All right, good morning and welcome to this week's edition of Encompass Live. I am your host, Prista Porter, here at the Brestville Library Commission. Encompass Live is the Commission's weekly online event. We're a webinar, a webcast, online show, the terminology is up for debate. Well, whatever you call us, we are here live online every Wednesday morning at 10 a.m. Central Time. And if you're unable to join us on Wednesday mornings, that's fine. We do record the show every week and the recordings are posted onto our website. And I'll show you at the end of today's show where to go and see all of those recordings. We have to record the show up there, any presentations, so we'll have a link to this. So if you want to look at the slides later, you can do that. Anything you need will be there afterwards in recordings. Both the live show and recordings are free and open to anyone to watch. So if you know of anyone, colleagues, friends, neighbors, family, anybody who might be interested in any of our topics that we're doing, please do send them to our website. Have them, they can watch our recordings or they can register and watch any of our upcoming shows. We do a mixture of things here on Encompass Live. Interviews, book reviews, mini training sessions, devils of services and products. Really the only criteria we have is it's something library related. Something libraries are doing, something they shouldn't be doing. I think new products and services that they might be interested in. Programs and things we're doing here at the library commission. That's all over the board. And any types of libraries, if it's public libraries, academic, special museums, we've had everything run the gamut on the show here. Like I said, our really, your only criteria is libraries. We do have Nebraska Library Commission staff that come on the show, usually representing things that are service programs or things we're doing here at the commission, but we also bring in guest speakers. And that's what we have this morning. From our Nebraska Library Association's intellectual freedom round table. We have Michael Elmsner and Todd Shulfi and Dan Timlens there at the end. They're going to talk about the new manual they put together. There was one that was ice and cream used by some people out there. There is one. I don't get it. It's completely revamped. So I'm just going to hand it over to you guys to talk about it. Thank you for the invite too for having us on here today. We appreciate it. And yeah, I'm Michael Elmsner. I'm the chair of the intellectual freedom round table for a few short months later until Tim Lens takes over. But really, we kind of want to talk about what we've worked on all through the last year or year and a half, which was coming up with the new manual. Because our old manual was pretty old, we just knew that we had to create a new one based on a lot of different factors. So another thing I always want to say, anyone that's watching out there that's live watching, if anyone wants to join, please go to the NLA website and join the intellectual freedom. We always are looking for new members. We see a little under that we have a lot of members. We're growing, which is good, but it's such an important topic and we really want a lot of people to understand a lot of the concepts and work with us. So now really what we're going to talk about is kind of the new manual and the process and how we made it. So why did we need a new manual? The last update of our manual was 2004. And that's pretty much just before Facebook wasn't around that, right? So the whole world was kind of a different environment back then. And in 2004, you know, so the manual was about two pages long. It didn't really address many issues and it was just kind of time for an update. So the team, you know, we talked about whether we're going to edit it or create a new one and we really decided we need a brand new manual. So we scratched that one and we made a new manual. It's available digitally for free. You can purchase it for about $6, I think. You can see it books through the UNL press. And so we really want a lot of libraries to order this and use it as an everyday manual. So how we created it, ALA actually updated their manual in 2015. And that was kind of our jump off point to say, oh, we should probably update our old guide and make sure that we have our things up to code. So we worked with ALA and Todd ordered a manual for himself and they were really generous in saying, you can use this guide. They were kind of like, you can use the guide. Use all the parts of the guide. Just don't copy it, you know, for data. Use it exactly. So we base a lot of it on. They probably want you to use five errors if you're just going to copy it. I still just use errors instead of share. Yeah, I just kind of run it through a little copy but NLA on the top. So they were really generous with what we could use. But we definitely wanted to make it unique to Nebraska and make it based on what's going on here in Nebraska. So we revamped it quite a bit and it's a lot shorter. There's about 200 pages. So yeah, we just want this to serve as a guide for librarians all across the state to be used daily when issues come up. So the way we did it, we kind of each took a section from the intellectual freedom manual of NLA and we revised it, read through it, recreated it and wrote. And then we, and a lot of times when you're working as a team like that, there's a lot of overlap in different chapters. So we had a couple editors get together and then we'd be back and streamline it. And that's kind of the product that we have. And I'll hold it up. They can pass here. And so this is what it looks like in print copy of the NLA manual that you can order. And you can also download it for free. So if you just want to read through it and make sure, you know, $6 to go to good use, feel free. So, and I'm going to kind of talk about the Office of Intellectual Freedom through the ALA. So it was established in 1967 and it's charged with implementing ALL policies concerning the concept of intellectual freedom. And really the responsibilities are to educate librarians and the general public about the nature and importance of intellectual freedom libraries and support librarians, teachers, and administrators who are undergoing a material service challenge. So the service challenge would be if someone wants to ban a book, if someone wants to remove material, and we really support that. That's one of the main things we do. And so, you know, so if you have a challenge or policy or someone's challenge in a book or wanting to ban a book, contact us because we really want to know about that. It's one of our important things that we do. So, yeah, that's interesting. So, yeah, we're censoring our material. So what we do, yeah, we do more than censorship and getting rid of books and banned books. And it addresses really fundamental rights for patrons like access to resources and making sure that the library is really representing the community and ordering books that appeal to everybody, not just with a library and things they appeal to. Filtering software can really block searches and can be a form of censorship. A lot of times we'll block searches, maybe medical searches, but we'll look at more. And it's not very well done sometimes. And privacy, people really need the privacy to look up information about the judge or thinking people are looking over their shoulder. Meeting rooms, or well, copyright issues is kind of an intellectual thing. You know, make sure you're not stealing people's ideas. Meeting room usage, are they neutral? Are you letting anybody use it? Miners' rights. Miners have the same rights. And we are not to, they're to parent the minors. We're there to provide access to information. So labeling materials. And Todd said he talked a lot about labeling materials. That can be a form of restriction and censorship also. And free speech is really, you know, one of the things that has to be defended. It's really ugly and disgusting, but we really want to defend free speech. So responsibilities of librarians. And I'll kind of read this quote because I like it. But librarians significantly influence or control the selection, organization, preservation, and dissemination of information. And in a political system grounded in an informed citizenry, we are members of the profession explicitly committed to intellectual freedom and freedom of access to information. We have a special obligation to ensure free flow of information and ideas to present and future generations. So I think that really comes to what we do. You know, this is, we have a lot of power at what we get for our patrons to look at. We kind of decide what kind of information they can see. And it's even becoming different in this new era of post facts and alternative facts where a lot of things can be, you know, even anti-science can be put on the shelf. And we have to really decide how we, as librarians, are able to make sure that we are not censoring any information, but at the same time, we need to make sure that we are not just putting it all out there as if everything was on equal footing. It's like kind of a difficult challenge of censorship versus informed. Yeah. What is going on out there? Yeah. So when there's someone who's discredited, like Dr. Oz, there's a medical issue, and you really want to put that on the shelf right next to your medical things. I mean, there's a lot of choices in there. So, yeah, so then you can't really have like a discredited viewpoint shelf, right? Like, you know, maybe, so we're going to put it on this one shelf. You have to figure out how to really do that. So yeah, so it's kind of how do we help patrons distinguish between good and bad information on censorship and not just be a search engine like Google where we're just throwing information at them and making them decide that that can lead to some problems as well. So we do want different viewpoints, but having them based in some sort of fact is an important aspect also. So I think with that, I think with that, I'm going to turn it over to Todd. Okay. I really like that quote that Michael put out there because it shows just how committed my brains are to intellectual freedom. That's right there in introduction to the Code of Ethics. And we're going to look just very quickly at the basis for that comment. Why are we so committed there? For one, it comes from the Constitution. The first amendment right there, you have the freedom of expression, the freedom of the press. And then this seems really obvious. If you've got those two things going on, you have to have the freedom to access that information. It hasn't always been obvious to everyone, so the Supreme Court did at one point rule, yes, this is a necessary corollary to the first amendment to the freedom to expression of freedom of the press. You have the freedom to access information. So that's one of the reasons why librarians are very committed to that. It's right there in the Constitution. And then to help that process of accessing information did not be judged for what you're accessing. We have the right to privacy. Now in the context of the Constitution, we have the right to privacy unless law enforcement or the government has a reasonable suspicion, probable cause, to believe that we committed some sort of crime. So privacy unless there's a reasonable suspicion that you committed a crime. So that's really pretty, I mean, gives us a lot of room and a lot of things that we can do to keep people's freedom to access information out of, you know, for them, for them to conduct it in a safe environment. Nebraska law also strengthens that for public institutions, especially public libraries, gives public libraries the right to withhold any kind of record that would reveal the identity of a library patron. So this might be a circulation record. This might be something that's in, you know, simply the information that you've got on file about a library patron. You'll have to reveal any of that. If you have computer sign-up sheets where people sign it, it's probably a good idea to shred those at the end of the day because, again, those are identifying pieces of information. Take the count from that computer sheet if they get rid of it. Computer sign-up sheet. So, again, there's that idea in order to protect privacy, you keep as few records as possible. And generally speaking, also, you know, ours, I come from Southeast Library System. Nebraska Library Association, I believe also the Nebraska Library mission would also extend this to things like videos and libraries. Under Nebraska law, those need to be subpoenaed or there needs to be a warrant in order for those to be turned over. And the ALA has really helped us in the process of developing our professional, I guess, attitude towards intellectual freedom. It's really embedded in the Code of Ethics, the Library Bill of Rights, and the Freedom to Read Statement. So that freedom to access information and privacy is just all over in these documents. And so we've included them in the Nebraska Library Association's intellectual freedom manual. And they're a really good document to read. And there's more. I mean, that's certainly not all of them. There's interpretations of the Library Bill of Rights here. And there's other documents as well. So that freedom to access information. Let's talk about access for just a little bit here. I'm going to try to keep it just a little bit. So far, it's not been a little bit when we've done this in other places. Okay, access and information is traditionally meant for libraries accessing the collection that the Library has. And today, that's both print and digital. Obviously, when somebody comes into the Library and says, you know, I'd really like to read this book and you don't have it. You want to either order it or enter a library. You want to find a way to get it into your hands. You also want to consider, okay, what does the community need? Is there, you know, a Spanish speaking element in the community that's not using the Library? Because it doesn't know either that, you know, if there's Spanish speaking things that can be gotten there or because you haven't ordered them. So those kinds of things need to be considered. We also want to go beyond just simply what the computing community wants and needs to be on what we can see. Because a Library, again, is a place to access information and to expand your mind. So we want a pretty good amount of diversity in our collection. In many Nebraska communities, children and adults don't get many opportunities to even travel outside of the state. So the Library can be a place for them to grow and find out what other cultures think, what other kinds of viewpoints exist in other parts of the world. So we want to have that sort of thing in the collection. We want to have a few closing viewpoints in the collection. Michael's always spoken to that a little bit that that can be a bit of a tricky thing. We want to make sure there's something for everybody in the community. And we may have to do some research sometimes on this. You want to look at your demographics. You want to just be aware of some of the facts that are out there. For example, if you've got 300 people in your community, you're going to know that there's three people with high polar disorder and three people with skills of training just statistically. Plus there will be people with depression and anxiety. And you've got your friends and family members, so you want to have a collection on mental illness. And those books generally will get checked out. So just an example, those people you may not, you oftentimes will not be able to tell at all that they have a mental illness, but that doesn't mean that they aren't there in the community. And that there's not a fair number of them there. It's important as librarians that we resist censorship in every way that we can. So oftentimes we have an opportunity to engage in education. This is often really informal, because somebody will come into the library and say, is this really appropriate for the library? Is this DVD? So when somebody's coming in like that year, you just say, I can see your point of view, and maybe you can agree with it. And I think it's okay to say that in that case. At the same time that you say, it's fine for you to know or to feel that this is not appropriate for you or for your household, but we have households and people in this community who believe that it's appropriate for them and we have to serve everybody. So there's a lot of opportunities for education when we're facing possible, when we face people who would like this to engage in censorship. This is something that needs to be done with library reports and possibly college administration sometimes, things like that. And there certainly needs to be policy and procedures in place in case somebody wants to go beyond that informal conversation and actually tries to make the move to remove an item so that there is a coherent means of doing that and that they have the opportunity to express their wishes and that will be handled in a good way. There's other ways of having censorship taking place in a library. People may realize through their conversations with librarians or neighbors or whatever, they may realize that the library really isn't going to simply remove items easily. So it may be easier to just put an item somewhere in the library where it's going to be hidden for a long time or walk out the door with that item. So I think it's good for librarians to kind of have their items that might potentially be controversial. And if they do go missing, to be very ready to replace them. I know Jamie Lou at the office for intellectual freedom said that when he was library director, you know if something went missing he ordered multiple copies of that item and you know suddenly said okay, this item is here and it's here to stay. If there's something online that's written that I've been in some library talking about, someone had checked out everything on a certain topic and then just didn't return it. And he cared that they were going to have a problem with the site fees. He was like, I don't think you can go library and have a list of these items going to take a month. Yeah, yeah. And that's none of those on whatever the time we've been like, how do I do this? You buy them again. Yeah, exactly. And hopefully your budget can take that. Yeah, build it into your budget a little bit. You do have to have that built in, yes. I just think we're going to go missing on purpose or for access. There are plenty of things that don't get returned or depending on your community and so on. Okay, I'm going to talk a little bit about labeling because this can be a way of exercising censorship. We usually think of labeling as things like genre stickers on books and we think of those usually as something as helpful as a binding aid and at the same time they can be prejudicial and so that Eli has kind of put out the warning that labeling a book in a prejudicial way is a form of censorship. And when you think about it, for some people, if they see even something like a mystery label on a book, they're going to go, oh, that book's not for me. And not take a second glance at it and whereas if they read the description of the book, they might actually be drawn in and this is really interesting. And just because it's labeled a mystery doesn't mean that it's not a quote for them. So labels, while they can be a binding aid, they can also be prejudicial. And then there's a couple more specific examples that I have. The different rate and the issue going on with this book is that you have two moms and a boy. So there are some people who are going to find this book objectionable just because of that fact. So what would you do if somebody came up and said, I think this book should be labeled in some way? Put a genre label on it or put a label on it that says this may not be appropriate for all households. Well, again, that sort of thing is prejudicial. You certainly want to avoid that so that you're not, in effect, wanting people off the book. That is such a shift. The net goes back to we're not the parents. Not to us to make the judgment call this inappropriate for some people. It's up to you as a parent to look at the book first before your child gets their hands on it and decide, oh, this is cool. Dragons are also here. Read it or oh, no. Not your child. That's up to you. Not us to let it be. And that goes for anything that children are checking out. You know, the library is not playing parent. It's the conversation we see happening between the parent or the guardian and the child about what the parent and guardian believes is appropriate for their children at this stage in their life to be checking out. That's not something that we can decide. It's going to be, frankly, in the same household, often different for different children, and different households are going to be in different places on these sites. So, what may be appropriate in one household and other, what may be one household may judge appropriately in another household is going to be totally different. And we just need to keep ourselves out of that whole conversation and let this conversation take place where it needs to happen. Now, the next item really has almost a little bit to do with diversity. This is an example of Christian fiction. And I do know that this can act in a prejudicial way. There are people who see the label on their Christian fiction. Oh, yeah. I'm not going to read it. You know, it's going to be too much about morality, too much about mental liars, whatever experience they have with it at any point. And whereas for other people, it's a finder's aid, and they ask for, you know, those specific glass where the Christian fiction is in their labels and monitors. It helps them find those books. One thing to be careful of here is that, well, the library's iPhone can simply haven't labeled it. You know, you can find it in the account by searching Christian fiction and then it pops up. Yeah, I agree. All of the subject headings in which you can always look up whatever you want there, rather than having it all, like here's a big sign where you want to be insulating things like book storage or label, yeah, that's where they're at, but libraries. Well, the thing that can be problematic here is that we want to be serving the entire community. And there will be Christians in the community who don't particularly care for Christian fiction or for most Christian fiction. Christian fiction does come in some different forms and flavors. So, you know, it just tends a little bit, but we have to realize even within the Christian community, there's differences on that. And then what do you do about the people in the community who silently or openly are not Christian? So, you know, they may tend towards Buddhism. They may be agnostic. They may have a totally different point system. So, what message are you sending to those folks when you have books labeled Christian fiction, but you don't have books? Labels? You send the letter to them. Yeah, you're going to feel crazy if you start to do that. You're quite, in a way, you are quite favorite to some. Yes. So, you know, are you sending the message to that? You're censoring the other religions, I don't know. So, that has a problematic side to it as well as being a biker's aid. Now, the next item is, again, that example that Chris mentioned where the library really wants to keeps itself out of this discussion that should be going on with parents and child. This is an example of an R-rated DVD. So, you know, should the library check this out to children and teens? Well, that's really up to the parents or the guardian. And so, the librarian isn't the person who should be making that decision. There are some libraries, I know, with this solve that issue with movies at least, which do have ratings, which are designated not by us. They have no label. There are some libraries where they, you know, if you want to as a parent, you can say that your child's not allowed to check out our R-rated books. And we can double check that when we're going to check out. And you can be here with them every time to check out something, but you can say, for my child, don't let them do anything that's above R-rated or not. And then, if that's built into that child's patron record or somehow, is that a way of working around that that the parent's done their parenting, but they're not there holding them every single time? And the library is then, kind of case by case, basis following the instruction from the parents and saying, we got to talk to your guardian about this first. Where that's still, I know I've heard a lot of children, it's making it easier on everyone. Just tell us if your child can. Here's a form where they are not allowed to check out so that when they do go in, you can follow your instruction. And this is something to where, this is the ideal. You don't get involved. At all, if we can help, because again, the parents really need to be on that. The guardians need to be, parents and guardians need to be having those discussions with their children. And we're not helping at all by getting involved. Now, you will have community situations that arise, and you know, so sometimes libraries will have the base for making decisions. Do I respond for the library, or do I make some accommodation here that parents, that particularly local citizens, for example, will find acceptable, and you may have to kind of roll with the punches there and make a little bit of compromise just because of the community situation. And, you know, you don't really want to risk that the library gets a bad name, or that sort of loses funding. So it's not always black and white. Yeah, it's not a hard festival. It's such a slippery slope.  So I think, yeah. Well, just like every child in the world, they did something to children not do. I mean, that's just parents that works, you know, all of them. So logistically, there's a real question of how a library, or most libraries, would gamble that. Yeah. Yeah, can the technology even do that? Is there a way to block a person in, in a, you know, online data, online circulations, even giant systems? Yeah, I mean, there's such a wide variety of circulations systems out there, or ILSs out there. A little bit about internet access, almost all public libraries, at least so, computer, so that people can access information over the internet. Mike's talked a little bit about this already, so I'll just mention quickly, filtering prevents access. So you've got that in place, be cognizant of that. Also be cognizant of the fact that pornography is not illegal. Sometimes there's acts, sometimes people have the feeling that it is or should be, but it is not actually illegal. That is something that's protected under the First Amendment. Also the courts have ruled that adults must have access to unfiltered computers. So you can't, if you do have your computer's filtered, they can't all be filtered, or you'd have to be able to really quickly get to one of them unfiltered, so that an adult at least can have access to unfiltered content. Now on the flip side of that, there are illegal activities that can happen on computer such as viewing child pornography. And if a librarian were to see that taking place, well you wouldn't, you yourself would not get involved, but you'd call the police. Or if a patron alleges that, it's the same thing, you just don't get involved. You let the police know, and they decide how to investigate, whether to investigate, etc. It's that's something that's outside of all of them. Okay, and then finally, access to meeting rooms. Many libraries do have an area that they offer to the public. And the courts have gotten fairly involved here, so some of this language comes from, is based on what the courts have said. Meeting rules have to be controlled, they have to be applied equally to all groups, and they have to be really narrowly defined in regards to time, place, or matter of use. And here is what that concretely means in some examples. So if you're open to, if the meeting room is open to public use, religious services must be allowed. It used to be that many public libraries interpreted the establishment clause of the First Amendment to mean that they should not allow religious services in their meeting rooms. The courts have ruled otherwise, especially the lower courts. The Supreme Court hasn't specifically said that, but what the courts have said is that, you know, librarians can't even, aren't even in a position to judge what is actually a religious service. So to prevent government entanglement with religion, religious services must be allowed publicly on an institution that's opening its meeting room to public use. Now a library can do other things that help protect its submission. It can limit frequency of group meetings. Again, this test applies to all groups, so you could say a group can meet a maximum once a month, or use a meeting room once a month, so that other groups have a chance to be in there and regulate the notice level so that they don't interfere with other activities. And you can just allow the collection of money. Libraries again, connecting to their mission can restrict non-profit groups, or they may choose to charge commercial groups at a meeting. And all of this is not, this is what you have to do. This is going to be the thing you can do. These are things that you decide, which you can. Yeah. Like you might allow a, well, if you have a book signing, an author comes in, you'll probably let them sell their book to people who come to the library potentially. It's not the library collecting the funds or anything like that, but that means, it's not like you can't do these things. It's just, these are things you're going to want to know. What are your policies? What do you have room for in your policies? So you don't have to allow even authors to collect a percentage author book sales, but it might be in your interest to do so, just to get the authors there. And sometimes, then a percentage of the books they'll can also be donated to something like friends to the library, something like that. But you do have to really, in the formulation of the policy that every meeting, you're going to have to make sure that it is fair, whatever you're doing is fair. So if you're allowing somebody like authors to basically collect money, you're going to probably have to allow some other books to do it, or you're going to need a good reason not to. So obviously, if you're holding library programs and meeting rooms, that is so closely connected to you that they have the right to grant anything else. And you can also, since you allow everybody to come into your library, you can require groups using your facilities to also allow anybody to attend their meetings. Now, Tim's going to take off here and talk a little bit about privacy and confidentiality. All right, thank you. Privacy and confidentiality, those are two separate words. So I kind of open this section by just discussing what both of those mean and kind of the relationship you need to do. What is the difference? Privacy is about the person and their experience in the library. It's making sure that they are protected and that they are able to use library resources in comfort and without concern about somebody looking over their shoulder, whether that, looking over the shoulder is digital, whether it's actually somebody coming up behind me and noticing what book I'm reading, any of those things. We want to make sure that your privacy is protected when you're in the library. That's a direct corollary to freedom to read. I should have the freedom to read. I should also have the freedom to read whatever I want and I should not have you nosing into my privacy, taking notes of what I'm reading. The extension of that is confidentiality, again related, but not exactly the same. That's the data we have on a patron. That's anything from keeping a list of books that people have checked out, which you should not do, or it's knowing, hey, you know, this computer went to these websites, so on and so forth. That's not necessarily something that's going to impact the user's experience, but that's going to be data that's collected on the patron. If you collect that data, you either have to be very, very careful about keeping it confidential, or as I'll talk about in a little more detail, the best thing you can do is to whatever extent possible simply do not collect data on your patrons. The best way to maintain that confidentiality is just to never have the data there. So those two concepts really are related, and they do have some ethical and legal considerations. Obviously, as librarians, privacy is embedded in the right to read.  I'm offended by that. I no longer have the right to read in a full form if my privacy is being compromised or violated or kind of went away. Yeah, the other thing I think librarians need to keep in mind, and we really built this whole manual with the idea of making sure that you are all well prepared for this, there are legal protections at both the state and federal levels. That's been touched on a little bit earlier throughout the presentation. The point that I want to highlight about that, that means that if you mess up somebody's privacy, you could put yourself in your institution on the coin. And that is something, obviously, I mean, I think all of us know that's something you do not want to do. It's going to be bad for you, it's going to be bad for the institution, it's going to be bad for the community. So when you're talking about that, that legal grounding is something that you need to be aware of to protect yourself, to make sure that you're doing things right, to make sure that you're providing what the patrons need, and also that you keep your institution running well. And I'll talk a little bit more about how and when you kind of want to mention the legal protections as well as the ethical protections. As far as practical considerations, the key concepts you're looking at here is, and again, I'm just going to kind of read this whole quote. Libraries should minimize the collection of personally identifiable user information. They should store it only locally and securely. And they should maintain legal control of the data and ensure that library practices do not divulge user information or put it on public view. For example, self-serviced old shelves that you know, users identity, you go up, it's terribly convenient.  Well, the concern that you have there, and somebody else can come by and say, well, Mike appears to be reading up on this particular medical condition. Gosh, I wonder if his insurance is going to tell us about this. You know, there's a health concern there that's not being told. So there are some major concerns along the things like that. And it is really partly in how you structure your library and how you design some of your practices in your library. There are ongoing concerns that you want to be aware of, and these are just some that I kind of wanted to highlight for this presentation. First, you do have community norms. One of the things that you're talking about there, again, kind of adjacent to some of the things that Todd mentioned, say that you have a young person who is reading books and their parent wants to know, what is so-and-so reading? What is so-and-so reading? How are they doing so on and so forth? And that's going to be kind of a community norm. And you might have said, oh, well, so-and-so is reading theater app, and later on, oh, well, so-and-so is reading Beverly Clary, and all of a sudden, somebody is 12 or 13, and oh, well, so-and-so is reading about a religion that's not in your household. Oh, well, so-and-so is reading books about LGBT books, and all of a sudden, you know, you've kind of established what was an innocent practice. You just keep in the parents or whatever what their kids are reading, and you build that practice, you build that norm, and all of a sudden, you are radically evading that young person's privacy, and you never set out to get there, and then you have a real sticky-wicked parent comes in and says, well, you always told me what my child's been reading from time to time. They were five to seven to elementary school.  So it's a little bit tricky, but what you want to do in those situations is set up a benchmark early. You want to be very early at age three, age four, age five, talking about, hey, talk to your kid about what they're checking out, and you don't have to couch it as this is raw privacy, etc., etc. You can say, you know what, I think they have to check in some books out, have a conversation with them. I think they've got some interesting stuff, see what they're willing to tell you about it, encourage the parent to have a conversation rather than getting yourself in the middle of something that can ultimately become very dangerous, both ethically and legally. Another ongoing concern that we all want to be aware of is law enforcement. Law enforcement will come in that want to know, hey, it was so-and-so in the library, hey, did so-and-so read such-and-such book, etc., etc., and again, you won't have a good relationship with law enforcement, so there's a component of education that needs to take place there. Again, you do want to make sure that any data that you keep, that you do provide it to the necessary authorities as required under law. If they do come in with a subpoena, you do have to give them the information that you have. So on the back end, you want to make sure that you have very little information just to keep yourself from getting entangled, and on the front end, if they come in and ask for information without a subpoena, you want to remind law enforcement that they can actually break their own case. If they come in and they get information from you and they go to build their case based on the information they got from you, but they didn't go through the proper legal channels to get that information, they're going to get it to court, and the defendant's attorney is going to say, listen, you didn't get a subpoena from the library, you have to throw this whole section of the case out. And again, you want to build that relationship ahead of time so you can have room to do that education, but then if officers of the law come in, you're in a really strong position to say, you know what, we're always going to work with a subpoena. I'm sorry, officer, I can't give you that information right now. Talk to your folks, come back with the necessary legal documents. We're absolutely going to provide what we're required to provide. For both of our purposes, though, we need to make sure that we do that correctly. It needs to be a win-win on both sides. Yes, yes, and when you frame it that way. Yeah, convince them that this is bad for you, you can just do this, you want to do it. Yeah, remind them they want to do it the right way. We're not adversarial. It's something that, hey, you want to do this the right way, I want to do this the right way. The worst thing that could happen is, they do things the wrong way, we comply with it, and all of a sudden that case is blown. And somebody who is probably going to be convicted of some bad activity. Because back on the library, the library must have been involved in burning the case. Yep, yep. The last one that I want to touch on, this is really interesting and you could go on it way, so I'm not going through today. We are increasingly partnering with vendors for a lot of the services we provide. Libraries have a strong ethical and legal commitment to privacy and confidentiality. Vendors do not always know or share those same values. And in fact, there are some situations, again without going into detail, it turned out that Harvard University was leaking information about their patrons to Amazon, because they were using Amazon's images. So you're looking through the catalog and you want to see what a book looks like, you want to see what the cover looks like. Well, Harvard had been getting those images from Amazon, and Amazon then, just a standard practice for Amazon, was loading some cookies in. Some of those cookies apparently collected personally identifying the future, which is a huge number. That's something you want to stay away from. So it's not just us. We need to build out the technology, and we need to build out awareness with our vendors and partners, so that they are also abiding by their student practices. That's one that could go on at length, and again, as I said, I'm not going through today. Okay. During to the next section that I'm going to cover, policies, really this is going to kind of summarize everything that's gone before. All the stuff we talked about up to this point are things that you want to have policies about. So this is just an overview of what policies should mean, and how you want to go about creating those policies. This picture right here, this is actually my worst nightmare. I have an ongoing anxiety dream, and it's about three weeks into the semester, and there's a class that I have not been to, and I finally found the class, and I am new to give a presentation, and I am not prepared. I don't know what the presentation is about. I didn't really know where the class was, and all of a sudden I'm in a situation where I am facing a real challenge and I'm not prepared.   Think of what your worst nightmare would be and write the policy about it. Yeah, that's a great way to put that. Exactly. Think of what your worst nightmare would be, and then check your policies and see if you have something about that. What are policies important? You know, sort of philosophically or conceptually, they promote equitable and personal access to libraries. More practically, they protect and empower you and your staff. So again, when a situation arises, you're prepared for it, you're empowered, your staff is empowered, and ready to deal with the situation. Just as a brief overview, some of the things we've talked about, you want to make sure you have a policy around collection development, because people are going to challenge that. Why did you get this particular book? Why did you not get that particular book? They're going to challenge you on privacy, both for and against. They're going to say, why don't they have access to this? Why won't you tell me? Again, why won't you tell me what my child's reading? You're going to have policies. You're going to want to have policies around the internet. Obviously, I think all of us know you want to have policies around expected behavior in the libraries. If somebody's acting up, we all know what acting up is in the library. But if you don't have a policy that prohibits a particular kind of acting up, if you throw somebody out for really, frankly, bad behavior, but there's no policy against it, you're exposing yourself to legal challenges, you're exposing yourself to lots of concerns. Again, I'm not going to do a lot of details. I gave this great information about meeting room, because you want to have clear policies set up. Just briefly touching back on what was mentioned there, when you have a meeting room, you have to set up your policies carefully. If you allow an author to collect a certain amount for signed books, and then you're allowing an author to collect in a meeting room, you want to think about whether you're going to allow a religious organization to collect in those rooms. When you build those policies, just think about all the implications that are there. Again, you do want to build policies around labeling and or rating any of the material that you have there. How to develop good policy? How do you do it? How does it happen? This is absolutely advertising, but if Michael, Jerome, I want to get this handbook. Yes, it's self-advertising, but you can get it free online, and we wrote it for you. This is designed to be a quick primer handbook. It's not a substitute for legal counsel or anything like that. ALA also has excellent resources, I believe, with a ton of those resources connected to this presentation. Once you started backing your policy, involve your stakeholders. Make sure your library board is on board. Talk to people in city government. If your library has legal counsel itself, be talking to them. If city government has legal counsel, be talking to them as well. As you're developing it, and once you have it developed, make sure you're sharing it and discussing it with your staff so that your staff know what is in it, and they know how to defend it as well, and they know how to protect themselves in the institution in any sort of challenging situations. Make it readily available, not just to your staff, but make it readily available to everybody. If they come in and they want to know what the policies are, let them know. Make that something that the community is aware of. And then most importantly, use it and adhere to it. If you have a policy that's not enforced or enforced here regularly, essentially, you don't even have a policy at some point anyway. So that's very important because, for example, community policy and other policies, if something does go to court on you, the court is going to look not only at the policy, but whether you have applied it consistently. Yeah, that's across the board. I mean, if you have great policies, but you're letting them bend for your buddy who wants to do a sales presentation, or you're letting them bend before a religious organization that you're affiliated with, you're exposing yourself to some huge red flags there. And with that, that kind of wraps up my point. I'm going to shift it back to Mike who's going to wrap it up and take us away. Yeah, oh, thanks. Yeah, so this is just kind of where to get help and become involved. So some national resources that talk about the ALA Office for Intellectual Freedom. That's where Jamie LaRue and Christopher Cole work. And they're intellectual freedom giants. They do great things. Jamie LaRue spoke last year at the NLA conference. He's great. And they send out kind of a newsletter. It comes out and it talks about challenges across the country. It talks about just different interesting things on this topic. And here's some other ones also. They're all in the handbook, so we hope you download it, so they'll just read through this, but they'll be in books, meet coalition, all these different places. Some Nebraska resources. We have the intellectual freedom roundtable, which is, I mean, more than us, that we're part of it. And kind of the Nebraska Library Commissions on there, ACLU of Nebraska, different places. And so, and this is something that was actually just signed in March of 2017. I just kind of want to talk with you because it's so important to just kind of how, how much disinformation is out there and untrue information. So NLA actually supported a resolution in support of the ALA's resolution on access to accurate information. And it's, you know, and it really does talk about the fact that libraries really could do more and help patrons and just citizens understand what accurate information is because it's such a problem in today's society. So, and it's kind of goes back to that quote, we do have the power to kind of disseminate information that we see fit, that we order, that we give access to. So we really have a responsibility to make sure that we're not giving that information to our patrons and we have to do it without censorship. And that's where the grill divide is, right? We don't want to censor anything. We also, you know, when we also don't want to have people look at that information and think that that's true. So, I think that's kind of thing. So the importance of intellectual freedom, you know, it's very complicated and difficult. There are two sides and, you know, we always err on the side of free speech and access to information as long as it's legal and you don't kind of go by what the courts have determined is legal. But it's an ongoing process and it is more relevant than ever, I think, in this post-truth world. And it's, you know, things that we're seeing daily in the news and the protesters in Berkeley and conservative speakers shutting them down, you know, team mascots that are offensive. These are all freedom of speech but also they are offensive to people so it makes it very difficult. And just hurtful views, we hear all the time that, you know, we defend the right to say those hurtful views as long as they're safe and we don't have to like them and then we should reform but that's kind of why we live in this society. So, and that's kind of thing. We don't want to be just another kind of search engine, right? So we think about how we should approach this big news and misinformation and just the volume of information resources and that's the problem. There's a lot of times Google, as everyone knows, it's kind of a search engine and whatever's most popular will go to the top. And a lot of times I think that bots that just make things will increase the search on that. Most popular is not most accurate. Yes, it's not the same thing. It's very often not most accurate because they definitely like to promote that. So we're kind of not what librarians can do more to help I think and it's not censorship. It's just information literacy skills and I think that's where we really have a lot of power to do that. And it's so that we're not another search engine. We're not just doing information on people and telling them to sort it out themselves because you know people need the skills to evaluate different sources and we are kind of that's kind of in our profession and we're equipped to teach patients how to do find better and more useful information. So whether that's classes at public libraries you know we do at academic libraries I mean they do take how to search how to do it. It's kind of one class sometimes in college and I think it really needs to be embedded in school libraries and make sure that a lot of students reach a lot of people because it's becoming it's not going to get better I don't believe as time goes on. And so I kind of want to talk about just the future of the information freedom. You know in a lot of where we're trying to go you know surveys report up to 85% of challenges go unreported by the office of intellectual freedom. And so what we're trying to work on is kind of an annual survey to capture more of that challenge material throughout Nebraska and it's you know just making sure that maybe a library director gets a challenge or has a book stolen that it never gets reported anywhere because they just replace it or something like that. But we're kind of the team that want to hear about that and want to keep track of that because if we see trends that we see different you know different groups that are getting targeted that's something that I think the office of intellectual freedom can respond and know where it's coming from. I'm surprised by that that's so much of it is unreported but I don't know is it because they don't want to let people know it's happening or they just deal with it and it's just part of the regular day unfortunately and they just they dealt with the person who won't have the issue and gave you took care of it. I mean they don't feel the need to let everyone someone know. Or do they not know that there's a place it should be reporting. So keep tracking your statistics of how many times someone confronts you or questions why you take their book. Well I think some of it sometimes is not even realizing that there is a place that you can report these to and the office for intellectual freedom has recently simplified its form and made it easier to report these things and we're trying to Michael especially has been creating that survey so that we hopefully can in the future capture that information much better that you know people will have an easily available place to go. I think that was part of the infrastructure really hasn't been there. Yeah pretty much how do I tell anybody. Yeah and that study was based on you know they surveyed states that tried to find the office of intellectual freedom and they found out that I think in Texas 3% actually reported the office of intellectual freedom so it's more they're not getting into this information and and really if you if you go even farther in some of the states that were serving I'm sure even less of that gets reported. I mean a book that was hidden for a while and they find it they might just put it back on the shelf. They don't realize that that's what that was all about. It wasn't just this shelf or put some other accent. Yeah and that's the same thing ALA is starting to include hate crimes in libraries and so they and I know the thing I just read in the last year there were or maybe early this year they already had seven reports of hate crimes in libraries so so they're trying to also keep track of that as well as part of the survey reports that might be something we also just ask them out as a question of our survey. So yeah as far as as far as the fact that if there might be anyone else have you have any questions or great. If you have any questions that you want to ask go ahead and take it in. If you have any situations maybe that you've been in and you're not sure what should I do in this situation or if you're thinking of asking advice right now while we're here. I will say this is a little after 11 o'clock and especially the show goes 10 to 11 a.m. but we don't cut off that's okay. We don't get cut off the software or anything either. If people have questions cut and say if they want to say we'll go as long as you guys are asking them. Something I do have is a question about and I think we'll go maybe and show it. The one about the URL is actually to the handbook and if you want to you can go to that here on the computer. Yeah you can show it yeah. So it escaped and it'll pop you out of the school. I looked up here and it was like okay. Do you want the mouse? I'll use that so I'm going to move around a little better. So it's a URL somewhere. Yeah it is but it's um. It's digitalcomments.uat or you want to Google it and show how you get to it. I just Google it. I think I might be too far away from Google because I can't tell you. Actually this is your just anymore. Presentations. Presentations. There we go. But I think you can do this simply Google it. Yeah I'll say rest it. Okay. There we go. Well that's uh. That's the other thing. Oh come on. There we go. There is that first link. Yeah. Yeah. Ed and Jerry Ellsner. Oh yes your name's your first there. So this is the page that you land on when you follow that Google link and you can see there that you can buy the book and you'll get a print edition and take someone just a little bit to actually print it out and send it to you. But you can also download it here and that will be a free download. It will be a PDF. But then you can print out yourself. Yeah. There's the editors and authors. Yeah there it is on the digital comments. Mike suited all the artwork. He did the editing which yeah I think there was a lot of work involved in that. And then the the um the ALE us intellectual freedom forum for reporting things. Do you Oh we can find that out. Or is that in the book? Is it in there somewhere? Um I said believe me. There's a lot of resources here. We've been on the office for intellectual freedom. There's a sample request for reconsideration. See I don't look that far. I don't think I will include all these links afterwards in the recording notes as well so you'll have direct links to them as well if you're not catching them all as we're showing here. Yeah a challenge report. So this is what it looks like. So what are your reporting material and we based ours on this also. So it's pretty similar to this when we send it out. Now there's just over any time you go to the recorder is there's going to be somewhere like on the IAP website or how are you doing your sit-in and survey. We are hoping to do because people don't really go to it as much for traffic so we're hoping to send it through the library systems probably. We send it to um schools I mean I guess we kind of we have a meeting from that um you know send to maybe schools because schools they'll probably get out of challenges here they go and report it um and just because I'm sure there's and you know I actually fall down to see to the commission to see and there really isn't a system in the rest of it that puts those all together and I found a site um Oregon Intellectual Freedom they have kind of a theory house and they do this every year I'm kind of basing it on what they've been doing for years and every year they've done it since like 1990 we'll show if there's more or less and what the trends are. Yes and theirs is a little more because this is their simplified one I think they based on the old one so I do have some extra kind of why this doesn't really have that they recently did some yeah oh just why didn't you say this is an insert. The Oregon one has like a drop box of different choices. Oh this one is just free tech type and whatever you have. Tell us whatever happened yeah. I could put two. Yeah so if you do have a challenge though they they do want to hear giving it to ALAs is really important. Oh yeah they're collecting nationally. I love what they have in the description because I was wondering too on what are you recording it on what um is considered a hate crime.  These are like a property. To target a specific group. Yeah so if you're not sure because that I also think that's something that often times in cases is both is it a crime or not. This list gives you an idea of the kind of things that they're talking about. And I think they did talk about that it being I think in one library it was defaced and they considered that to be a hate crime. Yeah. So nobody sent in any urgent questions they desperately need to answer right now. Except I want to know where to get a Holy Man. Oh we just got it. So I think since nobody really needs anything right now we can wrap it up. You guys can always contact them. Where's your contact information on the website or through. You can contact us through L.A. through the L.A. intellectual freedom around you a little bit. You can contact myself. I'm sorry actually let's see. Yeah they're listed on the L.A. website yeah. Because they email addresses would be to their working emails most likely. So we'll look them up. We'll be asking any questions you want. So yeah I think we'll wrap it up. Jay thank you. Thank you everyone for joining us. Yeah thank you very much. No that's fine. This is a very important topic and I'm glad we had you guys on as I told them and I attended this session earlier in the year as one of our meetings and it's been they've been presenting a little bit of place. I don't know if you did also at L.A. and SLA conference. So it's going to be a twice I think we're extending it to more. Yeah yeah that's good. So definitely if you have more questions and things come to conference and Karni and actually we're going to talk directly. But I know it's very important a lot of issues are things that people are having so much of a always have more than years and unfortunately I think it's getting even worse. So I'm glad you guys and I'm glad they updated theirs and I'm glad you guys updated yours as well for Nebraska. So please do go out there take a look at it. So a little wrap up today show it has been recorded and we posted on to our website maybe later today maybe tomorrow and how quickly I get to it. Can we just take a minute and cut the slides and I'll show you on our website where all this is. And so far nothing else on the internet is called Encompass Live so you can come to you when you google it. We are the first results that you're going to get. All of our friends are posted to YouTube so it depends on how they cooperate when I try to upload things up there. These are our upcoming sessions but right beneath them is our archives and our most recent ones are right at the top. This is last week's session. The recording will be here. Send me a link to the presentation where the public link to the google file will get that going and then any links that were mentioned in the website will list here as well directly to the handbook link to the intellectual freedom web page within the NLA website because sometimes those are hard to drill down. We'll get that all up for you. For anyone who attended today or registered I will email you when it's ready so I'm going to look for that email. And like I said today maybe tomorrow and how quickly things go. I'll hopefully join us next week when our topic is a whole bunch of net puppet central netline. What are all of these things? There's so many different medical things you can do. And then Maas from she is well she's a couple of different things. She's national network libraries of medicine. She is the librarian related to that group out of Creighton University and she's going to come over here and talk to us about what all these are, what the difference is, why would you use certain ones for certain things and I generally do look for things that are from netline when I'm online but is it the next one? We're talking about medical research. So check in with us and the net will tell us what that's all about next week and all of our other topics for the in July are posted here. I'm working on sessions for August and of course future ones will keep an eye on our schedule and they'll be added here as we are confirm them. Also end compass live is on Facebook so if you're a big Facebook user please do pop over there and give us a like. This will probably have a little pop up that says join Facebook net. But here's our page and you see I have a post reminders of when shows starting up. This is a reminder for your day show, when our recordings are available. Like was done here last week. So if you're a big on Facebook like end compass live over there and you'll get reminders about what we're doing here. That wraps up the links. Thank you all for attending. See you next time on end compass live.


Aloha everyone. Welcome to Hawaii Together on Think Tech Hawaii. I'm Kaley Iakina, your host and also president of the Grassroot Institute of Hawaii. If you know anything about Hawaii's healthcare industry, you realize that it's almost on life support. We have a shortage of doctors and other personnel. If you live on the neighbor islands, you could wait up to a year to get an appointment with a specialist or you may not be able to do that at all on the island and you'll have to go to Oahu or to the mainland. We've heard some very sad stories of people dying without the appropriate medical attention simply because they couldn't get it. Now there are many things we can do about Hawaii's healthcare situation and at the Grassroot Institute we have made several proposals. There's one thing in particular and that's what I'd like to talk bit about today. That's taking a careful review making a careful review of the approval process for new hospitals or clinics or medical facilities right now to build a new medical facility even a kidney dialysis unit or add new beds to an existing hospital. Healthcare businesses have to go through a whole bunch of coups, a very arduous state approval process in order to obtain what is called a certificate of need, that's C-O-N certificate of need. So why do these rules exist? Are they here to help people have access to medical care or do they hinder and can we change these rules so that we can have for our people the kind of access to healthcare that they deserve? Those are some of the questions that we're going to ask today as we talk with my guests. Joining me is Matthew Mitchell, Ph.D. He's an economist and Dr. Mitchell is a senior research fellow at the NEA Center for the Study of Occupational Regulation at West Virginia University. Dr. NEA or Matt Aloha welcome to the program. Aloha thank you so much for having me. Well Matt I'm delighted that you and I are able to see each other from time to time at national conferences. You're in demand as a speaker, you travel quite a bit. One of the areas of your expertise happens to be this whole business about certificates of need or the rules that have to be adhered to if businesses or hospitals or others are going to be able to expand and open facilities. Now before we dive into it, can you tell my audience a bit about how you got into this kind of work and what attracts you to this? Maybe a little bit about what you do nowadays? Yeah absolutely. So I mean part of my interest is just the interest in healthcare in general. My father is a physician, my brother was a physician. So I've always had a little bit of a tangential interest in the healthcare industry anyway. But this one really came up not so much because of the healthcare but just because the nature of the regulation is so obviously anti-competitive. It so obviously exists to protect incumbent providers, those who are already offering care to the expense of their competitors but also unfortunately to the expense of patients and payers. And so because of that, that's really what kind of got me interested in the issue. My view is we should be trying to amend and reform and eliminate those regulations that are the most obviously anti-general welfare type of regulation. Are the ones that should be the first ones to go? And so there's reasons for those on the right who are interested in seeing more markets flourish and seeing more competition want to get rid of these regulations. But there's also interest I think in those on the left trying to get rid of regulations that benefit big and wealthy providers at the expense of the little bag. So that's really kind of what attracted me to the regulation at first. Well, there's something in this indeed for everyone regardless of political background. We're looking at a real human need. People are not getting the medical care that they absolutely need and we need to do something about it. I can't see anything more worthy to rally around than something like that. And I like your approach, but first brass tack, but let's talk about what a certificate of need is and why in the world it is required. If you would just speak to our very wide and general audience, give us a little bit of explanation. Absolutely. So it's an unusual regulation and it's unusual in so far as the aim is not to assess the quality of the provider, the adequacy of their facility, their safety record, anything like that. The entire aim of the regulation is to second guess the provider's belief that the service that they want to offer is actually needed. So as you can imagine, this is pretty strange, pretty unusual in a market economy to have a regulation like this. The vast majority of other goods and services, nobody asks a provider or a would-be service provider, do you think that this service is needed? Obviously, by virtue of the fact that they want to offer the service, they must think it is needed. So that makes it unusual right off the bat. But then there are other characteristics that make it quite unusual as well. So in their attempt to assess whether a provider, the service is needed, it's quite costly and why it's uniquely costly because there's no limit. It goes up to the potential fees are a percentage of the cost of the investment and so there's with no cap on it. That's somewhat unique and it can take months, sometimes even years for the process. But that in itself doesn't make it all that unusual. There's a lot of regulations that are like this. But here's the part that's really strange is in your attempt to try to prove that the service you want to offer is needed, your competitors, those who are already in business actually have a role to play. So they are allowed to come before the regulator, oppose the application. They are allowed to even sit on the con boards often in states and play a role essentially in determining whether or not they get any competition. Now remarkably in a lot of states, it's pretty common for the incumbent providers to then sort of negotiate with whoever is trying to enter the market and they may come to an agreement that says, okay, so long as you don't encroach on my territory, you don't offer your needed healthcare service anywhere near me or then it's okay. You know, that's pretty remarkable in antitrust. That would be a per se violation of the Sherman Antitrust Act if it were a private people colluding like that or giving up territory. But because it's encouraged by the state, it's not illegal. And then finally, the regulation itself typically will a certificate of need will be denied if it can be shown that it will duplicate an existing service.  So it's essentially mandating that there not be any sort of competitive provision of healthcare. It's a pretty bizarre sort of regulation. Well, indeed it is. And just so that we understand what you're talking about under certificate of need laws, if a hospital wanted to add services or if a group of people in a rural community want to have a clinic started, they have to go before a board that contains, I mean, that has competitors judging whether or not there's a real need of this service. It's kind of like saying a group of people want to start a hamburger stand, but they have to get the approval of McDonald's and Burger King to be able to set one up. Yeah, that's absolutely right. And I often make that analogy and I hear other people make the analogy of McDonald's having to get Wendy's permission. But it's worse than that because we're talking about life and death here. We're talking about services that patients want and that medical professionals are qualified to give. And Hawaii is unique in that it requires a certificate of need for more healthcare services than any other state in the union. We'll get to this in a minute, but there's actually quite a few states that have no certificate of need laws whatsoever, which is why we kind of know how they were. But Hawaii requires it for 28 different services and technologies, including services that are needed by vulnerable populations, substance abuse facilities, psychiatric care facilities, and then, of course, open heart surgery and organ transplants and neurosurgery and all sorts of other types of services as well. What are some others that people would be surprised to hear Hawaii requires a certificate of need in order to operate? Well, let's see. So ground ambulances, burn care. Whenever I see that one, I always scratch my head because one of the original rationales for a certificate of need is to try to discourage providers from offering care that's not needed. So there was this idea that, well, maybe providers are offering more care than people need. Maybe they're sort of like upselling patients for more expensive and elaborate procedures, especially in light of insurance and the fact that patients often aren't actually paying the bills. So okay, that makes somewhat sense. But I don't think there's any evidence anywhere that has ever been accumulated to suggest that doctors are offering burn care when burn care is not needed. That's just sort of silly. Same thing goes for neonatal intensive care, which is also regulated of nursing home care, hospice care, which is generally thought to be a low cost alternative to end of life care in a hospital. This is exactly the kind of alternative care that politicians left, right, and middle have been trying to encourage. It's bizarre that in states like Hawaii, we're actually trying to limit this low cost alternative. It's counterproductive as well. Now, there are a lot of states, as you mentioned, that have reformed or abandoned their con laws. And one of the reasons is that there has been some research out there showing what the negative impact is of con laws on various communities. Can you sum up some of that? Yeah. So going back to almost your original question of what made me interested in this topic, and one of the things that got me interested in it is just the fact, the sheer number of studies that have been done on this. It's really, you don't encounter this very often. But what has happened, so basically, the federal government encouraged states to adopt con laws dating all the way back to the 70s. They withheld federal funds from any state that didn't adopt a con law. And by the 80s, they were already amassing some data and some evidence to suggest that they didn't work. So the federal mandate went away. And at that point, about 15 states, 12 states did it right away, and then over the next few years, a few more did away with their certificate of need laws. So now we have essentially this kind of nice natural experiment. You know, Louis Brandeis famously talked about the states of laboratories of democracy. What's interesting is that that was a certificate of need case that had to do with selling ice. It's one of the other rare areas where you need a certificate of need. But there was a, it really is truly a laboratory because now about a third of the country happens to live in a state where there's no, either no or extremely limited certificate of need laws in healthcare. So these are, you know, high income, low income, urban, rural, coastal, intercontinental, all sorts of different varieties of states. And we can look at what's happened in those states that have either done away or significantly pared back their certificate of need laws compared to states like Hawaii that have them. And so as it turns out, it's been an extremely well studied topic. So there have been over 400 separate tests assessing the effect of con on access, cost, and quality. And it's really extraordinary in terms of how overwhelming the evidence is because they almost all point in the same direction. So, you know, just to take one example, all of the tests that look at the effect of con on spending. So 65% of them find the con is associated with increased spending per service. Only 7% find that it's associated with diminished spending per service. And the rest, which is 28% find negligible results. Availability, so the availability of services for patients, 79% of studies that have looked at this question find that con is associated with diminished availability of services, only six tests, 8% of the entire sample find the con is associated with greater availability services. Quality of care, 49% of tests, almost almost half find the con actually undermines the quality of care, just 10% of tests that have looked at that question find that it increases the quality of care. And in many cases, in those instances, it actually they're not finding that it increases the quality of care, it just stops the use expensive procedures that may, for which there may be, you know, better alternatives. So among the tests, you know, that are finding that it's associated with lower quality, though, we're talking higher mortality rates, falling heart attack, heart failure, pneumonia, higher readmission rates, falling heart attack and heart failure, lower patient satisfaction levels, patients are less likely to give their hospitals a nine or a 10 on a 10 point scale. Greater use of physical restraint in nursing homes in states that have con laws relative to those that don't. There's lower nursing staff ratios in certificate of need states. Hospitals are more likely to be performed by surgeons that are lower quality surgeons based on metrics of their the outcomes that they that they are able to obtain in con states relative to non con states. So very serious consequences for patients. And of course, serious consequences for taxpayers who are paying more for services and for anybody who just wants convenient care. It's pretty extraordinary. Well, it's quite remarkable when you take a look at the quality of care, the cost of care, access to care. We definitely received low marks in Hawaii. And what you're telling us is that that may very well be partly due to con laws. Now, why then do we keep them? Yeah. So that's a great question. So it really goes back to what economists, it's a probably a favorite phrase among economists when they're teaching political economy, which is this idea of concentrated benefits and diffuse costs. And the basic idea here is that you may have a policy where the costs outweigh the benefits. But if those who bear the costs are so numerous, so diffuse, and typically, don't know that they're bearing the costs, then those who benefit from it are able to get organized and maintain the policy. So I've go around the country and have testified in about, I don't know, maybe a dozen, two dozen states on certificate and need laws. And every time I show up, there might be somebody from an antitrust official from the Federal Department of Justice or the FTC because they now have come to the opinion that con laws are anti-competitive. And so they're happy to tell legislators that these are anti-competitive laws. But then on the other side, it's usually 20 deep of hospital association lobbyists who are there to defend the laws very strenuously. And they have come up with a number of different arguments over the years. I mentioned the initial rationale for con law was that it was going to discourage unneeded or unnecessary procedures. But over the years, they've come up with other rationales. They say that it's needed to increase access to care for vulnerable populations, which is there's no zero evidence that it does that. In fact, we have some evidence that it decreases care to vulnerable populations. It's associated with higher racial disparities and the provision of certain procedures. It's associated with less care in rural populations. And it's associated with lower profitability for safety net hospitals, hospitals that cater to lower income populations. So the arguments sort of shift over time, but no matter where they shift, the data still suggests that con laws don't work. OIE health officials often point out that the con laws are not a real problem, because con applications are very rarely denied. Would you agree that this is an indication that our state con laws work? So it may be. I wouldn't say it's an indication that they work, but it may be an indication that they aren't especially severe, which is we have great metrics of which states regulate which procedures. And I mentioned Hawaii tops the list in terms of the number of services and procedures that it regulates. We have pretty good metrics, but it's kind of spotty in terms of looking at things like the cost of the procedures or the cost of the application. One thing that you kind of have to have to figure out on a case by case basis is how often applications are accepted or denied. And so you kind of go through FOIA requests and you figure that out. Now, if you have a state that has a pretty high acceptance rate, that still may not be an indication that this is a low barrier to entry. You'd want to look at a couple of other things. So one of the things you'd want to look at is the number of people that are choosing not to apply because they don't want to go through the hassle. If you only have large players, which is typically the ones that benefit from con laws, if you only have them applying, then they're typically able to get through, then it's exactly doing what they want it to do. But it still is harming patients and harming other providers. So that'd be one question. Another question would be to look at how long does it take to obtain a certificate of need and how much time and money do people have to spend in order to do that? So one of the things I often recommend to people, there are some states that are just like ready to get rid of certificate of need laws tomorrow. South Carolina you may know just passed pretty significant legislation doing away with just about all of their con laws except for nursing homes. And they were like Hawaii, they were a pretty high regulator. But other states are not ready to take that step. And so one of the things I often recommend is there are a number of things you can do on the way to full repeal. And one of them is you could actually use the legislative process to mandate that the con regulator gather data that's helpful for you. So require the con regulator to on a regular basis publish what percentage of con applications are granted and what percentage are denied. Report how many of those that are denied and accepted, how many of those are opposed by incumbent providers so that we have a sense of how much our incumbents able to block their competition. It would be great even if the regulator gathered data from providers to help illustrate, help us better understand what kind of a barrier is this. So anytime anybody applies for a con, the application could ask, how many man hours did this con application take you? By your best guess, how many patients, how much care are you not providing because you had to go through this process? So kind of gathering some information like that I think could help us better understand the veracity of that claim that you encounter. Or stay like Hawaii, which has such extensive con laws. What's the most practical way to get started reforming the system? What are some lessons we could learn from other? Yeah. So I think what the types of reforms I just mentioned I think would be good easy steps. There's nobody really can have an objection to transparency. I think a next simple step is always to raise the thresholds at which con is triggered. So if it's a very low threshold that you just want to spend a thousand dollars to add a hospital bed or whatever and you have to go through a con that's pretty ridiculous. So that's kind of simple. Some other steps though that would start moving you closer I think to the end goal are worth considering. So we've already mentioned some of the rarely regulated procedures that I think it's really hard to come up with a rationale for them. So if it's standing in the way of care for vulnerable patients, I mean substance abuse cons, I don't think they have any business in your 2023. Same goes for psychiatric care cons, burn care, neonatal intensive care, hospice care, home health care, anything that is providing care for people that's a lower cost alternative or that's to vulnerable populations. I think that should easily be looked at and that's what a lot of states have done is they just get a do away with those types of cons. If you want to go more significantly, five states have certificate of need laws, but they don't involve incumbent providers. And incumbent providers aren't allowed to oppose the application of would-be competitors. They're not allowed to sit on the con board. That to me makes eminent sense. Another step in that same direction is to get rid of the word duplication in the regulations so that a con isn't denied just based on the fact that a competitor might duplicate, i.e. compete with an existing service. Could you share some insights on the potential economic consequences of reforming or abolishing con laws in Hawaii? Yeah. What way, for example, might it impact job creation or economic growth in the health sector? So this is actually sort of cutting edge research. I know of a few researchers that are looking at the jobs question and I think we'll have results in the next hopefully weeks to months, but I can't answer the jobs except to say that we know that there are more service providers. So that almost certainly means more jobs. It'll be interesting to see what kinds of jobs, but the average patient in a con state has access to 30% fewer hospitals. They have access to 14% fewer ambulatory surgery centers. They have access to about 30% fewer rural hospitals and 13% fewer rural ambulatory surgery centers. So all of those are going to be once those cons are eliminated, that's more jobs in both urban and rural settings, I think. I'm guessing that's what these researchers are going to find. The other way we can look at the economics of it is to look at the profitability of providers. And so back to one of your questions was why do we have these? Providers are scared that they're going to go out of business if they are open to competition. The evidence actually is that profits go up over the long run. They take a short-term dive as new competition comes in, but over the longer run profitability actually returns and exceeds what it was before it was repealed. In states that have successfully repealed or in some way modified their con laws, what do you think are some of the more important strategic factors in being able to bring that about? So I do think it's very helpful to have a pretty broad coalition. So in South Carolina, for example, there were physicians who were pushing for the elimination of their certificate of need laws. The American Medical Association is opposed to con laws. There were antitrust officials at the Department of Justice and the Federal Trade Commission that were willing to come and talk about these. There were economists. There were also people who had a financial stake who could gain from the elimination of con laws. They were device makers, people who make CT scanners and MRI machines and things like that. I think we're involved in that. As were insurance companies. Con laws make the cost of care more expensive and as payers, they don't like that. So they were opposed to it. I think that helps a lot. But ultimately, I think being able to tell the human story and talk about how there's actual patients, actual constituents in your community, who frankly, their lives are put in danger by not having access to higher quality, lower cost care. Why do we want to protect incumbent providers at such an incredible cost? It doesn't make a lot of sense. And I think helping to tell those stories really does make a difference. Very good. Well, Matthew, thank you so much for being with us today. You've certainly got a great deal of expertise on certificate of needs. And perhaps we could have you out here in Hawaii helping us to reform our laws. That's certainly a great need. But glad you were able to be with us today. Thank you so much. I appreciate it. It was great to chat with you. Well, my guest today has been Matthew Mitchell, a senior research fellow at the Needs Center for the Study of Occupational Regulation, all the way away at West Virginia University. Until next time, we wish you an aloha. I'm Keeley Akeena with the Grass Street Institute. You're watching Think Tech Hawaii's Hawaii Together. Hello.