now everything that you buy related to music, entertainment, movies, film, you have to go to the itunes to download it and actually own access to the content that universal spends millions and billions of dollars creating so they can get 30% of what apple makes 70% of what they're making. so they literally came and took over the music business because they didn't see tomorrow. >> akon, let me just pivot for a second because we're running out of time. i want to bring it back to africa and i want to convey a twitter question we've had. this to you, amadou, what is being done to bridge the gap between for instance in the continent and those in the dais practice and can media play a role in this? >> yeah, i think actually every day, and i'm sure akon would do this, too, every day you get news and information online from

your own country every day. and media is doing that. almost every african-american has a flagship website that's on top of all africa. so media is playing that role, and it would keep going that way. >> okay. let me -- i think we have time for a couple more questions. right here. >> this question is for akon and amadou. i'm a technologist and we have an army of developers in africa. we constantly thinking about creating something to own that content and navigate it through, but because we are so bound into our technology mind, we don't know what to do. what kind of focus -- what is the media focus we should be basically focusing on? >> my name is abdel and i'm from

dci. my question to the panelists and you kind of touched about it a few minutes ago but you didn't go deeper. the first fdi from africa to united states, it was here. and so far it's not utilizing to its full potential to change what you all are talking about as the narrative about africa. we all in this room have been to all those little of this country and when you get to a person in charge of africa, you see the american guy who been on the continent one or two times and write a book about it but doesn't have all the perspective that the people have here. so how can we, people in this room, make that change happen that america can use the real

african who is here and can tell them what really happened on the continent or what really matter as a change that we are looking for? and i want an opinion from the panelist. >> one more question over here. >> thank you very much. thank you. i think my name is joshua. i come from kenya. i think we operate in a region where perhaps covering over 250 million people within eastern central southern africa today. me quai estion to the panelist i'm a proud african. we continue to run the race of transforming the continent today. i think the question for me when you spoke in the last panel was around the technology around data and voice. for 500 million people connected

on the continent shifting the conversations happening today. a huge opportunity for investment. and we have a lot of american investors today we see in our markets. is there a chance to be -- it's a complex continent, i agree. it's 55 countries. it's not one story. one is positive in nigeria is negative in another country and it will be like that for a long time. sometimes we want to see it as one africa. it's not one africa for us. every single country is different. so is there a chance to see and i love what amadou is doing, are we able to see you utilizing that technology platform to shape this the stories that transforms the continent? >> so we just have a couple minutes. so why don't we just go down the panel and everybody can respond to some of those questions, make some final comments on what we've heard. akon, we'll start with you. >> which question first? >> well, there's several questions that were put to you. one about technology and how that can be utilized.

>> absolutely. on what technology you think you should start, right? i would start with mobile. because right now mobile hand helds is the key communication for africa. anything that you can operate from your phone, you'll win. so create apps that you can actually use on dumb phones and smartphones because a lot -- a lot of the rural areas they don't have smartphones, but there's a minimized type of technology that creates apps that can utilize, you know, technologies that actually work with smartphones or more just to be able to communicate in other ways. but i think they business revenue you have that can operate from a cell phone, you can actually win in africa for sure. >> great. john, do you want to respond to any of those or anything else. >> i was going to ask you if you could help me make that dumb phone be a little smarter. >> you have a blackberry. >> i have something to talk to you about afterwards.

i'm one of the loyalists, i can't let go. the blackberry. i was going to try to answer the question only to say that in the 30 years that i have sort of been involved in politics in the american system and in policymaking on africa, it is very powerful when african constituencies in the dais practice work together and come together around specific issues. i go back to somalia in the late 1980s where they helped dismantle the dictatorship. now, they couldn't anticipate what came after that, but the power of somali americans working together and congressional district after congressional district made a big impression on me and i have seen that replicated many, many times over the last 25, 30 years. and i think about the trade agreement between the united states and africa that needs to be renewed in the coming year and for for instance to come together for that name of which

is -- >> agoa. >> african growth and opportunity act. the way the lost boys were sent throughout the united states in their reintegration journeys, getting asylum in the u.s. and how they're plolitically in eac congressional district they live in. and the impact they can have. the congolese-american and how much of an impact. when the dodd/frank bill came along and there was a provision that said we just want american companies to divulge and be transparent about the investments that they're making in africa. the companies that are listed on the new york stock exchange. just be open and honest about how you're getting your resources down stream in your

supply chain. it's that unity really that in diversity, that impact, the raw possibilities of that impact. >> just add a footnote in 2008, the obama campaign, i remember going into district after district talking to communities and it didn't even matter if they were americans or not because even if they weren't, they knew somebody who was and they could get out the vote and it was just incredibly electric and i think that power can be replicated over and over again. amadou, let me come to you for a thought here. >> thanks, witney. just want to end by saying, of course, we hear all the time that necessity is often the mother of invention, which is true. but at the same time what i usually say is des prperation i

the mother of action, and when you look at, you know, my brother there when he was talking about like how to use american companies, when this in the middle know that this here knowledge and talent they can use to get them ahead because they are losing ground more and more, they will do it. so when they become desperate, they'll go to action. and i think, you know, the outlook for me is great. and i really want to end it there. there's still a lot of work to be done but it's all of us in this room and our kids who would really ultimately finish it. >> yeah. great, thank you. william. >> just speaking about the diaspra, one of the less told story are those going back to take advantage of opportunities.

but i think to take it right back to how you started this sort of complex picture that comes out of the continent, it's amazing that you've got this trend alongside this extraordinary kind of exodus where tens of thousands of people are marching across the sahara desert into in many cases a watery grave in the mediterranean. i think that kind of -- those two trends actually rather sum up what's happening on the continent today. there is still place where is people are really suffering and desperate but you've also got these tremendous opportunities which are bringing them back. >> incredibly complex picture. helene, i don't know which side of the chair you want to sit on. >> i'm going to sit on all three. i think we had a question earlier just about the whole idea of how to get the african story across, and i think the

western news media part of me says that we at the "new york times" and "the financial times" and "the wall street journal" and these news institutions really need to do a better job of finding for instanafricans t their stories. ditto for hollywood and tv, and then the american in me says we have to find a better way of telling our own stories as africans and doing it ourselves. this is a job for us. it shouldn't be africans relying on "the new york times" to tell our story. we should be taking charge of our own destiny and telling the world what we have to say and then the american in me says that we also here, those americans who have been interest in africa, should read those stories. go out and buy "americana." read "ghana must go." support this burgeoning group of

african writers who are fantastic. >> hear, hear. [ applause ] >> well, we've gone over our time and before we depart, just let me say there's a reception after this immediately. drew, where is it? >> right next door. >> right next door. so please come and join us, and let me thank the panelists for really your willingness to come on and sort of tackle a subject that's not often taken on and not easily discussed but i thank you very much. let me ask you to give them a hand of applause. [ applause ]

and here on c-span3, president obama awarding the medal of honor to two vietnam era veterans. you can watch our live coverage in about 40 minutes, 1:50 p.m. eastern time. and turning to capitol hill today, the house and senate both in. the house starting legislative work at 4:00 with more than a dozen bills on the schedule, including ones dealing with steroid trafficking and child care subsidies. you can watch the house live on our companion network c-span and the senate gaveling in at 2:00 for more work dealing on a bill with campaign spending and federal elections. watch the senate live on c-span2. the house rules committee is supposed to meet to consider a continuing resolution to temporary fund the government and related agencies number law

ma -- until lawmakers pass a budget. you can also tune into the meeting streaming live online at cspan.org. tonight on "the communicators" anna eshoo talks about net neutrality and rules governing the internet. >> i spoke publicly about what i thought the fcc should do to be on firmer legal ground and pointed to title two. now we've had fast forward, we've had discussions at the committee about it. this is all about net neutrality obviously. people in our country feel very, very strongly about the internet. not only how they use it but how they think about it and the access to it and that it be free and that it be open and that no

one, no isp or anyone should be able to interfere with that. >> tonight at 8:00 eastern on "the communicators" on c-span2. next, a look at president obama's four-part strategy to fight the militant group isis and the legality of it. this is from today's "washington journal." >> eli lake is a national security correspondent for the daily beast. author of a piece from last week "obama's new war on isis may be illegal" is the headline of that piece from last week and eli lake, let's start by laying out the white house legal argument for its effort in iraq and syria. >> sure. when president obama first authorized bombing in iraq for the first time i guess since 2011, the authorization was that, you know, the constitution first article says congress only

declares war, but the second part says that the president is the commander in chief and presidents before him have used article two authority saying he's the commander in chief of the military and as the president has the responsibility to keep m.a.s.american citizens interests secure, and he used that as presidents before him have used those powers. but the problem is 1973 there is something called the war powers act which was a reaction to using these kinds of inherent constitutional authorities to wage very long, drawn out wars. the classic example that everybody points out is there was never a declaration of war against vietnam. so the vietnam war was always seen as a police action although it was probably our longest and worst war from the perspective of just casualties. actually civil war would be our worst war in terms of casualties but at least in the 20th century. so in 1973 congress passed the war power act and that said that every 30 or 60 days the president needed to inform congress about these kinds of

prolonged activities and it tried to narrow what exactly could count as that. so, you know, certainly a rescue operation in syria would count as something that would be covered under the war powers clause and the clause in the constitution, but once you start getting beyond really basic stuff like protecting u.s. interests and u.s. personnel as the bombing campaign in iraq quickly did. remember, it then became to protect and to prevent sort of for humanitarian reasons a genocide against the yazidis, then it became protecting crucial iraqi infrastructure such as the mosul dam and he used a phrase preventing isil from action that is could cripple -- permanently cripple iraq. so as the war expanded, i believe that the white house was looking for another rationale for that. then it gets to something called the 2001 authorization for the use of military force but really that is the post sort of three

days after 9/11 congress says we are declaring war on those who are responsible for 9/11. and that quickly became obviously al qaeda and was used by both bush and obama as the legal justification for air strikes, indefinite detention of individuals not just in al qaeda but also associated forces of al qaeda as it became sort of argued in the courts. >> in your piece you say this is where they start to get into shaky legal ground by using that when applied to isis. >> exactly. because isis while it does begin as a franchise of al qaeda is today a force that is really in competition and in some cases at war with al qaeda's franchise in syria. because the leader of isis right now has declared himself the caliph of all the pious muslims in the world he's a rival to ayman al zawahiri.

and they correspond publicly in various ways but they both have sort of acknowledged they're out of -- isis is now no longer affiliated with al qaeda. so i called up some legal scholars who have since written on their own in more detail but the view was that you cooperaul really say isis was an associated force of al qaeda because they've kicked them out. theed ed administration's argums if it walks like a terrorist and quacks like a terrorist -- talks like a duck and quacks like a duck, it's a duck. i don't think that's going to pass legal muster. it's hard to make this argument that isis is an associate force. it's a wholly separate force than al qaeda. >> is it then leaving it up to the terrorist groups thegez mse to define who they're related to

or what groups they come from? i mean, an argument that the white house has been making on capitol hill is that -- >> it's a very -- first of all, i mean, this is independent entirely from whether or not the united states should be at war with al qaeda -- i'm sorry, with isis. but the problem is that even before they used this justification for isis, there were a number of people who were very concerned that the original purpose of the war resolution, the people responsible for 9/11, had expanded to the point where it was justifying american air strikes in somalia and pakistan and yemen, really all over the muslim world. this raises this issue which i have written about before of, of course, is this a recipe for war without end, a permanent war, if you expand the definition of who was responsible for 9/11. bin laden is now dead. most of senior leadership of the organization at the time is in guantanamo or has been killed. if you continue to define it out

and this original resolution becomes to elastic that it allows for a kind of permanent war that will last beyond obama's presidency and maybe this new normal. so that's been a concern from not just a legal perspective but from a kind of political perspective. so i think the alternative could have been a new resolution that was narrow and against isis that was sort of just everyoncompass everything obama said. certainly i think most republicans would have voted for it and i think you would have gotten a number of democrats just based on the public statements they've said. and i still don't really know. i don't think -- i don't know why exactly they haven't gone to congress but i can say the last time they went to congress, similar things, air strikes in syria, this time against assad about a year ago after assad violated the red line on chemical weapons, they ended up not having the votes. >> we asked our viewers in our first segment this morning

whether they thought congress should hold a vote and if they did, should it happen before or after the election. is there any chance that something like that could happen before the election at this point? >> well, we haven't seen speaker boehner say he would hold that vote. we haven't seen harry reid say he would have that vote yet. so it's up to them. they're the leaders of the respective chambers of congress. but the other thing is that if they have from a military perspective, if you have, you know, baghdadi in your sights and he's in syria, then would you not then take the shot if you knew you could get him because you didn't have a formal authorization? and that's why i think they are asserting that they do have that authority under the aumf. we're talking with eli lake. if you have questions democrats call 202-585-3880. republicans 202-585-3881. independents, 202-585-3228. if you're outside the u.s.

202-585-3883. as you are calling in want to note that we've used the term long term war, new war in iraq. secretary of state john kerry was on "face the nation" yesterday and was asked about calling the fights against isis a war. >> can i clear up one thing first? this week you went to some lengths to say you wouldn't call this a war but yet at the pentagon and at the state department even they were saying we are at war with isis. are we at war? >> well, bob, i think there's frankly a kind of kor toured debate going on about terminolo terminology. what i'm focused on obviously is getting done what we need to get done to isil. but if people need to find a place to land in terms of what we did in iraq originally, this is not a war. this is not combat troops on the

ground. it's not hundreds of thousands of people. it's not that kind of mobilization. but in terms of al qaeda, which we have used the word war with, yeah, we were at war with al qaeda and its affiliates. in the same context if you want to use it, we're at war with isil in this sense. i think it's a waste of time to focus on that frankly. let's consider what we have to do to degrade and defeat isil and that's what i'm frankly much more focused on. >> eli lake of the daily beast. again, we see bringing up al qaeda and isis here in the same sentence. >> i mean, it's a war because the united states will try to seize its assets, kill its leaders, take its territory. it won't do that they say for now with combat troops on the ground although there are over 1,000 americans right now in iraq that have been sent since june. they will be using air power to do so and nobody at any point

ever said we weren't at war with al qaeda even though there were not combat troops in pakistan or yemen or various other places. so it's a little precious to sort of hear kerry say that. that said, it's to me kind of interesting because john kerry has been i think out front on saying that the united states needed to stop and defeat isis. he called them the face of evil last month. the president was the one who was very reluctant. he went from degrade to defeat or destroy isis. the president i think was the last holdout there, and i think kerry's main point is that there isn't going to be an invasion like we saw with iraq and afghanistan and i don't think there's any republicans really clamoring for that either. so it's kind of a red herring. >> we're talking with eli lake of the daily beast. his recent piece from last week. we'll start with matthew in mechanicsville, maryland, on our line for republicans.

>> caller: good morning and thank you for taking my call. i heard -- with my comment i heard it said in other ways, i will try to do my best here, but i can remember us going into iraq when i was in the fifth grade and we've been in that area for about 25 years now, and if you're in the beltway and you're listening to these people and you're seeing the way that they define the actions we're taking over there, it's starting not to pass the smell test. they're kind of letting people that don't have the united states in their best interests define the way that we approach security issues, and you can hear it from the way that the president tries to use different acronyms to describe. i mean, let's be honest, these are the same people that we were fighting in afghanistan, and you can just read general history like universal history books on these topics. they're learning to fight us in

a way that they can define the term, and this is just from what i have noticed from the semantics that our own leaders are using. they're tying themselves in knotts with who they're fighting and it's like they can't -- if they just read some general history on the area i think they would figure out who they're fighting and they are all the same people. >> eli lake? >> well, there is an ideology. we could calm it jihadism, islamic extremism. it's not the same as the religion of islam. in fact, we know that muslims are often the first and worst and their most victims i suppose of these barbarians. the caller does have a point if you want to say that the ideology that motivated osama bin laden is the same one that motivates baghdadi and eisis an al shabaab. it seeks to bring back this caliphate. it basically would enslave all

women. it would make it illegal to be anything but a muslim and if you were jewish or christian you could pay a tax. it's gruesome stuff. i think i would say it's fair to say it is rejected by the people who have to live under it and we've seen that over and again, and the only way they can enforce the ideology is through just horrific and kind of almost theatrical violence. it has also recruited i think a fringe group of kind of losers in the west who feel that this is an opportunity to, you know, have a kind of exciting -- to participate in some sort of worl historical movement and it's true that the united states has been fighting this current for some time. i would say 9/11 was kind of the hinge point. the irony here is that the president has until really about june. obama has tried to say, no, no, no, we're only at war with al

qaeda central and we're only at war with the franchise in yemen. and he has really resisted the idea of talking about the enemy in this kind of ideological sense, that there is this ideology, it's probably wrong to say it's political islam per se but it's kind of an extremist version of political islam and now he's facing that, and the great irony of the earlier point about the 2001 authorization for the use of military force is that by saying that, you know, that justifies the war against isis, he's making his point implicitly that this is all part of the same war and even though the franchise of isis is fighting al qaeda's formal franchise in syria, they are still sort of fellow travelers of this same ideology. there was a really revealing interview in "the atlantic" with hillary clinton who talked about needing a component to address this ideological element of it and saying it was similar to america's war against

totalitarian communism during the cold war. i think it's wrong to say that these are the same people because they share the same faith of islam because there's so many muslims who fought against them. when i have been to iraq as a reporter, i spoke to several tribal sheikhs who had come to reject al qaeda even though they felt at first they sort of reached a pragmatic deal with them and i think in those cases such as some of these sheikhs, not all of them, al qaeda and this ideology will have an enemy for life because they faced the brutality themselves. >> davis is waiting on our line for republicans. davis, good morning. >> caller: good morning. first of all, you know, i would just like to say that all this war is because of the lies from george bush's administration, dick cheney, rumsfeld. you have these guys repeatedly on tv.

there was an article that the think tanks are taking money from overseas in order to influence what they say and in the united states government. he was also captured by the american military in iraq and turned loose. he was part of the anbar awakening, the very same people who john mccain and them armed -- >> let me ask you you're calling in on our line for republicans. do you disagree with republicans in congress and how they're handling this? >> caller: i'm more like powell who don't believe in this war and stuff. >> all right. >> caller: let me -- >> go ahead. >> all right. first of all, ron paul is now giving his lunatic opinion on foreign policy on the kremlin funded rt network, so he's the one who is taking direct payment from a foreign government and a foreign government that just invaded and occupied ukraine. you hear this a lot and

certainly politicians lie. there's a bit of dissembling in the intelligence community and operating in secrets and you can sort of debate this stuff but the truth of the matter is this president was uninterested in a war until this isis which is sort of a terrorist army was able to take over iraq's second largest city and then really became engaged when they threatened to wipe out the last of the yazidis, and now that we have three gruesome internet videos of the beheading of westerners, i think it has moved world opinion to the point where they realize they cannot live in a world in which you have the equivalent of al qaeda stand in the middle of the middle east. now, those are just facts. this is what this group has done. the argument you could leave them alone and they would leave us alone i think is clearly -- i think it's discredited by events so i would just leave it there. >> eli lake is a national security correspondent with the daily beast, previously worked with the washington times, the

new republic, new york sun. how many times have you traveled overseas to iraq and the region? >> well, i have been to iraq on three different occasions, three different extended trips. i have been to the region several times. been to sudan. fortunate enough to travel a lot in my job. >> he's leer to here to take your questions and comments. joseph is up next on our independent line. >> caller: how are you doing? i want to thank you for taking my call. >> go ahead, joseph. go with your question. >> caller:ist list isis isist io the people complaining, as a military person, vietnam, gulf war, and bosnia, i want to tell you something. i served with a lot of different people, muslims, arabs, jews, whatever you want to call them, roman catholics. you know, my mom and my grandmother were concentration camp. they escaped because my father

helped them. this here i think it is an illegal war against muslims. not all muslims are the same as we think they are. you know, we have a group of people like here in america, ku klux klan, organized crime, neo-nazi thing. fine. you take care of it as a person. >> eli lake i will let you jump in if you want to. >> it is correct i think it is a fair analogy to say al qaeda and isis are the -- are to islam and muslims as the ku klux klan is to clhristianity. so that is a correct analogy. >> ernie is in littleton, colorado. >> caller: good morning. a few questions here. as far as isis and al qaeda, are they not one in the same, just different terminology for isis? and, two, as far as going into

syria and iraq to bomb them, is this just another say round about way to go in and get assad out of power? and then my third question is the bush administration, the obama administration, neither one of them want to release the 28 panges of 9/11. i'm just wondering why. >> i don't know why they won't release the 28 pages. i suspect it's because it implicates the saudi government. i think that's probably it. on the second point, i don't think that these air strikes are a threat to the assad regime although it's true that assad has had an opportunistic relationship with these ultra jihadists. he certainly worked with them when they were funneling foreign fighters into iraq. he is fighting them now in his civil war but not fighting them consistently. he's gone after much more moderate encampments of the free

syrian army and has largely left some of the isis positions in syria untouched. he's -- he has intended to create a choice, it's either me or these lunatics. that said, what was first thing he was -- >> the general question about the relation between isis and al qaeda. >> we talked about it. isis began as an al qaeda franchise. they share the same ideology but the two groups are very much competitors right now and simple distinct and the key here is that you could -- both zawahiri and baghdadi have said this themselves. they've said you are no longary formal affiliate of al qaeda. so that i think is why you can't say that they're exactly the same organization. they certainly are the same ideology. >> one thing i wanted to talk about is your latest column in the daily beast, gotten some attention. contractors ready to cash in on isis war. >> well, first of all, i would

just -- i want to point out that people who are military contractors, a lot of them have had long and important careers in military usually at the tip of the spear and there's nothing wrong with kind of going into the security contractor industry. i'm not one of these -- not like jeremy scahill who thinks it's all sort of suspect. that said the president have said a couple things that are noteworthy. number one, this is going to take more than a few months. remember he started saying it's not going to be weeks, it's going to be months. now he's saying it's going to be a few years probably lasting beyond his presidency so the length of the time is important and the second is he's promised these no combat boots on the ground. there are companies, triple canopy, academy have just merged, that are specialists in training up local forces similar to our green berets in the military so that, you know, sort of turning them into these fighting forces and it's been done by contractors for some time now and so the view is that

it's probably going to be a lot of reliance on these contractors, an irony because, of course, you know, blackwater was very much associated with the republican party and joe biden himself i think in the first term in one of his trips to iraq compromised to prosecute blackwater from the justice department. this administration at least politically tried to distance itself from these contracts and it's almost certain that at least the contractors i interviewed say they believe this will present a business opportunity for them and that obama will be relying on them for this new war. >> we're talking to eli lake. he's here to answer your questions or comments. atlanta, georgia, is up next. al is waiting on our line for democrats. al, good morning. >> caller: yes, good morning. yes, i'd just like to get something understood here. i do know that obama -- first of

all, i do agree with what obama is doing. he has a hard job. i mean, gosh, this is -- i don't know of anybody who would want a job like that. the question is it seems like the talk is out now that he has to have the permission of congress to do things and everything. why is it that going back 20-some years or so that president reagan did not have to have the permission or i believe he did not have, maybe i'm wrong, but he did not have the permission from congress to send army troops into granada. i don't believe he had permission to send 1,000 combat marines into lebanon where over 400 men got killed. i wonder if he could answer that. >> sure. well, the constitution at least

legal scholars would say has two views. one is that congress declares war and the other is that the president is the commander in chief of the military. modern presidents including reagan have said that article 2 gives them the authority to do things such as granada. on granada it was a very time limited operation. it was so save medical students after a communist coup. in the case of what we're envisioning now against isis is by the president's own admission a long war. you know, not just weeks or months. it's not a couple air strikes and then we're out. so that is one factor i think that plays. i'm not a lawyer but i think that's an important difference. but, you know, i think there's a broader point beyond the law and that is that, you know, what we saw in the bush years was that despite even a resolution authorizing the iraq war, once that war went badly, once there were no weapons of mass destruction that were found, it became a very partisan issue. when you can have a kind of

resolution that authorizes a war like this, it's a way of having a political buy-in so you avoid having that war becoming a partisan issue. this should -- in my view it shouldn't be a democrat war or an republican war. it should be an american war. that's the one benefit of having one of these authorizations i think. >> gloucester, virginia, is next. robert is on the line for democrats. >> caller: good morning to you. i serve with the 82nd airborne many -- a couple decades ago. i see us not being able to squaup der our resources any more. when you have an iraqi army that threes down its weapons and runs away after a decade of training, why are we the policemen of the world? you know, why do we have to involve ourself? we can't afford this anymore. >> well, i mean that is a -- i think that that's a viewpoint that has been gaining a lot of

supporters recently. certainly this idea about america not being the policeman of the world. here is a great irony. the 2000 republican convention condoleezza rice and her introduction to the mass media i guess gives a speech in which she says america is not the world's 911. then 9/11 happens and then, of course, we become even more engaged in this long war which the president obama has tried to get us out of and now he's kind of dragged back in. so i mean i think it's true that america shouldn't be the only kind of -- the nation of last resort that's engaged in this nation building. it's so frustrating. i was there seeing a lot of on the job training in the last decade where the american military mentored iraqi military and to see them throw down their weapons in mosul. but i would just say this, i'm not making any excuses for it because i think that in some

ways does show the limits of american power, but one of the factors that led i think to the failure of the iraqi military in mosul is that the prime minister, nuri al maliki, governed in many ways like the shia saddam. he alienated the sunni minorities and others, including the kurds, in his own country and replaced a lot of competent military leaders with cronies and tried to consolidate his power the way a petty dictator would and people don't want to fight for someone like that or something like that. so that i think is another factor. all these wars have that political component. i'm not entirely sure we've seen this was a matter of just -- that we failed in training them. i think it was that maliki failed as a leader and i think we failed in trying to use our influence to stop maliki from doing what he's doing which was tearing the country apart.

>> mary in ohio. rich is on the line. >> caller: great. its curious people declare war on us and we just ignore it. before 9/11 they declared war on us and they're too small to cause trouble. world war ii on pearl harbor, they attacked first and then declared war. why we kept all the ships together and didn't pay attention there is beyond me. but we can't be asleep at the switch. we ought to look at 9/11, who was getting benefit from shorting the markets then, what countries, what peoples, and stuty that and find out whether it was more even than just an attack, it was a financial attack on our country to try to really set us back. >> eli lake on being asleep at the switch. >> it is the way of things usually when the united states is attacked and then we're

surprised. since 9/11 there's been enormous amounts of resources in the military and intelligence committee trying to prevent another one of these attacks, to track these terrorist groups. i think the united states is better at fighting a war on terror since it started after 9/11. >> carnegie, pennsylvania. >> caller: when i listen to your guest, it's almost astonishing when i listen to the level of deceit particularly when it comes to the facts of the words existential threat. the only ex shen shall threat to the united states is the israeli government which represents a true threat which was an active participant in 9/11. >> would you like to jump in? >> i would like to jump in. make sure to listen to the man in the white lab coat. he's only trying to help your recovery and i wish you luck with your mental illness. >> jim is in winston-salem,

north carolina. >> caller: good morning. the problem with what the we're having today is the same problem we've had with washington as a whole. republicans and democrats, regardless who the president is, we do the same thing in the same manner expecting different results and we never get that. evidently there's not enough people up there to realize we're not at war with isil. if we have a problem, let's go take care of it quickly and be done with it. we're not at war with the whole muslim world even though who knows. but with this particular group when there's a conflict and who calls it a conflict? i haven't heard anybody call it a war or a conflict. let's take care of the problem. they've killed two of our citizens. if we need to bomb them, let's bomb them and get out. >> that's what we're doing. i mean, yeah, i agree we're not at war with all the muslims.

sure. i think it's an ideological component of it that you probably can't win with just bombing and military action alone. there's a lot of things there. >> do you want to talk about the coalition that is being built here? some headlines of a lot of the front pages in the major papers today, arab nations offering air power in u.s. strikes against isis. although unnamed arab nations to this point. >> it's been a harder slog than they originally anticipated but keep in mind this entire effort has really caught the white house -- the white house did not want to do this. they have not -- they have been reluctant at every stage. i think every stage has taken longer than they thought. i don't think it was a particularly fruitful meeting between kerry and president al si si in egypt. i think america lacks the influence it did before but that said particularly for the gulf states, particularly for saudi arabia, united arab emirates,

they know that while they have been saying for some time that iran is their number one threat, they also know these groups like isis and these radical extremists are also a major threat and i think that in that sense they have an interest here in trying to defeat them. although, you know, i have to say they came after -- they came two years ago to the united states, three years ago when syria was devolving into civil war and they said we need you to do something and obama pretty much declined. so they might be saying too little, too late but at this point i think, you know, the u.s. is engaged and they probably eventually will end up helping. >> a few minutes left with eli lake p lake. try to get to as many kuls as we can. freeman has been waiting from sioux falls, south dakota. freeman, good morning. >> caller: good morning. listen to this guy here and you kind of started talking about what i was going to talk about. the fact is that barack obama,

president barack obama had tried to keep us out of the syrian mess and people like mccain and probably guys like this guy here when this conflict first started wanted -- basically wanted the boots on the ground and things like that. the isil deal popped unand we've had the ukrainian deal and the president wasn't just, you know, willing to just jump in there and risk american troops' lives and what he did do was hold out and make sure he was able to get a coalition. just like with the germans and the english and the surrounding nato countries. just like down there in the middle east, there was no, you know -- if the americans would have went in there like mccain and this guy -- >> we are going to leave the last five minutes or so of this to take you live to the white house where president obama will be awarding two vietnam era veterans the medal of honor, the high he is awaest award that ca to military personnel.

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♪ and here at the white house waiting for president obama here shortly to award the medal of oh honor to army command sergeant may jr. benny adkins and donald

sloet. major adkins will receive his medal for serving as an intelligence sergeant during the vietnam war and sergeant sloat for his actions as a machine gunnerer during vietnam. dr. william sloet will accept on his brother's behalf.

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♪ ♪ ladies and gentlemen, the president of the united states. [ "hail to the chief" ] ♪ let us pray.

most high and gracious god we pray today that you remind us of the value of sacrifice. how hero is a venerable title, the price paid by soldiers like the two we honor today. remembered by persistence to defend his brother to never accept defeat and never quit. one who saved the lives of his friends by selfishly giving up his own. these brave men living and dead consecrate our history and faith, the courage of our soldiers, sacredness of values, strength of the nation. today we weave their actions into the fabric of history as we served in the jungle mists in the kasan lowlands. may we never forget what they did, the friends they lost, the family they left behind.

we ask you to grant these, your holy name, amen. >> please be seated. good afternoon. welcome to the white house. more than four decades ago in early 1970, an american squad in vietnam set out on patrol. they marched down a trail past a rice paddy. shots rang out. and splintered the bamboo above their heads. the lead soldier tripped a wire, a booby trap, a grenade rolled

toward the feet of a 20-year-old machine gunner. the pen was pulled. that grenade would explode at any moment. a few years earlier on the other side of the country, deep in the jungle, a small group of americans were crouched on top of a small hill. it was dark. they were exhausted. the enemy had been pursuing them for days. now they were surrounded and the enemy was closing in on all sides. two discrete moments, but today we honor oh two the american soldiers for gallantry above the call of duty at those moments. specialist donald sloat stood above the grenade and command sergeant major benny adkins who fought through a ferocious battle and found himself on the jungle hill.

nearly half a century after their acts of valor, a grateful notion bestows upon these men the highest military decoration, the medal of honor. normally, this medal must be awarded within a few years of the action. but sometimes even the most extraordinary stories get lost in the fog of war or the passage of time. when new evidence comes to light, certain actions can be reconsidered for this honor and it is entirely right and proper that we have done so and that's why we are here today. before i go any further, i want to thank everyone present here today whose research and testimonies and persistence over so many years finally resulted in these two men deserving the recognition they so richly deserve. i especially want to welcome members of the medal of honor society as well as two american

families whose love and pride has never wavered. don sloat grew up in the heart of oklahoma in a town called powita. he grew big. over 6'4". he loved football. he played for a year at a junior college. then he decided to join the army. when he went to enlist he didn't pass his physical because of high blood pressure. so he tried again and again and again. in all he took the physical maybe seven times until he passed. because don sloat was determined to serve his country. in vietnam, don became known as one of the most liked and reliable guys in his company. twice in his first months, his patrol was ambushed, both times don responded with punishing

fire from his machine gun, leaving himself completely vulnerable to the enemy. both times he was recognized for his bravery. or, as don put it in a letter home, i guess they think i'm really gung ho or something. then one morning, don and his squad set out on patrol, past that rice paddy, down the trail when the shots rang out. when the lead soldier's foot tripped that wire and set off the booby trap, the grenade rolled right to don's feet. at that moment he could have run. at that moment he could have ducked for cover. but don did something truly extraordinary. he reached down and picked that grenade up. he turned to throw it, but there were americans in front of him and behind him.

inside the kill zone. don held onto the grenade and pulled it close to his body and he bent over it. as one of the men said, all of the sudden there was a boom. the blast threw the lead soldier up against a boulder. men were riddled with shrapnel. four were medevaced out. everyone else survived. don absorbed the brunt of the explosion with his body. he saved the lives of those next to him and today we are joined by two men who were with him on that patrol -- sergeant william hacker and specialist michael moleheim. for decades, don's family only knew he was killed in action. they heard he stepped on a land mine. all those years, his gold star family honored the memory of their son and brother whose name is etched forever on the granite

wall not far from here. late in her life don's mother evelyn finally learned the full story of her son's sacrifice. she made it her mission to have don's actions properly recognized. sadly, nearly three years ago evelyn passed away. but she always believed she knew this day would come. she even bought a special dress to wear to this ceremony. we are honored that don and his mom are represented here today by don's brother and sisters and their families. on behalf of this american family i would ask don's brother, dr. bill sloat, to come forward for the reading of the citation and accept the gratitude of the nation.

>> the president of the united states of america authorized by act of congress march 3, 1863 has awarded in the name of congress the medal of honor to specialist four donald p. sloat, united states army. specialist four donald p. sloat distinguished himself by acts of gallantry at the risk of his life serving as a machine gunner second ba tall i don't know, first infantry regiment 196 light infantry brigade during combat operations against an armed enemy in the republic of vietnam in 1970. that morning specialist of the squad was conducting a patrol. serving as a blocking almost in terms of tanks and other personnel in the area. as the squad moved up and filed formation the lead soldier

tripped a wire attached to a hand grenade booby trap. as it rolled down the hill, specialist sloat knelt and picked up the grenade. after initially attempting to throw the are grenade he realized detonation was imminent. he drew the grenade to his bind shielded his squad members from the blast, saving their lives. his actions define the ultimate sacrifice of laying down his life in order to save the lives of comrades. donald p. sloat's heroism and selflessness above and beyond the call of duty are in keeping with the highest traditions of military service and reflect great credit upon himself, company d, second battalion, first infantry regiment 196 light infantry brigade, and the united states army.

[ applause ] [ applause ] at this point i would like

to ask benny adkins to come join me on stage. now let me just say the first thing you need to know is benny and i met in the oval office. he asked if he could sign back up. his lovely wife was not amused. most days you can find benny at home down in alabama. tending his garden or oh his

pontoon boat on the lake. he's been married to the mary for 58 years. he's a proud father of five. grandfather of six. at 80, still going strong. a couple years ago he came to the white house with his fellow veterans for a breakfast we had on veterans day. he tells folks he was the only person he knows who has spilled his dessert in the white house. i just have to correct you. that makes two of us. i have messed up my tie. i have messed up my pants. in the spring of 1966, benny was just 32 years old, on his second tour in vietnam. he and his fellow green berets were at an isolated camp along

the ho chi minh trail. a huge force attacked bombarding benny and his comrades with mortars, white prhosphorous. it was nearly impossible to move without being wounded or killed. benny ran in to enemy fire again and again to reare troo trieve ammo, carry the wounded to safety, man the mortar pit holding off wave after wave of enemy assaults. three times explosions blasted him out of the pit and three times he returned. i have to be honest. in a battle and daring escape that lasted four days, benny performed so many acts of bravery we actually don't have time to talk about all of them. let me just mention three. on the first day, benny was helping load a wounded american onto a helicopter.

a vietnamese soldier jumped on and aimed his weapon at the wounded soldier. benny shielded his comrade, placing himself this the line of oh fire, helping to save his wounded comrade. at another point in the battle benny and other soldier ares were trapped in the mortar pit, covered in shrapnel and smoking debris. their only exit was blocked by enemy machine gun fire. so benny thought fast, dug a hole out of the pit and snuck out the other side. as another american escaped through the hole he was shot in the leg. an enemy soldier charged him hoping to capture a live p.o.w., benny fired killing that enemy and pulling his fellow american to safety. by the third day of battle, benny and others managed to escape into the jungle. he had cuts and wounds all over his body. he refused to be evacuated.

when a rescue arrived benny insisted others go instead. benny, wounded and bleeding, found himself with his men on the jungle hill exhausted and surrounded with the enemy closing in. after all they had been through, as if it weren't enough there was something more. you can't make this up. in the jungle they heard the growls of a tiger. it turns out the tiger may have been the best thing to happen to benny in those days. he said the north vietnamese were more scared of the tiger than they were of us. so the enemy fled. benny and the squad made their escape and they were rescued finally the next morning. in benny's life we see the enduring service of men and women in uniform. he went on to serve a third tour in vietnam. more than two decades in uniform. after he retired he earned his master's degree -- not one but

two -- opened an accounting firm, taught adult education classes. became national commander of the legion of valor veterans organization. he has earned his retirement, despite what he says. he's living outside auburn. yes, he's a fan of the auburn tigers but i polled the family and there is some crimson tide fans here. so there is obviously division. benny will tell you he owes everything to the men he served with in vietnam. especially the five who gave their lives in that battle. every member of his unit was killed or wounded. every single one was recognized for their service. today we are joined by some of the men who served with benny including major john bradford, the soldier benny shielded and major wayne murray, who benny saved from capture. i would ask them and all of our

vietnam veterans who are here to please stand or raise your hand to be recognized. [ cheers and applause ] now i ask for the citation to read. >> the president of the united states of america authorized by act of congress march 3, 1863, has awarded in the name of congress the medal of honor to sergeant fist class benny g.

adkins, united states army. sergeant first class adkins distinguished himself by acts of ga lan tri at the risk of his life above and beyond the call of duty while serving as an intelligence sergeant with detachment a-102, fifth special forces group during combat operations against an armed enemy at camp eshu, republic of vietnam in 1966. when the camp was attacked by a large north vietnamese and veet congress force in the morning hours sergeant adkins rushed through intense enemy fire and continually adjusted fire for the camp despite incurring wounds as the pit received several direct hits. upon learning several soldiers were wounded near the center of camp, he temporarily turned the mortar over to another soldier, ran through exploding rounds and dragged several comrades to safety. as the hostile fire subsided sergeant first class adkins

exposed himself to sniper fire while carrying wounded comrades to the dispensary. when he and his group of defenders came under heavy small arms fire from members of the civilian irregular defense group that defected to fight with the north vietnamese he evacuated a seriously wounded american and draw fire while successfully covering the rescue. when a resupply air drop landed outside of the camp perimeter sergeant adkins again moved outside of the camp walls to retrieve the much-needed supplies. during the early morning hours of march 10, 1966, enemy forces launched the main attack and within two hours sergeant adkins was the only man firing a mortar weapon. when all mortar rounds were expended sergeant adkins began placing recoilless rifle fire upon enemy positions. despite rounds exploding on his

position, sergeant adkins fought off intense waves of attacking vietcong. he eliminated numerous insurgents with small arms fire. running extremely low on ammunition, he returned to the pit, gathered vital information and returned through intense fire back to the bunker. after being ordered to evacuate he and a small group of soldiers destroyed classified documents, dug their way out of the rear of the bunker and fought their way out of the camp. while carrying a wounded soldier to the extraction point he learned the last helicopter had already departed. sergeant adkins led the group until they were rescued by helicopter. during the 38-hour battle and 48 hours of escape and evasion, fighting with mortars, machine guns, small arms and hand

grenades, it is estimated sergeant first class adkins killed between 135 and 175 of the enemy while sustaining 18 different wounds to his body. sergeant first class adkins's extraordinary selflessness above and beyond the call of duty are in keeping with the highest traditions of the military service and reflect upon himself, a-102, fifth special forces group, first special forces and the united states army. [ applause ]

over the decades our vietnam veterans didn't always receive the thanks and respect they deserved. that's a fact. but as we have been reminded again today our vietnam vets were patriots and are patriots.

you served with valor, made us proud and your service is with us for eternity. so no matter how long it takes, no matter how many years go by, we will continue to express our gratitude for your extraordinary service. my god watch over don sloat and all those who sacrificed for our country. may god keep safe those who wear our country's uniform and veterans like benny adkins. may god continue to bless the united states of america. at this point i would ask our chaplain to return to the stage for the benediction. >> let us continue to pray. as you go forth be not afraid. go into the world with peace, hold onto good.

support the weak and help the suffering. honor all people. let us love and serve and may god's blessing be upon us. remain with us always, amen. >> at this point, i would welcome everybody to join the sloat family, the adkins family for a reception. i hear the food is pretty good. once again to all of you who serve and your families who serve along with them the nation is grateful. your are commander in chief could not be prouder. thank you very much, everybody. [ applause ]

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the presidential medal of honorer ceremony wrapping up. if you missed any of it, we'll have it up shortly online. check it out any time at c-span.org in the video library. today at the u.s. capitol the house and senate have govled in. the house starting legislative work at health care 4:00 eastern time with more than a dozen bills on the calendar in the house including steroid trafficking, and child care subsidies. watch the house live on c-span and the senate and speeches now and more work on a bill dealing with campaign spending in federal elections. you can watch live on c-span 2.

the house rules committee is supposed to meet to consider a continuing resolution. a short-term federal spending to fund the government and related agencies until lawmakers pass a budget. c-span cameras will be there at the rules committee. we'll take you live. it's scheduled to meet after the last vote in the house today. you can tune into that meeting streaming live online. c-span.org. several hearings coming up this week on the u.s. strategy to combat isis. defense secretary chuck hagel and the joint chiefs of star chair dempsey will appear before the senate armed services committee. live coverage at 9:30 a.m. eastern here on c-span 3. also tomorrow a hearing on the ebola outbreak in west africa and the international response. witnesses in that hear ing include the head of the national institute of allergy and infectious diseases. also health workers who treated people directly who are infected

with the virus. watch that joint hearing of the senate health committee tomorrow live at 2:30. >> tonight on "the communicators." california democratic representative anna eshoa talks about net neutrality and rules governing the internet. >> i spoke publically about what i thought the fcc should do to be on firmer legal ground and point it to title two. now we have had, fast forward, discussions at the committee about it. this is all about net neutrality, obviously. people in our country feel very strongly about the internet. not only how they use it, but how they think about it and the access to it. that it be free and open and that no one should be able to

interfere with that. >> tonight at 8:00 eastern on the communiqcatoommunicators. >> ted nichol talked about the mixed approach. he spoke during a panel discussion with the lines for health reform in washington, d.c. a former official with the obama administration took part in this discussion. it's about 90 minutes. >> okay, folks. we are going to go ahead and get started. good morning. on behalf of the alliance for health reform and our honorary cochairmen i would like to welcome you to this morning's session about network adequacy. i would like to thank our sponsors, the blue cross/blue

shield association and the university of pittsburgh medical center. if you are following us on twitter, the hashtag this morning is # network add question si. if you are listening by phone or watching on c-span 2, you can e-mail questions to us at questions@all health.org or you can tweet them to # network adequacy. the title of the session is network adequacy. we have heard many names for these networks. we have heard everything from limited networks, narrow networks, value networks. why are we having so much trouble naming these things? first, what are they? some new insurance plans in the marketplaces offer consumers networks that are -- that do not include certain docker tors, hospitals or medical providerers. some are saying that the smaller networks are causing problems for provider access, choice.

many are saying if done the right way, this can help by creating competition and controlling costs while also maintaining quality. so there are a lot of questions about this. therefore the trouble naming them. do they save consumers money? is the quality of care as good as in broader networks? do consumers have enough choice? do they need all that choice? how prescriptive should the governments be in setting requirements for the networks? what is the consumer experience so far and what will it be going forward. we are fortunate today to have three experts with us. we are going to start with ted nichol today, wisconsin's insurance commissioner. he also plays a leadership role at the national association of insurance commissioners. where he's a point person on this subject and is heading up

efforts to update model regulations for the states. joe ario is managing director of menat health solutions. he was first director of the office of health insurance exchanges at the department of health and human services. he's been pennsylvania's insurance commissioner. also oregon's insurance commissioner. michael chernu is a professor of health care policy at harvard medical school. he's a member of the congressional budget office panel of health advisers and the institute of medicine's committee on national statistics. he's also a former vice chair of the medicare payment advisory commission. once the three of them have given presentations we'll open up to questions and answers. at that time, diane holde executive vice president of university of pittsburgh medical

center and elena pabin within the value partnerships department of the blue cross/blue shield of michigan will join us for the q&a. we are going to go ahead and start with ted. >> good morning. thank you for having me here today. this is really an important discussion. one that's going to continue for quite some time into the future. we want to focus on network adequacy. i want to provide a little bit of background and update from a regulator's perspective on network adequacy. first of all it's important to know, realize and remember that there are a lot of conflicting issues surrounding network adequacy. for consumers the main issue is whether or not their doctor or hospital is in their insurance plan and whether or not they can receive the care they are

looking for. also whether or not they can ultimately be able to afford a particular care. and to keep their health care costs and insurance costs down. for providererers on the other hand, the wider the networks the greaterer the reimbursement rates. the more attractive it is for consumers to pick from those plans and increase patient numbers. then providers are constantly negotiating with insurers for higher reimbursement rates. insurers view wide networks a little bit differently. they would typically see those as increasing costs and decreasing the ability to manage care. insurers are constantly negotiating with providerers on reimbursement rates to narrow at times networks to increase and better manage the care of patients and consumers.

all of this is to a point from the regulator's perspective the networks must be sufficient or the insurer may have to pay in network benefits to out of network providers. with the divergent issues in play, how do we as regulators referee. it's really a mixed regulatory approach. it differs from state to state. networks are subject to a number of different reviews. first is state review. the network must meet any state standards. then there are a number of -- excuse me. then any number of insurers may try to become accredited by national accrediting firms such as ncqa or iraq. this is optional but used as a sign of quality. good housekeeping seal of approval. for insurers selling on an exchange or opting for qualified

health plan designation, they also must follow federal standards. again, from a are regulatory perspective who do we regulate to assure network adequacy and network -- folks following networks. for the insurer, do we regulate the insurer, the network itself. do we regulate tpas? for a fully insured plan it's simple. the insurance regulators regulate the insurers and can regulate the plans through that process. for a self-insured plan it's not as clear. as a result some states have looked at regulating third party administrators to get to the issues. most states will only be able to regulate the network issues through the insurer oversight function. it is also important to note there might be different standards for different products. in wisconsin, an hmo or a closed

panel may be required to report more quality measures or may be required to allow direct access to certain providers such as an ob/gyn. there are also appeals processes in place for emergency care. ppos and open panel plans may have lesser requirements because consumers have an option to choose from any provider. one of the other debates at this point may end up revolving around this business of multi tier plans. a larger network is attached with higher co-pays and out of network benefits. do we look at the tiers? how? should the smaller tier be regulated and should it have to be a full network? typically that tier level doesn't include specialists.

all of this is to get at my next point. many cases in the past -- excuse me. in many cases the passage of the aca has resulted in the accelerated use of, focus on and narrowing of networks across the country. harken back to my earlier point that no control or narrower networks can lower costs for insure insureds. widerer benefits under qhp, under aca increased the cost of insurance. insurerers to keep insurance costs lower, look to network design to slow the anticipated increase in rates. renewed focus on networks and network adequacy caused the nic, of which i am a member to re-examine and update the modern law. not unusual but usually environmental factors cause the naic or the normal vicissitudes

of time to up update laws. the current model has not been looked at or updated since the late 1990s. state that is adopted the model are able to make their own changes at any time. the model was adopted in 1996, very flexible and is still good. its pliability reflect it is diversity that exists between states in terms of market differences, large versus urban -- excuse me, large urban versus vast rural and the way insureds operate. open versus closed panel but keep it is same standards. the model itself file a plan to

ensure they are meeting the standards of the area. wisconsin chairs the group. it's charged with revising the model. we have sought a lot of input from all parties affected by the law. consumerers, providers, insurers and accrediting organizations. we have received 26 comment letters thus far from interested parties. once we are finished reviewing those, we'll continue working on revising the model. the goal is to add all the changes or look at the changes and take a fresh look and go through the model one more time. in and around network adequacy, in some cases we may not be able to come up with an answer. as a regulator of insurance it may not be our place to answer. issues we'll be grappling with are narrow network as problem? what if no wide networks are in a market.

what if the insured doesn't offer out of network coverage. how narrow is too narrow. does it matter if an insurers cover all out of network services. what is the appeals process for uncovered services? should there be a single state-wide standard? what happens when a doctor or hospital leaves a snunetwork? and to what degree should there be continuity of care. and requirements as well. the list goes on and on. finally, we as regulators and folks working on this very important issue need to keep things in mind as well. we always need to be mindful of costs. we need to look at access to med call care for vulnerable consumers and recognize and understand that we as regulators don't have all of the answers. we need a model that can address the existing and emerging issues for another 15, 20 years.

>> actually, before we move on, can i just ask you what can you tell us at the moment? i understand you haven't finished your work at the naic, but where do you think we are headed with the regulations? are there any based on the comments, where the other insurance commissioners are? what can you tell us about where you think we are headed with the regulations on questions you raised? >> that's a broad question. >> state to state differences needs to be recognized. we have states with significant urban populations.

then you have states like wisconsin with pockets of urban populations surrounded by cows. it's important to make sure that there is a model in place and a framework in place to get ultimately get consumers the type of care, the type of access they need. again, keeping in mind the cost issues. the other issue that we have seen so far is in talking with staff, this issue of network adequacy, while always being something we get questions or complaints about we have not seen an uptick in the amount of

questions about, gosh, my insurer cancelled my network or oh threw out my doctor. we are not seeing that yet. we are trying to keep those things in mind as we look to, again, update the model. and update it with an eye toward new products out there. there is new technology available. a lot of the entire health care market, entire health insurance market has changed since the model has passed. heading in that direction of updating the model given a lot of environmental factors that we have seen. >> one more question and we'll move on. regarding the comments that have come in from stake holders and others. are there any particular themes

that you -- this red threads yow or disagreements you think are going to make your job a lot more difficult. >> think the one issue that's always going to be a challenge is access. you're going to want -- there will be a certain folks who want to have complete wide access to whatever is available out there and you're going to have the other side pushing back saying it's a great idea. but it's just not affordable at that level. and you're always going to -- we have seen that there's a need for more managed care. there is so much more technology out there. there are so many ways to better handle individual care.

and i think joel will address it at some point this morning. that this idea of focusing on a narrowing of networks and better managing care is really becoming a huge part of the landscape. it's really promoting healthier outcomes. >> handling these issues, looking to the naic and different perspectives and the way they are represented is a good way to get a window into

the issue. i i hope we keep this issue primarily at the state level. i think it is the kind of issue that differs dramatically across the states. one more comment i want to make is the last time we were here at the press club it was for an event that john carr asked me to attend. i learned of his sudden death. i think he was a reporterer in the very best tradition. just a natural curiosity about issues and just really did a bang-up job covering the issues, particularly at the naic. i will get into my comments. i have three points to make. one is around the networks and what was intended in the aca in terms of setting up exchanges and competition. issues within the aca to the network issue.

and what are some of the consumer concerns here. ultimately, i think consume rs will be the barometer on this issue. we've going to have a different outcome than if they starting with the networks, shows you how controversial the issues are. you get in trouble right away depending on what you call these things. narrower value networks were clearly intended in the aca. you take out a lot of the other variables on particular risk selection. i'm glad it's gone as a form of competition or maybe not completely gone. it should be and will be gone. you have to look at other ways to compete.

i think it was clear as the aca was set up that one of the things that insurers do to compete was really asking hard questions about the networks and trying to manage price around how they set up the networks. it was also envisioned in the aca that part of the reason it would work in counter distinction to the 90s was because exchanges offer a multitude of choices to people. so it wouldn't be like your employer deciding to go with an hmo as the only product and you are forced into a narrow network and it's a one size fits all situation. the exchanges allow you to have a situation where if people want they can choose broader ppos. if they want, they can choose other narrower network products. i think that's important. i would want to make sure all the products weren't tightly managed products that there were choices for consumers in the ppo

world. i will come back to that to talk about the consumer. the consumer has to be educated, know the difference between those issues. the first point is this is not a surprise to people who take the aca together. they have this competition and it's a healthy kind of competition to have in the marketplace. i feared one thing more than anything else in this arenament it would be that some events happened that caused people to sort of set a one-size fits all type solution to the problem. it takes away the rich competition that can happen around different approaches to networks. if you look at the rest of the aca outside the exchanges now, you do see the things ted talked about at the end there of the acos, affordable care -- accountable care organizations which could call them affordable care, too. the acos, really other dimension

of the payment reform initiatives out of the innovation center, bundle payments. they all require are tightly managed oversight of the provider networks. and between the provider network and the insured. you could call them kaiser-like approaches to the issue. when i was at the agent setting up the original network rules. some people were proposing fairly stringent standards that would apply to everybody as we were just kicking around ideas. i would ask the question, what would you do with kaiser under that situation? people would go, oh, kaiser is different. i would say, well, what about other people that are going to say when the law is in place, we want to be kaiser. you can't just say, well, kaiser is different. you have to let everybody have an opportunity to do that or you say you can't do it at all. i think those integrated delivery systems are very

important. we saw earnings calls last week. david credani of sig that and mark -- from aetna talk about flexibility around networks and how the aco work which they are busy creating acos in conjunction with the insurance activities that those become examples of products. i think ted, you have some in your state now. the chinese plant in san francisco. you will make these plans in local areas that have a select network and i want those products on my exchange. i do want them. insures have to be pushed into creating products. in massachusetts, it was the legislature that had to say we want all the insurers to offer a product with a lower price point with a narrower network. we want the choice available. so i think all of that is important here. it's intended for price comp oh technician.

it's also key to managed care and improving the quality at the same time you are reducing the cost. the way in which networks are managed are critical to that. and i think the future does hold that a number of the aco-type developments happening around the country will show up as targeted products on the exchanges. so that gets me to the third, probably the most important point. again, consumers are the ultimate barometer here. the insurers, politicians, everybody that's part of the is system, even the insurance commissioners, depending on what consumers say and how they vote in the marketplace. will react to that. and the rules will differ. so i think two issues are important to make for a vibrant and competitive network. one is transparency. the consumer need s to know who is in what network, which plans are which kind of networks.

unlikely to see a kaiser being challenged on its networks because of where it operates. people pretty much know what they are getting there. it's more or less a closed a closed system it's a much different thing if a broader plan that has a reputation and advises itself as all the doctors in the state and our networks and so forth. there was a small print who said that's not part of that. you don't have that. we have something else. you should be able to do that and have those networks. it has to be transparent. there is a lot of work to be done. finally i think there have to be some kind of safety valves for out of network protections if you are going to draw around the out of network and reward people around the state and network and big penalties and no

reimbursement out of network. you have to have rules like i go to the in network hospital and i get a bill that said unbenounced to me, one of the professionals is not in networking. new york now regulates that and said consumer doesn't know about it ahead of time, they get the in network price. a lot of issues to make sure the consumers are educated around these issues and that there is full transparency. it would be wise and i suspect that they'll come to this conclusion that we ought to give states wide latitude to regulate this in response to local market conditions. >> so let's turn to mike. >> great. thank you. i am thrilled to be here. when i speak at events like this, sometimes speakers disagree and there a lot of

fireworks and it's exciting. unfortunately i am going to be in agreement with the previous speaker. for those who wanted a jerry springer event, i don't think we will have one. maybe later. first let me start by saying something about the term narrow versus value. value and narrow, narrow networks may be high value. about but value imi plies cost and not just that. value has a specific manying about what you are getting for the amount and not to be used for the sake of that. you could have a high value, but you may not. i think the discussion here is what to do when you have a narrow network that is not high value. let me start by laying out a general part. one of the things i find frustrating is when i read articles, the topic is when they move to another area and they

forgot what was written last week. there was a lot written about the prices we have that are high. that's an issue. so one advantage about having narrower networks, the price that is paid to providers. one advantage of narrower networks is it strengthens the hands of the people who are focusing. he is buying a car and he funds to his wife and one of the sales men. it was interesting to say it wasn't that useful in the negotiation process. if you are negotiating and the other person knows they have to be in, it changes the price. if you are worried about the price and you may or may not be in a market system, the ability to exclude becomes important. another topic that has been interesting and we get the

geographic variation. and actually across providers. there is a lot more. if you knew that, wouldn't it make sense to try to construct a network for you folks on those providers and follow more efficiently the advantage of having a narrower tactic. there other reasons. if you can concentrate enrollment and it facilitates engagement and may reduce administrative costs. i can make a strong case for why there is merit to these types of things and that said, there is a lot of reasons to be concerned about the products. most importantly, people need access to good doctor and convenient doctors and their

doctors. we very much want to have people have that opportunity. the problem is in general, you choose your plan before you get ill. it's not clear who you know. i can name one doctor who is my doctor. i have a lot of body parts and all of them can break. i have no idea which doctor i would want to go in that eventuality. i would be forced to choose my plan. i don't want to investigate who the best neurologist and dermatologist and whatever else i might need before i choose my plan. i can't make that choice. even though i agree with the other speakers, the consumer awareness is important. it would be how much we can inform consumers. the time they choose their plan versus the time when they need their care. in the case where you use a lot of doctors.

i might not know and the relationship with the oncologist. it was the primary physician. people were very serious. it was difficult to see now you have to choose. so transparency is obviously important. it's not going to be a full solution. it was a bait and switch thing that might happen. the network changes all of a sudden your doctor is not in. we have to think about how to

deal with that. both said and i think it's important one of the ways to deal with this type of problem is to reduce the consequences if your physician or hospital ends up being out of network. what do you have to pay to reduce the harm that occurs if there is some mismatch between what you want and need. there is another problem. another concern about the types of networks, the concern related to selection. it is true that i can make a compelling case with variation and proficiency and pick those who are more proficient. you might be able to pick different patients by picking certain doctors. we have to worry about them. i believe in a personal comment, we made ard vances in risk and i am less concerned about that and i could show you evidence that suggests it might be more

appealing for plans for folks with chronic disease as opposed to out with the way we do risk adjustment. that's the end of the process. i think that matters. a few other final points, the first is and i hate to say this because we are going out on tv somewhere, but i believe this. fairness to providers is important. it is not the goal of the health care system. there is sometimes fair to providers. at the understand of the day the ability of providers to get into a network is not what we are concerned about. it's more about patients having access and the cost they can afford. we will see through the networks a big reorganization and how the providers respond and that will

be one of the most important to monitor. the providers are going to have to negotiate in different ways with the plans. a few other things as was mentioned before, we need to think about the issues that is narcotic and not plan specific things. that creates challenges and i'm glad i'm not one. we have to focus on that and the second thing is ideally, we would be able to focus on measures of out come and not structure. things that were mentioned as opposed to those things on structure. it will remain hard if we focus on structure. the more we can improve our measures, the less important the decisions we make and the easier it will be to make decisions about the underlying adequacy things because we will be able

to make sure to avoid the most egregious cases. in summary, we will not get this perfectly correct. there will be complaints for a variety of reasons. many are likely to be justifiable, but we have to avoid the temptation to move to a system that creates a creative network development because we want to avoid there ever being a problem when those networks do get developed. thank you. >> great. thank you. before we head into the q&a, one question for the three paneli s panelists. what do we already know about cost and quality? if you comparing the narrower to the broader networks. do we have numbers and research that show us numbers in terms of cost