slow ta there's been no information released on where the family units have been allowed to resettle. most of them were released from custody before the department started detaining them. the reason for that was -- were multiple, but one of them was that i.c.e. did not have a detention facility that was appropriate for these people. despite the existence of a mass migration plan in which they knew how they wanted to, and could, stand up a detention facility for a situation such as thi

thi this. ice forgot about the plan or is not using the plan. it closed its family detention center in texas a couple of years before this got out of hand. what i.c.e. ended up doing was releasing some of the family members, some of them getting parole status. they have released information on where the unaccompanied juveniles have been resettled so far which i put in the packet. total of 37,000 of them they've provided details on with the majority going to a handful of states -- which are a little bit different than the unusual patterns of illegal settlement here. over 5,000 in texas. 4,000 in new york. 4,000 in california. almost the same number in florida as in california. and also significant populations of almost 3,000 in virginia and maryland. what they're doing is people are going to places where there are already existing established communities of central americans who arrived before them.

the numbers, i'm sure, are going to increase next year. and the reason is no one is being sent home. so our country has yet to establish an effective deterrent for more people to come here illegally through south texas. according to news reports, there have been exactly -- not exactly -- roughly 280 of those 200,000 new arrivals who have been deported from the country. that's about 280 people associated as a family unit who were deported from the center in ar t artisia. that's a miniscule drop in the bucket compared to the sizable influx. the main cost, as mayor kennedy indicated, to communities that are absorbing these individuals

is education. to give a sense of the sum total of what this cost is going to be, i took a look at what some of the states that are most affected have estimated for the costs of providing an education to just -- to all of the kids who have arrived in this influx. texas estimates that it is going to be spending about $9,500 per child. that's a figure that was developed for their budgeting process in the legislature. florida has estimated that its average cost for educating a child is about $8,900 a child. per year, but that these unaccompanied juveniles require an investment of an additional $1,900 per child. the national average -- both of those states, by the way, seem to be running a little bit less

per child cost than the national average which is more like $11,000 to $12,000 per child. so if you apply those costs to just the number of unaccompanied juveniles who have arrived just this year, which is expected to be 90,000, that works out to about billion per year. just for the ones that arrive this year. not counting previous arrivals, not counting future arrivals. it is an enormous sum of money that american taxpayers are going to be putting out to cover the costs of education. again, we don't know how many kids are in the family units. it's got to be at least 60,000, assuming one child, one parent. it's certainly much more than that. another relatively undiscussed impact of this surge is going to be on the labor markets in our

communities. how many of these individuals are going to be working and where and what kind of jobs. we know that some of the kids in lynn are working, particularly in the landscaping industry, as i understand. and i think it is reasonable to assume that that's one of the primary motivating factors for them to come here, is that they will be able to work, whether legally or illegally. what. many people don't realize is the family units who were admitted before they started detaining some of them, because they were released as parolees into the united states rel gibl united states are eligible to apply for a work permits and many will certainly be granted work permits while they're here. work. permits have really become the primary vehicle for executive amnesty. the executive branch has the authority without restrictions from congress on issuing work permits. they can issue an unlimited number of them. it has become apparent that when

the president can't issue more work visas, he turns to the work permit as an option for providing people with the ability to say here and support themselves. but finally, the worst unintended consequence of our failure to control this influx is the public safety consequences that are going to be a result of this. the most affected state has already quantified this and that's texas. they've already budgeted $300 million for this year which they had anticipated, because they've seen this surge happening over the last couple of years. they've had to add on an additional $17 million a month in state funds for public safety, primarily to back up the border patrol because. many border patrol agents are taken off the line in order to manage the custody of the families and juf nice who are

crossing. but beyond the immediate expense of trying to contain the surge and limit the ability of criminal enterprises that are exploding this weakly controlled border in texas, there is another very serious, but again predictable, potential unintended consequence and that is the resurgence of violent criminal street gang activity that is almost certain to result from this new influx of illegal immigrants. i know the mayor referred to a decline in the number of gang members in lynn. i think it is a pretty safe prediction that lynn and other cities like it that have been absorbing a lot of this influx are going to see an increase in street gang activity. we know this from experience but we also know it because of changes in i.c.e. policy that have affected their ability to do gang suppression and dismantling efforts.

it is predictable because it's happened before. one of the unintended consequences of a previous wave of illegal immigration from central america which occurred if '80s and '90s was the emergence of a new breed of extremely vicious and unusually degechlt nerate street gang. ms-13 was started by thugs who settled illegally in california when gangs were not a focus for law enforcement and they were able to expand across the nation into areas that already had large illegal salvadorean populations. a large share of the membership of ms-13 and 18th street and other gangs is comprised of illegal aliens. that made them before, and makes th them today, vulnerable to immigration enforcement in a way that they were not so vulnerable to local law enforcement or even to the fbi. as a result of targeted

immigration enforcement activity starting at about 2005 and continuing until just a couple years ago, through a program known as operation community shield, these gangs were depleted and weakened throughout the country. it was a huge success. i.c.e. made more than 30,000 arrested of gang members across the united states. ooh significant share are from the three central american countries of the surge. i've given you some statistics on those arrests nationwide and countries of origin. we also find that a disproportionate share of the most violent street gang members and leaders and associates who are arrested do come from the central american countries and particularly from ms-13 and 18th street. the success in i.c.e.'s program was possible because of the

aggressive use of force by immigration authorities. they were arrested sometimes just because they were here illegally. i know that sounds like a quaint, antiquated concept now for them to arrest someone just because they were here illegally, but they were targeted because of their known affiliation with a criminal street gang. mostly due to their involvement in crime and even minor crime. i.c.e. successfully penetrated many of the more organized and larger street gangs and got them off the street. central american gangs have evolved in many ways over the years. they are now less flamboyant, less public, better organized, more professional, they have a lot more money and a lot better equipment. that makes them even more dangerous and harder to suppress and control. as a result they are even more of a threat to public order now than was the case ten years ago. many of them were deported to their home country and were able to continue and expand criminal activity there. they've recruited a lot of new

members, often through intimidation. gang crime and especially violence is, as we know, pervasive in the three central american countries that are the source of the surge where they operate with near impunity there. but in recent months they've had the opportunity to take advantage of the chaos at the border to return and in fact many of them are involved with the smuggling organizations, either doing the smuggling or providing security for the smugglers or discipline enforcement. whatever. but one thing has changed. i.c.e. is now less able to address that public safety threat posed by these gangs because of changes in immigration policies. agents are restricted in who they can arrest. they have to wait before an individual is convicted of a serious crime before they can keep them in custody and process them for deportation. family ties that a gang member has can trump criminal affiliations or potential threat to the public. even crimes that they've already

committed. some of these gang members now have quasi legal status, either through daka or their status is having come here as an unaccompanied juvenile. and d had hs has, frankly, inadequate screening to prevent the embedding of gang members here and enabling them to get status. i.c.e. policies often lead to the release of gang members who have been taken into custody, arrested and charged by some of i.c.e.'s investigative agents. one branch is arresting they will, another branch is releasing them back into the community. gang suppression, frankly, just isn't the priority that it was in years past for i.c.e. all of this leads me to have grave concerns about the potential for an increase in violence and crime due to street gang activity in those areas absorbing the surge. so i think it's probably about

time to see what you folks want to talk about and take your questions, which we're happy to do. >> there's a microphone, if you could wait for that and identify yourself. >> hi. penny star, cns news. this is for the mayor. you were talking about the ages of the students. can you be more specific? are you able to determine the actual age of the students and, say, are some as old as 18 or even older? it sounded like you were indicating that. >> we have no ability to confront the student directly and demand an accurate age. every once in a while we'll be able to determine that somebody is well above the age at which they would be entitled to an education in the lynn public schools. for example, if a student does not show up for a few days of classes, we will send our truant

officers out to find out what's going on at that home. so when they knock on the door and they say, we're looking for so and so, and the responding person says, well, they're at work. then every once in a while a person will out, for one example, the woman who answered the door said he's 35 years old. he's not going to show up at school. so we know -- we have good authority. but we cannot, per doj guidelines, we cannot ask them for any more verification of their age. and most of them don't come with birth certificates anyway. all they come with is a form from the jubilee center that says their date of birth was 1-1-98. we can't go beyond that. it does become very frustrating. >> any other questions? >> thank you. i'm a member of the fair board

of advisors. i'm also a massachusetts original by birth. mayor kennedy, why haven't towns and cities like yours stood up to the federal government, the justice department, and made them sue you for your doing your due diligence to establish the facts regarding your students, and why haven't you asked the national congress to cut the budgets of some of these agencies that aren't doing their jobs and redirect that money to cover the costs that the federal policies are imposing on your local government. >> well, actually, one of the reasons why i am down here in washington is to meet with some of the staff members of members

of congress to ask them to find solutions to help communities like mine. i can't speak for other communities. i don't know why they haven't stood up. i think the superintendent and i finally just reached our breaking point. i had gotten very good hold of the city's finances when i came mayor 4 1/2 years ago. we went from a baa1 bond rate i ing. i had had a solid financial backing for the city. in the last couple of years, it has all fallen apart and it has really frustrated me. so i am down here. this trip i'm meeting with some staff members of congress people because they're on break. but i am planning another trip in the next probably five or six weeks to come back down and meet directly with the congressional senators and representatives to find out what we can do to

assist communities like lynn and getting the money to pay for this increase in population. >> mike mackey, retired foreign selves officer. i've spent six years if central america and another five years in south america. so i'm aware of some of the issues there and what's causing some of the out migration. one of the issues here though is the responsibility of the federal government and a specific issue that we are looking at in fairfax county is title 1 resources. i'm wondering what's been your experience with title 1 which is basically based on the poverty index, a self-reported need for free and reduced lunches. is that helping? is it increasing? is it going to be part of your discussion with congress? >> well, lynn has always been historically a lower income community, a real blue collar community. we have about 8 % free or reduced lunches as far as our

student population goes. so the title 1 impact really hasn't been significant simply because we were at such a level even before this influx. one issue that i failed to bring up in my initial presentation regarding the schools -- i know this is more the at state level, but i wonder if virginia has something sim la. we have a massachusetts comprehensive test for students in the fourth, seventh and tenth grades that students are required to pass. they are expected to take and become advanced or proficient on those tests by their second year if the school system. our state funding can get jeopardized if our students don't score advanced or proficient. when i tell you these people are being placed in the ninth grade and they're illiterate in both english and spanish, the odds of us getting them to pass a tenth

grade math examination are negligible. so i am expecting that this is going to hurt the city of lynn's standing with the massachusetts department of education. the other issue concerning the schools that i did want to bring up is our drop-out rate. now the way massachusetts calculates this is if joe smith is a student in our system and he drops out in april, takes a landscaping job, comes back in october, drops out the following april, that counts for us as two dropouts even though it is one person. we've actually had one of these students drop out four times already and when our drop outrates go up, that also affects the city's standing with the massachusetts state department of education. so we see a lot of problems coming down the road as well as the ones that we're dealing with which are primarily financial right now.

i'm glad all of you have taken an interest in this. but i'm acting i guess in a way as a beacon or a warning to let people know that these are the consequences of the policy that the federal government has pursued. >> two questions. kno neil monroe. does this impact projects of economic development in lynn and what do the government officials tell you? what word do they use when you come up and say, i can't check their age, what are you doing to us? >> well, like i said, the i.c.e. that i've met with have told me that they're doing a really good job resettling these people but i don't think that they're really keeping track of where they're resettling them. we're not getting any firm answers. we're getting reassurances that feel more like pats on the head like just go about your business. and in fact, i've talked about the number of unaccompanied

minors that have been resettled here in the city of lynn. once they get resettled and they're claimed by a sponsor, those sponsors can be illegal themselves. but those sponsors then become conferred with the type of protected status because they are obligated to have control over that unaccompanied minor until their status hearing date. those status hearing dates are being pushed back through 2017 right now because of the backlog. so we haven't really gotten any answers from any federal officials as to what their long-tell plan is for helping out the communities where the resettlement is occurring. and the economic development. i really haven't seen any kind of impact on our economic development. lynn is, as i said, a poor community. it is an old factory community.

we have had actually a positive impact on the prices of our rental units and the availability of our rental units especially the ones in the desirable section of town. the prices have gone to the point where they're bidding wars when they come on the market. the stock in apartments is really scarce right now. so i guess in that way there's kind of perverse positive effect on the economic development. as far as business development, we've added a couple of businesses that have one that's going to generate 500 full and part-time jobs in the community, and another one that's generated 200 jobs for the community. so we haven't really seen any direct effect on the economic development prospects in the city of lynn. >> are people in the town glad to see the prices go up?

>> no. no. the landlords are happy that the prices are going up. but we have -- i guess as a consequence of that as well, the scarcity, we have started to see, although we can't directly confirm this, that apartments are being subdivide, which does create a public safety hazard for the community. one reason that we know this is happening is recently, about two or three weeks ago, we had a three-alarm fire in two multi-family homes. it started in one and spread to the second. and when the firefighters got to the third floor of the second building, they were finding it difficult to get into the bedrooms and find out whether there were people trapped in there because there were locks placed on those bedroom doors. they, in effect, became subdivided apartments, and that apartment effectively was used as a rooming house.

so we don't know how many more of those apartments are out there. i would love to just be able to knock on doors and take a look around but i'm prohibited from just bursting into people's apartments and checking that out. unfortunately, we found out about it when the fire occurred. fortunately, nobody was hurt, but it could have posed a real danger for either people trapped inside those illegally locked rooms or the firefighters that were wasting valuable time trying to look and check to make sure everybody had gotten out safely. >> dana milbank with the "post." you mentioned alleged teenagers with grey hair and wrinkles. can you say how many there are? have you seen them yourself? are there photographs? are there names? >> i have seen their applications, their processing forms that have come from the jubilee center. i would say, of the 30 or 40 forms that i have seen, maybe

seven or eight of them clearly, to me, looked older than the 17 or 18 years old that they were claiming to be. >> there are photographs -- >> photographs. i have not personally seen these people, because by the time i've become aware of them, they've been placed into the schools and -- i suppose i could ask the superintendent if i could take a walk over to the school system once school starts. for us it starts wednesday after labor day and maybe i'll be able to get some first-hand up-close looks at these students. but clearly, from some of the photographs, these people are adults. >> between legal/illegal, can you break down of the new student enrollment -- >> no. as i said, that's part of the problem with these figures i have been given. when i do get this out-of-country admissions sheet, it doesn't tell me how many are

refugees, how many are illegal immigrants, including unaccompanied minors, and how many have arrived in the community legally. but i can tell you just based on my conversation with the superintendent, that virtually all of those ninth grade guatemalan admissions are unaccompanied minors. another thing about lynn, we are projected to be the number one resettlement community for refugees coming in to the state of massachusetts. lynn is projected to get 202 new refugees this summer. and that opposed to the second largest city in massachusetts, springfield, is getting 58. boston's getting only 19. so we have -- >> these are not central americans. it this is through the regular refugee program. >> right. right. we have a multitude of problems. zpr tho . >> those are, by definition, legal immigrants and you don't know how many of these others are illegal immigrants.

now given that and the fact that the surge that you had actually predates the real surge that we've had in unaccompanied minors at the border, why are you so sure it is related to that as opposed to these other problems? >> because the start of our surge predated the national so-called -- when the national stage first became aware of this. as i said, in -- through 2012, we had only three ninth-graders from guatemala in 2011 and 2012. by 2013, it was 56, i believe. and then in 2014, it was 126. that was clearly the start of a trend. it was not any new factor that was introduced that was

complicating those figures. and again, we know that a lot of these unaccompanied children are coming through the jubilee center and the paperwork that they're coming up with is from the jubilee center. >> do you know how many you got from the jubilee center is it. >> i don't have the exact figure right now. i can get that. and by the way, if any of you have additional questions that you'd like me to answer that i don't have the answers for right now, you can send me an e-mail. the e-mail address to use is jcerul jcerulli@lynnma d jcerulli@lynn jcerulli@lynnma.gov. i'll be back at work tomorrow and i'll be able to start answering any more questions you might have. i'll have more access to research and be able to contact the school downtown to get any other information you might want. >> let's take a couple more questions so that you don't get e-mails. did you have something jessica? >> i was just going to add that,

there were some photographs of some of the individuals claiming to be juveniles who arrived in lynn that were published. so -- couple months ago. i can tell you where to get those. >> matt boyle. i wanted to ask you, what is the effect of this on lynn's citizens and on legal immigrants that are there, and are they aware of this and what is the community's thoughts of this surge that's happened? >> most of them are very afraid to speak publicly about it because they don't want to be branded as a racist. however, i can tell you that through the e-mails i have received and through the personal conversations i have had with the individuals in lynn, they are very concerned about the number of people who are coming in. they want to see it stopped. they're glad that i'm speaking

up about it. and even the legal immigrants are very frustrated that they had to wait eight, ten years and spend, in some cases, thousands of dollars to come to the country legally. they don't feel that it's fair that people who are coming across and throwing themselves at the mercy of i.c.e. are being able to get resettled more quickly and more cheaply than they were able to do. >> other than economic compensation for your budget, what specific changes in the immigration policy are you advocating before congressional staff? >> well, as i said, there's nothing specific. i will leave that to the policymakers at the federal level. but simply allowing all of the -- well not "all of." but to have a direct line from

the resettlement centers, such as the jubilee center, to the city of lynn without compensating the city of lynn for that direct line i think is unfair. i think, for example, if lynn has experienced an 8% increase in its school population, maybe there has to be a way to redirect students so that until every surrounding community has an 8% increase in their student population, then there's a moratorium placed on having the students enter the lynn school system. just to balance it out. that might be the fairway to do it. having immigration law changes might be the way to do it. having a tougher border security might be the way to do it. i'm not here to advocate for the value of one approach over the other. i'm simply making people aware that there are communities far away from the border that are feeling the economic impact of the policies that the federal officials have in place currently and i'm asking them to

look at them to acknowledge the impact that they're having on communities far, far away from the border and do something to change it. but as far as specifics, i leave that to the experts. >> some experts in the form of department of homeland security officials, border patrol and others of us who have studied this program over the years think that the appropriate response is to address the surge by deterring the continued entry and resettlement of people who are coming. we know that certainly the border patrol believes and has said and has written that when there are no consequences for illegal entry, and when people are allowed to rejoin family members who are already living here illegally, and when people who are here illegally are not subject to immigration enforcement unless they're

convicted of a very serious crime, and when our local government create sanctuary policies, for example, to prevent local law enforcement agencies from cooperating with i.c.e., those are all the conditions that lead people to believe that they will be able to successfully resettle here, and often with our government's help. so the answer is to enforce the laws we have, use the tools we have, to turn off the faucet of illegal entry rather than trying to redistribute funding to help out all the communities that are forced to absorb it. >> we're going to have to -- i want to respect people's time. we're going to have to -- one more question very quickly. quick answers. then we'll wrap it up. >> melanie uhb from numbers, usa. during my research on places like the juneby center, i found they describe their uac programs as placing children in foster care as one of the main

priorities. do either of you have any insight to the foster care program? have you talked to anyone who's been a foster parent? are they americans? the figures, the process. anything? >> i have not. that's a quick answer. >> okay. thank you, folks. i'm not sure whether the mayor or jessica will be around to be accosted afterwards but you can always try. i appreciate everybody coming. thank you very much. and thank you, mayor kennedy. >> thank you. >> some live events to tell you about. at 10:00 a.m. eastern, the

bipartisan policy center hosts a discussion on how terrorism threats are affecting national security. that's live on c-span. here on c-span3, the national press club will hear from former democratic senator jim webb of virginia. that gets under way at 1:00 p.m. eastern. over an c-span2, we'll be live from knocks with president obama speaking at the clinton global initiative's annual meeting. live coverage begins at 2:00 eastern. with live coverage of the u.s. house on c-span and the senate on c-span2, here on c-span3 we complement that coverage by showing you the most relevant congressional hearings and public affairs events. then on weekends, c-span3 is the home to american history tv with programs that tell our nation's story, including six unique series. the civil war's 150th anniversary, visiting battlefields and key events. american artifacts, touring museums and historic sites to discover what artifacts reveal

about america's past. history bookshelf with the best known american history writers. the presidency, looking at the policies and legacies of our nation's commanders in chief. lectures in history with top college professors delving into america's past. and "real america," featuring archival government and educational films from the '30s through the '70s. watch us in hd, like us on facebook and follow us on twitter. president obama recently awarded the medal of honor are to two vietnam war veterans. army command sergeant major benny adkins and army specialist donald sloat. command sergeant major adkins receives his medal for his action as an intelligent sergeant. sloat was posthumousry awarded

for his work as a gunner. ♪ >> ladies and gentlemen, the president of the united states. ♪ ♪ >> let us pray. most high and gracious god, we pray today to remind us of the value of sacrifice, how hero is a venerable title because of the price paid by soldiers like the two we honor today.

to never accept defeat, to never quit. and one who saved the lives of his friends by selfishly and reflectively giving up his own. these brave men, living and dead, consecrate or history and our faith, the courage of our soldiers, the sacredness of our values, strength of our nation. today we weave their actions into the fabric of our history as they served in the jungle mist in the caisson lowlands. may the living never forget what they did, the friends they lost, the family which he left behind. and we take to heart the words spoken after battle by a grieving president, that it is for us the living to be dedicated here to the unfinished work which they who fought have so nobly advanced. we ask you to grant these in your holy name, amen.

>> please be seated. good afternoon and welcome to the white house. more than four decades ago, in early 1970, an american squad if 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 pin was pulled and 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 d 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 two american soldiers for gallantry govern and beyond the call of duty at each of those moments. specialist donald sloat who stood above that grenade. and command sergeant major benny adkins who fought through a ferocious battle and found himself on that jungle hill. nearly half a century after their acts of valor, a grateful nation 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 can get lost in the fog of war or the passage of time. yet 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 is why we are here today. so 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 kowita. and he grew big. to over 6 4.

loved football and played for a year at a junior college. then 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.

and then one morning don and his squad set out on patrol past that rice paddy, down that trail when those 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 he picked that grenade up and he turned to throw it but there were americans in front of him and behind him inside the kill zone. so don held on to that grenade. he pulled it close to his body and he bent offense it. then as one of the men said, all of a sudden there was a boom. the blast threw the lead soldier

up against a boulder. men were riddled with shrapnel. four were medevac'd out. but everyone else survived. don had absorbed the brunt of the explosion with his body. he saved the lives of those next to him, and today we're joined by two men who were with him on that patrol, sergeant william hacker and specialist michael mulheim. for decades, don's family only knew that he was killed in action. they'd heard that he had stepped on a land mine. all those years, his gold-star family honored the memory of their son and brother whose name is etched fref on thorever on t granite wall not far from here, later in her life, don's mother, evelyn, finally learned the full story of had her son's sacrifice and she paid it her mission to have don's actions properly recognized. sadly, nearly three years ago,

evelyn passed away. but she always believed -- she knew that 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, sisters, and their families. on behalf of this american family, i'd ask don's brother, dr. bill sloat, to come forward for the reading of the citation and accept the gratitude of our nation. please. >> the president of the united states of america, authorized by act of congress march 3rd, 1863, has awarded if in the name of congress the medal of honor to

specialist donald p. sloat, united states army. specialist donned p. sloat distinguished himself by acts of gallantry at the rick of his life above and beyond the call of duty while serving as a machine gunner with company d, 2nd battalion, 1st enfantry regiment, 196 light infantry brigade during combat operations against an armed enemy in the republic of vietnam on january 17th, 1970. on that morning, specialist sloat's squad was conducting a patrol serving as a blocking element in support of tanks and armored personnel carriers in the area. as the squad moved up a small hill in pile formation, lead soldier tripped a wire attached to a hand grenade booby-trap set up by enemy forces. as the grenade rolled down the hill, specialist sloat knelt and picked up the grenade. after initially attempting to throw the grenade, specialist sloat realized that detonation was imminent.

he then drew the grenade to his body and shielded his squad members from the blast saving their lives. specialist 4 sloat's actions defined the ultimate sacrifice of laying down his own life to safe the lives of his comrades. his extraordinary heroism and selflessness above and beyond the call of duty are in keeping with the highest traditions of the military service and reflects great honor upon his division and the united states army. snflt [ applause ]

at this point i'd like to ask benny adkins to come join me on stage.

now, let me just say, first thing you need to know is, when benfy 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 opa locka, alabama. tending his garden or his pontoon boat on out on the lake. he's been married to mary for 58 years. he's a proud father of five. grandfather of six. at 80, still going strong.

couple of years ago he came here to the white house with his fellow veterans for a breakfast we had had on veterans day. he tells folks he was the only person he knows who has spilled 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. i huge north vietnamese force attacked, bombarding benny and his comrades with mortars and white phosphorus. at the time it was nearly impossible to move without being wounded or killed. benny ran in to enemy fire again

and again to retrieve supplies, ammo, to carry the wounded to safety, to 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 to the helo trying to escape the battle and aimed his weapon directly at the wounded soldier ready to shoot. benny stepped in, shielded his comrade, placing himself directly in the line of fire, helping to save his wounded comrade. at another point in the battle benny and a few other soldiers

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., and benny fired, taking out 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 helicopter arrived, benny insisted that others go instead. and so on the third night benny, wounded and bleeding, found himself with his men up on that 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.

there in the jungle they heard the growl of a tiger. it turns out the tiger may have been the best thing to happen to benny in those days. because he says the north vietnamese were more scared of that 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. a total of 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 being captured. 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 benny g. adkins distinguished himself by acts of gallantry 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 first special

forces during combat operations against an armed enemy at camp eshu, republic of vietnam from march 9th to 12th, 1966. when the camp was attacked by a large north vietnamese and vietcong force in the early morning hours, sergeant first class adkins rushed through intense enemy fire and manned a mortar position, continuing adjusting fire for the camp, despite incurring wounds as the mortar pit received several direct hits from enemy mortars. 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 sporadic sniper fire while carrying his wounded comrades to the camp dispensary. when sergeant first class adkins and his group of defenders came under heavy small arms fire from members of the civilian irregular defense group that had defected to fight with the north vietnamese, he maneuvered outside the camp to evacuate a

seriously wounded american and draw fire all the while successfully covering the rescue. when a resupply air drop landed outside of the camp perimeter sarge ert first class 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 first class adkins began placing effective recoilless rifle fire upon enemy positions. despite receiving additional wounds from enemy rounds exploding on his position, sergeant first class adkins fought off intense waves of attacking vietcong. he eliminated numerous insurgents with small arms fire. after withdrawing to a communications bunker with several soldiers. running extremely low on ammunition, he returned to the mortar pit, gathered vital

ammunition, and ran through intense fire back to the bunker. after being ordered to evacuate the camp, sergeant first class adkins and a small group of soldiers destroyed all signal equipment and 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 first class adkins led the group while evading the enemy until they were rescued by helicopter on march 12th, 1966. during the 38-hour battle and 48 hours of escape and evasion, fighting with mortars, machine guns, recoilless rifles, small arms and hand grenades, it was estimated that sergeant first class adkins had killed between 135 and 175 of the enemy while sustains 18 different wounds to his body. sergeant first class adkins's extraordinary heroism and self-sness above and beyond the call of duty are in keeping with the highest traditions of the

military service and reflect great credit upon himself, detachment 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, have courage. hold onto good. turn no evil for evil, strengthen the faint hearted, 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 commander in chief could not be prouder. thank you very much, everybody. [ applause ] turning now to u.s. military strikes against isis, conducting

the first airstrikes overnight in syria. the hill reports that president obama is expected to talk about the airstrikes before he leaves today to address the u.n. climate summit in new york. the pentagon announcing last night that the u.s. and partner nations have begun striking isis targets with land and sea-based missiles. we'll have the president's remarks live this morning on our companion network c-span and we'll also take you live to the pentagon for a briefing on the airstrikes that's expected in about an hour's time, 11:00 a.m. and that briefing will be on c-span2. and reaction from members of congress, including the chair of the house armed services committee, buck mckeon. he issued a statement that reads, our men and women in uniform are once again striking an enemy that threatens our freedom. with strong coalition partners, a capable military, and a clear mission, it is a fight we can win. and ed royce, chair of the house foreign affairs committee says while this initial attack will be a big psychological blow to the terrorist group, an air campaign will need to be major and sustained.

the reported participation of arab allies in the region is welcome. this is their fight, as much as ours. we'll bring you related briefings and updates on the c-span networks. c-span campaign 2014 debate coverage continues thursday night at 9:00. nebraska's second congressional district debate between the incumbent representative lee terry and state senator brad ashford and sunday the iowa u.s. senate debate between u.s. congressman democrat bruce braley and republican jodiny ernst. c-span campaign 2014 more than 100 debates for the control of congress. we turn now to health care and a look at insurance providers. insurance commissioner ted nickel says he favors a fixed regulatory approach as several insurance company exclude certain providers from their networks in an effort to control costs. also this discussion will hear from the obama administration's former director of insurance exchanges. this discussion was hosted by

the alliance for health reform. okay folks we're going to go ahead and get started. good morning. and on behalf of the alliance for health reform, and our honorary co-chairman senators rockefeller and blunt i'd like to welcome you to this morning's session about network adequacy. i'd like to thank our two sponsors, the blue cross/blue shield association and the university of pittsburgh medical center. if you are following us on twitter, the hash tag is network adequacy. if you are listening by phone or watching on c-span2 you can e-mail questions to us at questions @allhealth.org. or tweet them to #networkadequacy.

so the title of this session is network adequacy. but we've heard many names for these networks. we've heard anything 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 doctors, hospitals or other medical providers. some are saying that these smaller networks are causing problems for provider access choice while many are saying that 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 these networks, therefore, the trouble naming them. do they save consumers money ? is the quality of care as good in consumer networks? do consumers have enough choice? do they need all of that choice?

how prescriptive should the federal government and/or the state governments be in setting requirements for the networks. what is the consumer experience so far and what will it be going forward? so we're fortunate today to have three experts with us. and we are going to start with ted nickel today. he's wisconsin's insurance commissioner. and he also plays a leadership role at the national association of insurance commissioners where he is a point person on this subject and is heading on efforts to update model regulations for the state. joel ario to my left is managing director of manet health solutions. he was the first director of the office of health insurance exchanges at the department of health and human services, what we now call csio. ize been pennsylvania's insurance commissioner and also oregon's insurance commissioner.

michael chernew on the other side of ted nickel is a professor of health care policy at harvard medical school. he's a member of the congressional budget office panel of health advise remembers, and of the institute of medicine's committee on national statistics. he's also a former chair -- vice chair of med pac, the medicare payment advisory commission. once the three of them have given presentations, we'll open up to questions and answers. and, at that time, diane holder who is executive vice president of upmc, university of pittsburgh medical center, and alina pavin, who is manager within the value partnerships department of the blue cross/blue shield of michigan will join us for the q&a. so we're going to go head and start with ted. >> good morning. thank you for having me here today. this is really a very important discussion and is one that's going to continue for quite some

time into the future. but it really is -- we really want to focus on the issue of network adequacy. i'd like to start off by providing a little bit of background and an update from a regulator's perspective on the network adequacy. first of all, it's really important to know and realize and to remember that there are a lot of conflicting issues surrounding network adequacy. for consumers, the main issue is whether or not their doctor or their hospital is an insurance plan and whether or not they can receive the care that they're looking for. and, also, whether or not they can ultimately be able to afford particular -- their care, and keep their health care costs down, as well as their health insurance costs down. for providers, on the other hand, the wider the networks, the greatest the reimbursement rates. the more attractive it is for consumers to pick from those plans and thus increase patient

numbers. and providers are obviously 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 their ability to manage care. insurers are constantly negotiating with providers on reimbursement rates and 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 all 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. a network must meet state standards. and 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 buraq. this is optional, but it's a sign of quality. a good housekeeping seal of approval. for insurers selling on exchange or opts for qualified health plan designation, they also must follow the federal standards. again from a regulatory perspective, who do we regulate to assure network adequacy and network folks following networks. for the insurer, do we regulate the insurer, do we regulate the network itself, do we regulate tpas?

for a fully insured plan, it's pretty simple. the insurance regulators regulate the insurers and can regulate the plans through that process. for a self-insured plan, it's not quite 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's also important to note that there may be different standards for different products. in wisconsin, for instance, 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. they may have certain appeals processes in place for emergency care. ppos and open plan plans may have lesser requirements because consumers do have an option to choose from any provider. one of the other debates, at some point, may end up being

resolving around this business of multitier plans, where one of the plans has very small copays, one of the networks has very small copays, and a larger network is attached to that with higher copays and out-of-network benefits. the question might be do we look at these tiers, how do we look at these tiers, should the smaller tier be regulated, and should it have to be a full network? typically, that tier level does not include specialists. all of this is to get at my next point. many cases, the passage -- in the past -- excuse me. in many cases, the passage of the aca has resulted in the accelerated use and focus on narrowing networks across the country. harking back to hi earlier point, control can lower costs for insurers. wider benefits under qhp, under

aca have increased the cost of insurance. insurers to keep insurance costs lower look to network design to slow the anticipated increase in rates. the renewed focus on networks and network adequacy also cause the naic, of which i'm a member, to re-examine and update the model law. not unusual, usually not -- but unusually environmental factors cause the naic or the normal business institute at the time to update our model laws. the current naic model has not really been looked at or updated since the late 1990s. but states are still able to make their changes. the states have adopt the model and able to make their own changes at any time. the model was adopted in 1996 and very flexible and is still very good. its pliability reflects the

diversity in terms of market differences, large versus urban, excuse me, large urban versus vast rural and the way insurance operates. open panel versus closed panld. but still keeps the same standards. the model itself requires sufficient number of covered services or provide coverage at no greater cost to the consumer. also, provider distances and wait times should reflect the norms of the area. it further requires insurers to file an access plan to ensure they are meeting standards of the area. wisconsin chairs that group and it's charged with revising the model. as chair we've sought a lot of input from all parties affected by the law, consumers, providers, insures and accrediting organizations. we've received 26 comments thus far from interested parties. and once we're finished reviewing those, we'll continue working on revising the model.

and the goal is to add all of those changes and look at all of those changes and then take a fresh look and go through the model yet one more time. a great deal of important questions to ask 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 that will be grappling with include are narrow networks even a problem? what if no wide networks are offered in a particular market? what if an insured is not offered out-of-network coverage? how narrow is too narrow? what does it matter if an insurer -- does it matter if an insurer covers all out-of-network services? what is the appeals process for uncovered services? should there be a single statewide standard? what happens when a doctor or hospital leaves a network? and to what degree should continuity of care requirements should there be?

and then, of course, consumer notice requirements as well. the list goes on and on. and finally, i just want to keep -- we as regulators and folks working on this, this very important issue, need to keep a couple of things in mind, as well. we always need to be mindful of cost. we need to look at access to medical care for vulnerable consumers and we need to recognize and understand that we, as regulators, do not have all of the answers. the bottom line is that we need a model that can address the existing and emerging issues foq another 15 or 20 years. with that, i'll turn back to you. >> okay, great. >> actually, before we move on. can i just ask you what can you tell us at the moment? i understand that you haven't finished your work at the naic, but what can you tell us about where you think we're headed with these regulations? are there any, based on the comments, based on where the other insurance commissioners are, what can you tell us about where you think we're headed with these regulations on some of these questions that you've

raised? >> that's a broad question. it's clear,and i was talking to some of my fellow commissioners, regulators last week, and it's clear that this business of state-to-state differences and needs to be recognized. we have states with significant urban populations and then you have states like wisconsin with pockets of urban populations surrounded by cows. and it's -- it's important to make sure that there's a model in place, and there's a framework in place, to get ultimately get consumers the type of care, get the consumers the type of access they need, but, again, keeping in mind,

keeping in mind the cost -- the cost issues. the other issue that we've seen so far is in talking with other regulators and talking with some of my staff, this whole issue of network adequacy. while always being something we get complaints about, or something we get questions about, we have not yet seen an uptick. we haven't seen an uptick in the amount of questions about, gosh, you know, my insurer canceled my network or they threw out my doctor, what am i going to do? we're not seeing that yet. we're trying to keep all of those things in mind as we look to, again, update the model. and update it with an eye toward, an eye toward there's new products out there. there's new technology available.

there's a lot of just -- the entire health care marketplace, you know, the entire health insurance marketplace has changed since the model has passed. so we're heading in that direction. of updating the model given a lot of the environmental factor that is we're -- that we've been experiencing that we've seen. >> okay. great. and one more very quick follow-up question and then we'll move on. regarding the comments that have come in, from stake holders and others, are there any particular themes that you -- thread that you saw in those or any distinctive disagreements that you think are going to make it -- make your job a lot more difficult? >> i think the one issue that's always going to be a challenge is access. you're going to want -- there's going to be a certain folks that want to have just complete, wide access to whatever's available

out there. and you're going to have the other side pushing back saying that's a great idea, but, it's just not affordable at that level. and you're also going to -- you're also going to -- we've seen that there's a need for more managed care. there's so much more technolog,k out there. there's so many ways to better handle individual care. and i think joel is going to address it at some point this morning. this idea of focusing and narrowing of networks and better managing care is really becoming a huge part of landscape. and it's really -- it's really promoting healthier outcomes. and so there's going to be that -- there's going to be that struggle. there's going to be those back and forths on, you know, wider

the better versus narrower the better. and i think that's what we're going to be grappling with as we look at updating the model. >> okay. so let's move to joel now. >> okay. thank you. i always enjoy following ted at these kinds of events because it reminds me of why i love my years in the naic, a sense of deep knowledge of the issues, a sense of balance of professionalism about how to handle them. i think a lot of these kind of issues, looking to the naic and the different perspectives and the different states and the way they're represented is a good way to get a window into the issues. so i thank ted for his comments here and i hope we do keep this issue primarily at the state level. i think it's the kind of issue that differs dramatically across the states. one more comment i want to make is the event that shawn carr asked me to organize and attend. and then shortly after i learned of his sudden death.

i just want to take a moment to commemorate shawn. he was i think a reporter in the very best tradition. just a natural curiosity about issues and just did a bang-up job of covering these issues, particularly at the naic. so with that i'll get into my comments. i basically have three points to make. one is around the networks and what was intended in the aca in terms of setting up the exchanges and competition within the exchanges. two, what are some of the broader issues within the aca that we waive to the network issue with intent to foreshadow that with the managed delivery systems and so forth. and then, three, what are some of the consumer concerns here? because i think ultimately, consumers will be the barometer on this issue. and if they react like they did in the '90s to some of these narrowing of networks, we're going to have a different outcome then if they see it as

one choice and one of many in a market place. so starting with the first comment, narrow or value networks, i'll try to use both terms. it shows you how controversial the issues are. you get in trouble right away depending only what you call these things. but narrower value networks i think were clearly intended in the aca. when you take out a lot of the other variables, insurers are used to competing with each other on particularly risk selection, i'm glad that's gone as a form of competition, or it's not completely gone but it should be gone and it will be gone, then you have to look at other ways to compete. i think it was pretty clear as the aca was set up that one of the things that insurers were going to do to compete with each other was really ask hard questions about their networks and try to manage price around how they set up their networks. it was also envisioned, i think, in the aca, that part of the reason that would work in counter distinction to the '90s was because the exchange would offer a multitude of choices to

identify other. it wouldn't be your your employer trying to go with ahmo 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 kinds of narrower network products. and i think that's very important. and if i were running an exchange, i would want to make sure that all the products weren't narrow networked, tightly managed network-type products, that there were some choices for consumers out there in the ppo world. i'll come back to that when we talk about the consumer side of this. the consumer has to be educated and know the difference between these kinds of issues. the first point is this is not a surprise to people who put the aca together. this 1 what was intended in the competition. and it's a healthy kind of competition to have in the marketplace. and if i feared one thing more than anything else in this

this whole arena, it would be that some events happen that cause people to sort of set a one-size-fits-all solution to this problem. and it takes away the rich kind of competition that can happen around different approaches to network. so that's point one. point two, if you look to the rest of the aca outside the exchanges now, you do see the kinds of things that ted talked about right at the end there, the aco, the affordable -- accountable care organizations, which could call them affordable care organizations, too. but the acos, and really, other dimensions of the payment reform initiatives that are coming out of cmi, innovation center, bundled payments, they all required tightly managed oversight of provider net works and integration between the provider network and the insurer, could call them kaiser-like approaches to the issue. i know when i was at the agency, when we were setting up the original kind of network rules

and some people were proposing, you know, fairly stringent kind of standards that would apply to everybody, as we're just kicking around ideas, i would always ask the question, well, what would you do with kiez kaiser under that kind of simpluation. people would say oh, kaiser is different. so you can't just say kaiser is different. you've got to let everybody have an opportunity to do that or you say you can't do it at all. and i think those kind of integrated delivery systems are very important. we saw an earnings call last week from cigna, aetna, both talked about the importance of having flexibility around networks, and how they're aco worked, which they're busy creating acos, in conjunction with their insurance activities, that those become examples of products. and i think teddy, i saw your state now or the chinese plan in san francisco. you're going to create these

plans in local areas that have a select network that works in that local area, and if i'm an exchange director i want those on my exchange. again, not as the only product, but i do want them. in some ways, the insurers are going to have to be pushed in to creating these products. in massachusetts, it was the legislature that had to say we want all the insurers to offer a product with lower price point with a narrower network because we want that choice available. so, i think all of that is important here. it's intended for price competition, but it's also key to managed care and improving the quality of the aaa and improving the quality at the same time you're reducing the costs. the way in which networks are managed are critical to that and i think the future holds these aco type developments that are happening around the country will show up as products, targeted products on the exchanges. so, that gets me to the third, probably the most important

point because i think consumers are the ultimate barometer here. the insurers, the politicians, everybody that's part of this 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. consumer does need to know who's in what networks and 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're getting there, and they know in more or less a closed system. it's a much different thing if a broader plan that's a got a reputation and advertises itself as you know we have all the doctors in the state in our networks and so forth, and then somebody buys that product and they say well, there was actually small print over here

and said, the part you bought, that's not part of it. we don't have that. we are having else. you should be able to do that everybody should be able to have those kind of networks but it's got to be very transparent. the consumer has to understand what they're buying. so i think there's a lot of work to be done and i look to the naic around those kind of issues. finally i think there have to be some kind of safety valves for out-of-network kind of protections if you're going to draw a tight line around the in-network and really reward people for staying in network and pretty big penalties if you go out of network and maybe you don't get any reimbursement in some cases out of network then you have to have rules for things like i go to the in network hospital and i get a bill a month later that says unbeknownst to me one of the professionals, i had to see the allergist or something, is not in network so i have an out-of-network price for that. that kind of thing, new york now regulates that and said if the consumer doesn't know about it ahead of time, then they get the innetwork price for that sort of service.

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 the naic will come to this conclusion that we ought to give states fairly wide latitude to regulate this in response to local market conditions. so let's turn to mike chernew. >> great. thank you. i am thrilled to be here. when i speak at events like this, sometimes speakers disagree and there are a lot of fireworks and it's pretty exciting. unfortunately i am going to be in agreement with the previous speakers. so for the viewers who wanted a jerry springer type of event i don't think we're going to have one today. maybe later. first let me start by saying something about the term narrow versus value. value and narrow are not synonymous. their row networks may be high value net woeshs. but value implies something about cost and quality, not just

cost. so value has a very specific meaning about what you're getting for the amount that you're paying. which is not simply to equated with narrow for the sake of you could have a high value narrow network but you might not have a high value narrow network and i think the entire discussion here is what to do when you have a narrow network that's not potentially high value. let me start by trying to at least lay out a general conceptualizization. one of the things i find frustrating is when i read articles the topic du jour is one area and they move to another area and they forgot everything that 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 -- and when i say price i don't mean premiums, i mean the price paid to providers. one advantage of narrower networks is it strengthens the negotiating hand of those people who are purchasing. so i had a friend and

unfortunately he said when buying a car in -- to his wife in front of the salesman i don't care what we do, we have to get the car today. which, you know, it was an interesting thing 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 your ability to negotiate price. if you are worried about the price and you may or may not be but if you are, in a market system, the ability to exclude people becomes important in that type of negotiation. another topic that has been very interesting we did some work and the topic was geographic variation. it's known as a variation of traffic patterns across geography and across providers. there are providers that are more efficient than other providers and there's a lot written about that. if you knew that, wouldn't it make sense to try to construct a network that focused folks on those providers that you thought were more efficient that ends up being an advantage of a narrower, and in that case probably more of a value network.

there's other reasons why these narrower networks are good. you -- if you can concentrate enrollment amongst fewer providers, it facilities 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 and you now realize i'm an economist because i'm about to say, on the other hand, there's a lot of legitimate reasons to be concerned about these types of products. most importantly, people need access to good doctors. they need access to convenient doctors. they need access to their doctors. and we very much want to have people have that opportunity. the problem is in general, you choose your plan before you get ill. so it's not clear you know who your doctors are. i'm a reasonably healthy guy. i can name one doctor who is my doctor. there's a lot of things -- i have a lot of body parts. 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 ologist i might need before i choose my plan. i can't make that choice. even though i agree completely with the other speakers, consumer information and awareness is important. there will be limits to how much we can inform consumers, because of the time when they choose their plan, versus the time when they need their care. in the case where you might need to use a lot of doctors it may be difficult to get the doctors that you want into the plan. for example i only have one doctor so i pick my primary care doctor where they are. but i might not, you know -- i might have -- in my mother had a lymphoma she had a very good relationship with oncologists. me could have been put in a wags where she had to choose between her primary care physician and her oncologist. you wouldn't want that to be a case. there are many clinical conditions where people have very serious and important relationships with their

physicians and in these models it is difficult to say to certain people, well now you have to choose and we have to figure out how to balance that concern with the other advantages that i mentioned before. so transparency is obviously important. it's not going to be a full solution. regulation of network changes i think matters. there's a concern about a bait and switch thing that might happen, you know. you join a plan you thought your doctor was in and in the middle, network changes. maybe because the doctor left. not something the plan did. you're stuck and 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.

and what your network looks like. 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 that there's variation and'oy efficiency ac providers and we want to be able to pick physicians that are more proficient. you might be able to pick certain types of patients by picking certain doctors. we have to worry about them. i believe, personal comment, we have made sufficient advances in risk adjustment that i am less concerned about that. i could show you some academic evidence to suggest that now it might be more appealing for plans for folks with chronic disease in as opposed to chronic disease out because of the way we do risk adjustment but that remains to be seen and we are certainly at the beginning not the end of this process. so i think that 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, but it is not the fundamental goal of the health

care system. so there is a sometimes an undercurrent in these discussions that we have to be fair to providers. and i do believe just on the record, i do believe we do need to be fair to providers. but at the end of the day the ability of providers to get into a network is not ultimately what we're concerned about. we're concerned more about patients having access to the care that they need at a cost that they can afford. we will see through the networks a big reorganization of delivery systems and how the provider responds and how that plays out will be one of the most important things to monitor as providers find themselves in a somewhat more complicated environment because the providers are going to have to negotiate potentially in different ways with the plans. a few other things as was mentioned before, we need to think about the issues of network adequacy as market not planned specific things. that creates challenges for the

regulators and i'm glad i'm not one. but i do think that does matter a lot and we have to focus on that and the second thing is ideally we would be able to focus on measures of outcome not structure. focus on the quality and the access, things that were mentioned as opposed to focusing on structure. it is always very hard and i think will remain to be very hard if we focus exclusively on aspects of structure and i think the more we can improve our measures of outcomes 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 that we can at least avoid the most egregious cases of where there are problems. we will not -- so summary, we will not get this perfectly correct. there will be complaints for a variety of reasons. many of them are likely to be justifiable complaints but we're going to have to avoid the temptation to move to a ses testimony that prevents any type of creative network development because we want to avoid there ever being a problem when those

networks do get developed. so, thank you. >> great, thank you. before we head into the q&a one question for the three panelists, and that is what do we already about cost and quality? between, if you're comparing the narrower networks to the broader networks. do we have any numbers, research, that show us our experience already in terms of cost and quality? >> one thing i can jump in on here is, with all of the data that's now available for research, what we're seeing and what's being seen by some of the insurers, is, in fact, that higher prices for services does not necessarily indicate better outcomes. what we're seeing -- is providers that are doing, let's

say, do knees, or rebuilding knees or fixing knees, the more they do it, the more familiar they get with it the better the outcome and because they do so many of them, oftentimes, the price of that procedure is lower than it is for the guy who does one a week or one a month. if they do or two or three a day versus one a month, what we are seeing in terms of the outcomes is that often times the lower cost procedure is really producing better outcomes. >> we know that narrow networks are cheaper, and i think we also know that we're seeing a lot of narrow networks in the chaex inks, and therefore prices are a little lower in general terms than people expected going in to the exchanges. and quality i think is pretty much anecdotal still. my view is that we don't really

know yet very much about how to measure quality. but there are a few things we do know and one of them that i like to point out is that if you look at who scores well on the medicare five-star system, which is, you know, one of the systems out there that's leading the way in measuring quality, again the caveat i'm not sure how well it does that but to the extent it does measure quality if you look at who comes highest on the achievement under that system, it tends to be the achp companies, which are the integrated delivery system companies so it's like dine's upmc company, kaiser, group health, intermountain, the groups that have integrated delivery systems do tend to perform better on that medicare system. >> just before you jump in, you mentioned the medicare, and the system for medicare advantage, and the federal government is looking at some new standards that will be similar to medicare advantage. is that where we should be going? and how is that going to work? >> well the federal government

did hold up to quality initiatives under the exchanges for a couple of years. there are several different initiatives there and one of the main reasons for it was that they wanted to make sure that of those alignments across these different federal programs. so the last thing we want, i think, is one approach to quality in the exchange, a different one in medicaid and a different one in medicare so there's a lot of work going on to align these things. but again, i think we're pretty primitive on being able to part of it is if you look at consumers they don't tend to pay a lot of attention to those ratqsn you can find examples where think do. i don't think the american people know how to measure quality very well yet. i think we have a lot of work to do. >> okay, mike? >> joel is right that the analogy to this discussion if you looked at the managed care experience in the past, which wasn't a resounding success in a variety of ways, but i do think the evidence at the time suggests that those plans were able to have a somewhat lower cost and perform well on the

state-of-the-art quality measures of the time. and the key phrase there is at the time. and again joel is right the quality measures weren't that good. the interesting thing there is the narrowing of the net woeshs in those plans was not the defining feature of those plans. the flair rowing of the network in those plans enables them to do a whole series of other things in those organizations. and so i think it will be a mistake, particularly given where we are in the process now, to try and generalize about these plans. i ensure there will be exceptional ones that can provide low cost and high quality care regardless of how you measure high quality care most of the time. i am also sure there will be some that won't be as good. the challenge here is to try to set up a system that both identifies, informs, and monitors those that are falling on the part of the spectrum that we don't like. i think it's going to be very challenging to try to generalize about anything about what these types of networks do.

they're going to be local. they're going to be done by different organizations with different abilities to manage them well, and they will have, as part of the network portion, a series of other tools layered on top that will vary. p you are not talking about just the network. although that's what our topic is today. there is a bunch of other things that occur related to the managing of the care and a bunch of other things that define the outcomes of these networks that you want and we're going to have to decide the extent to which we trust consumers which came up to choose amongst them and respect their choices, versus limit their choices for various reasons. >> okay. >> we are going to open up for a q&a now. i want to remind those who are listening on the phone line, or watching on c-span2, you can e-mail questions to questions @allhealth.org or you can tweet them to #networkadequacy. i also want to remind everyone that we have two on-the-ground

experts with us. we have diane holder. who is with the university of pittsburgh medical center, and she can give us an on-the-ground perspective, as well as alina painen who is with the blue cross/blue shield of michigan. we have some on-the-ground experts so they will be joining in the conversation, and you can direct your questions to anybody on the panel or just to the panel in general. and when you ask your question, if you could please identify yourself. yes. [ inaudible ] >> i guess my general concern would be regarding centers of excellence. their exclusion, for example, if i were diagnosed with cancer, for example, i'd want to go to a national cancer institute designated center of excellence. and those should not, in my view, be excluded for any disease. so, i guess my question is will

in fact most of these networks provide access to designated centers of excellence for various diseases? >> diane, you might want to talk about what just happened in pittsburgh, because they settled a case out there with two insurers arguing about networks and one of the parts of that was that certain facilities that upmc has, particularly the cancer facility, it does need to be in-network for both of these insurers who are essentially going to have separate networks over time. so i think the point's well taken. you might want to have a tiered pricing approach, maybe some pricing difference for the consumer depending on where they choose to go but i think cutting off completely access to certain kinds of facilities probably isn't going to work very well with the consumer. >> well the other thing is -- if the initial treatment choice is the best, and if you have that choice, i mean, to have that treatment, then it might, you

know, prevent more treatment down the road. >> yes, i think one of the things that is really at the heart of this debate is what really is adequate, and when you look at the outcomes people are trying to achieve, and they want clinical outcomes that are an improvement than what we have, you know, in many regions, and really across the country, we suffer from some deficits in our -- in our quality. you know, the struggle, i think that people have had gets to the heart of what michael said, which is a network's not a network's not a network. and a narrow network is not a narrow network. it's really about what is it that the people need in their region, and how do they get access to the right combination of cost and quality. i think there are certain minimal standards that have to be met and certain minimal access points. and it has to be balanced with both provider and insurance competition. because we're not going to get the kind of innovation we need if we stand in the way of trying

to do things differently than we've done them in the past. >> and i would add, so first let me say because i mentioned my mother did have a lymphoma and she was treated in pittsburgh, and cancer is one of the most complicated areas, because of this notion that you're not going to know beforehand exactly where you want to go for your cancer care. so i think it's unrealistic to expect someone when choosing a plan to be sure they're picking one that has the cancer center that they want, and of course that may, in fact, vary by the type of cancer. i'm very, very wary of a situation in which we force organizations to include particular providers in them because of what that would do for prices. and in fact, i think, and i might be wrong about this, i think that would be on the road towards some type of price regulation. you want to say everybody has to have in your network, that's fine. we're now going to tell you what price you're going to be able to charge and i'm not so sure how appealing that would be. i'm not arguing that that should happen or even that that would

happen. but the concern is if we think there becomes a monopoly-type provider, a cancer center, we have to think of some way of dealing with that beyond a rule which is every network has to include this particular provider, the type where they are competing, we might have a different approach in a place where we have different providers and all of the network development with b%ñ regulation to make sure they have access to good cancer care and in a way that doesn't give a blank check to the organizations to say now you can charge whatever you want and do whatever you want. it is the case that they may in fact save money to make treatment choices and has yet to be shown that they do for a variety of reasons. that's an academic discussion.

>> i wanted to make the point that in and around the work we are doing, in and around the model, to michael's point, when a situation does arise where you haven't decided where you want to go if something bad happens, there are formal and informal appeals peals processes built into the system. i can think of one informal process and they said i need to go where i can get the treatment and i need a way to get there. the long and the short of it, we made it happen and that person is alive today because of that. that's the role of the regulator. as long as we play it straight down the line when those situations come up. in terms of rewriting of the

model, that will be contemplated, the ability to file quick appeals for either emergency or specialized care and formal or informal means consumers when faced with those challenges have an avenue to pursue. >> this seems like something they haven't had in a long time to compel the hospitals in particular to do more and align their prices with a market response. we get a lot of hospitals in dallas that compete on whether or not they are a four star hotel and what the thread counts are for bed sheets and such. you don't see anything reflected in that that gives the insurers

the ability to say wait a minute, if you want that you can buy it. adequacy doesn't necessarily include four-star hotel experience. >> interestingly, of course, insurers could have had a narrower network in a variety of ways. back in the '80s and '90s people thought they would. they voted with their feet not to. what has been interesting and i'm not sure, again my co-panelists can comment on it. i'm not sure it was anticipated that on exchanges there would be demand for those things. the balance is to separate the thread count from cancer care. it is a question as to what level of sort of quality and separation we would want and when we want the consumers to make those choices.

we are having the discussion of how to create markets that work in a world where information is imperfect and we care about the outcomes in a way that we don't for other things. if you buy a third-rate cell phone, i'm sorry. but if you end up getting really bad cancer care i feel differently about that in a variety of ways. and so i do think we will see and i think we should allow consumers to make choices as fwr what they are allowed to pay to get access for different facilities in the network. we have to have a lower bound at some level and we have to be able to regulate the processes around that for information choice and some of the exception processes that were discussed so some more egregious things that might happen are minimized. i want to say eliminated but i end up sticking with minimized.

>> quick is dallas is an ideal place to have this situation because you have hk systems and health and hospital systems so there could be great competition. the side of this is you get to some parts of the country there is not the same kind of leverage to use network strategies. >> one thing that has become a hot topic which is another issue which you see on the pages of the press but isn't connected is issues of antitrust. one of the solutions if you are a provider is various types of mergers. so in combination with this discussion will be aspects of network consolidation. we can have a whole other press briefing on how we want consolidation to allow integration where we think there are efficiencies and maintain competition among providers. many of the issues i think are

in the forefront of the minds of policymakers end up overlapping. one of the themes that trn sends all of them is the extent to which we can end up with a competition that works and one that we have to put regulatory barriers to that competition. >> a question for ted. cms this year decided for 2015 that it was going to, i think, put in place more strict network adequacy standards for plans offered. they suggested in the future they might look at specific standards around time and distance requirements. do you think they shouldn't be in the business of doing that given what you said about recognizing state by state differences? >> i love my friends at the

federal government. but i'm very leery and very weary and concerned if folks at hhs come up with a floor. i know i have fellow regulators who would like a floor. given the diversity of market places throughout the country what i don't want to have is an extra or a heavy push by the federal government to get into the business of something that states do very well. they know their markets and know their market places and distances and urban versus rural areas. we do a pretty good job there. what we don't want to have is friends around here somewhere in d.c. or maryland to put

something in place that will mess up strategies that are already working very well in the states. they should give us a wide berth at the state level to make these kinds of decisions and better manage our market places because we are right there. >> i would like to actually ask if the other panelists want to weigh in on this question on the federal versus state or some combination of both that would work? where are we headed? what is going to happen with federal? is the federal government moving forward in some aspect? >> i have a quick comment from the michigan plan. i think i agree with what ted is saying. we would want the ability to do that for our own community. we have cases where we don't have network providers in certain geographies because a doctor's office doesn't exist in that area. i think it becomes complex for patients who live in rural areas where they go to access care, how expensive is it in that

geography. as a plan there is a way to work with providers and develop measures and programs where you have kind of a team between the plan and the provider to develop high quality low cost care for those parts of the state. so for my perspective we agree with the flexibility in allowing states to do that work. >> i would say we did set in the original regulations. that was the qualitative standard and not a quantitative. having said that, i think there always are wrinkles here. one wrinkle is the exchanges have a lot more low income with people coming into the commercial market place now than has been the case traditionally. there is a second part of network adequacy which is essential community providers who serve that population. we did start with quantitative regulations, 20% of all of the essential community providers to

make sure that the providers who dealt with low income population will be represented. i would be wary of where it goes. all generalizations are false is a good motto to keep in mind when thinking about these issues. >> robert? >> i would like to follow up maybe with a question for mr. nickel. have the medicare advantage standards created problems? those have like five different levels based on the diversity of a community total population, population density. have those failed or inadequately recognized diversity among states?