourning consult poll of consumers showed a preference

with 58% preferring a less expensive plan with a limited number of doctors and hospitals. health plans are focused on value by finding the right balance for consumers between quality, affordability, and choice. plans are constructed on the premise of insuring the highest quality at the lowest price to deliver that value to consumers. the report i mentioned finds that high value provider networks allow for more affordable coverage options with 5% to 20% lower premiums compared to broader network plans. while placing an emphasis on quality and effectiveness of providers. the mckenzie report found similar results. many consumers are looking for this type of balance that delivers value, affordability, and choice.

regarding choice, a recent mckenzie report that paul summarized in his presentation shows that consumers now have expanded choice of network offerings on the exchanges. broad networks are available to close to 90% of the population. mirror networks are available to 92%. this increased prevalence of networks gives consumers a wider range of value proposition and prices among health plans. importantly, mckenzie found there is no meaningful performance difference between broad and narrow exchange networks based on hospital metrics. the millman report explains in some detail that high-value provider networks are specifically geared toward providing personal and comprehensive care to patients in an environment where providers effectively

communicate and coordinate with each other regarding the best treatment for patients. high-value networks are developed through a deliberative evolution process with providers that consider more than just fee levels. active cooperation and collaborations between health plans and participating providers is really the hallmark of success for high-value networks. performance on quality measures is the key part of the criteria used for provider selection and inclusion in a plan's network. in addition, health plans must meet robust standards for network adequacy and access to care. professional accrediting organizations like ncua and urac require plans to meet standards for access and availability of service and measure themselves against these standards on an annual basis. state and federal network adequacy laws insure that consumers have access to a

sufficient number and type of physicians and hospitals and health plan provider networks. importantly, network development is now occurring in a reform market where health plans have new requirements that restrict their ability to vary plan design and control costs. including essential health benefits, preventive coverage requirements limits on cautionary and restrictions on age ratings. variation in network design is one of the few tools for health plans to keep costs low for consumers while insuring quality. >> i think i'm missing a slide. here we go.

we'll try to go backwards. there we go. >> bingo. >> sorry for the delay. here's our commitment to consumers. this is an important slide, so i'll spend a little time on this. our health care system is in a period of significant change, which means now more than ever, patients are looking for value and stability in their coverage. understanding that a health plan's top priority is to provide consumers with the information they need to navigate the new system and to make the decisions that are right for them. one important step health plans are taking is to improve transparency. i know paul talked a lot about this. while the use of provider networks has been a key tool in delivering value by preserving benefits, mitigating the impacts of rising costs and promoting quality of care, consumers may

not be aware of the critical role networks play, how they work or understand which providers are in their networks. consumers should have the information they need to make the right choices for themselves and their families. and that is why health plans support insuring greater transparency of network design by providing accessible, understandable, and up-to-date information about which providers are in the network and timely notice to consumers when providers leave the network. providing that summary of information about how plans put together their tailored network said s to balance cost, quality and access considerations, providing information on how consumers can appeal plan decisions submit complaints, or obtain referrals to out-of-network care when necessary, and we also support continuity of care for a minimum 30 days for individuals undergoing an active course of treatment for conditions that require more complex care or

serious terminal illnesses, and for mental health. so that wraps up my presentation. thank you, and i look forward to our discussion. >> health. that wraps up my presentation. i look forward to our discussion. >> we will turn to catherine arbuckel. >> i thank everyone in the room. i better get some volume here. >> press it and then wait a couple of seconds. they are temperamental. >> okay. very good. well thank you all everyone in the room for allowing me on behalf of this company to have this opportunity to have this important discussion with you todayment esection health is the

u.s. catholic health system we have 19 sites of care in 23 states in the district of columbia. all the hill systems that have sponsored by assention. we are named in all of the networks offered. in other markets we're included in some narrow networks but excluded from others. in some marketed we off our own offering and finally we participate in the nonnarrow

market. the prod evering generally, it fits with our mission to serve the low income and the vulnerable since that's is who is accessing these products on the exchange. so i do want to comment about these narrow networks and then how they can benefit payers patients providers. we do believe there is benefit in naft oe noetrrow networks. it could be done with preintegrated care. some of the benefits you can outline when you have this tighter integration is that providers can communicate more openly and easily sharing information between them about

patients patients. that's especially health with electronic platforms. payers and providers can share more meaningful data. work to determine what is the right improvement we can make to quality and cost. >> the providers within a clippically network can be more familiar with the protocols but the administrative processes. also these tighter relationships to comment with the players back to them where there are service needs and where things need to be approved. there needs to be adequate consumer protection and education according to hhs 85%

of individuals that have purchasing products on the exchanges qualify for an exchangeex- exchange subsidy. 1, they tend to be at the lower end of the income scale and two they did not have insurance previously. 57% in one study did not have insurance perfect. i'm glad we're talking about this question today. so starting with consumer protection and education, we've invested 200 individuals who become certified application counselors. they receive federal training and they are there to help access the webb sites. what we learned is that this counseling takes a lot of time. many times when necessity arrive

with the providing the medical care. i will tell you in one example a patient arrived at our emergency room in critical condition and unfortunately he just signed up with a health plan that was not in his network. we admitted the patient but either the family nor us knew what that patient's financial obligation would be when it was completed. we were fairly confident knowing we had admitted, that if this patient is lower income, they will qualify for charity. we will be left for the compensated care because of the

confusion of proer confusion of providers. they need to know they may face higher deductibles and coinsurance. we would advocate to you today that the insurers need to be more accountable on educating their products. that includes that when we offer products on the exchange. it should seek education on trade offs to be made when choosing a lower coverage, heyer premium perfected you can. this is important with these folks that do not have experience

experience. we found that the exchanges sometimes have inaccurate information. hard copies are not existent. >> finally, the access hours an the capacity is also important. when an veried is ep rollinge ep role enrolling at healthcare.gov. we believe that information should be accessible through the healthcare.gov webb site. i want to move onto the quality standards. we have been a leader in patient safety over the past decade. our work in the last decade on ulsers has results in our pressure ulser rate being 94% below our national norms. it has made it among the safest

places to deliver a baby. we should stream line them into an outcome based program. we made this recommendation last spring in a document entitled sustainable health care. a defined set of outcome based measurements can provide consumers with more understandable and meaningful information. current practice allows insurance to develop their own quality metrics. sometimes these are the same or similar as medicare. a recently released study found that the primary measure found in evaluating narrow network providers are quality measures. the study goes onto describe how

the quality measures can be used. there are seven different types in the document and each has different measures and metrics. in our system they are evaluated by three insurance plans. one is a three star, another a four star, another is a five star. that causes us back and forth with the insurance is the patient population that's looked at. what are the differences that are diving them. it's much more difficult to see how they've been fwradgraded for qualities. there should be uniform quality information as part as the decision on the networks. >> what is the decision number of providers to include a narrow

network. i'm understanding the work is in progress andle continue to evolve. i'm glad. i want to point out a couple of things. first of all the individual marketplace includes many low income families that are also medically vulnerable. sometimes it is not simplistically solved by ten miles. if you have no transportation and you rely solely on transportation that can be 100 miles to you. also we have folks that are buying on the ex-change that have complex child care needs, flexible work hours. their information regarding providers accessibility within hours, after-hours, is also