So this is Senate government operations. It is Friday, January 29th, and we have a couple of items on the agenda today, and I will because the couple of people that are with us today are not used to being in our committee, so I will just remind them not that they would be tempted to do it, but we don't use chat in our committee because I consider that a sidebar conversation, and if we were in the room in person, we wouldn't allow it to go on. So the only thing we use chat for is, if you have some kind of a document or a link that you want to give to Gail, she'll put it on there, and then she'll make sure it gets on our document list later. So with that, I don't know Commissioner and Elizabeth, if you know everybody that's here, but I think we'll introduce ourselves because we have at least one new member. So I'm Jeanette White from Wyndham County. I'm Anthony Polina from Washington County. All right, Colin Moore from Rutland County. Allison Clarkson, Windsor County District. Pisha Rom from Chittenden County, and since we're not using chat, I just wanted to remind my chair and others that I'll be gone for about 15 minutes at 1.15 to report a bill to Senate education, and I apologize. Thank you, thank you. Those other committees are a drag, but we lost Senator Polina yesterday for a little while. So we don't actually have this bill, S42. It is in health and welfare, but last year, because it's the creation of a new commission, and we kind of oversee the organization of government. So we often weigh in on boards and commissions. And we weighed in on this one last year and supported it wholeheartedly, but we just wanted to make sure that we had the same information this year and that we're so that we can let health and welfare know that they might have five people on their side. So with that, I think what we'll do is instead of walking through the bill first, Katie, I think we'll have Beth go first because I know that she has an appointment she has to leave for one of those little vaccine in the arm for a relative of hers. So we'll start with you. Can you hear me? Yes, yeah. Thank you first. I have to say it is really nice to see you and actually be connecting with you. I've been watching your committee, but to connect with you this way is really meaningful. It's been a hard year. And I look forward to the opportunity to come back to the state house and see you each in person. So thanks for this. I'd like to start with just a little bit of a story just to set the table here. This fall in September, my son came downstairs and said, Mom, I'd like to join the Jericho Underhill Fire Department. I find that COVID is an isolating experience and I want to connect with my community and this is the way I want to give back. And I paused for just a second or I must have. I'm not even sure I was aware of my reaction.  And I said, I took a breath because I had to for my own peace of mind. And I said, no, I'm actually, I know what you're going to say. I served six years as a prosecutor. I did the sexual assaults, the serious crimes of violence, homicides, domestic violence. I went to the crime scenes and the awful and timely. So I knew what he was going to say. And it broke my heart. And I told him that he had our permission but that we had to have an agreement that when he could come home from one of those awful experiences, that first we needed to talk about it and also that he needed to avail himself of the support if there was any at his local fire department and if there wasn't, he needed to let us know so that we could figure out a way to find him that support. That is not a unique story. Two days ago, I was talking with retired UVM chief of police, Gary Margolis. And I shared that story with Gary and Gary laughed.  And I told him that he had my blessing but for two pieces of agreement. And those were the exact same concerns that Gary shared because Gary, like Jim Baker and like anybody who's been associated with this world knows that what you see and what you experience is traumatic. And if you don't address that trauma, the injuries are lifelong. And if you want to look at it from a government perspective, they impact not only the employers they serve, their coworkers, but the public that they interact with. So with that in mind, thank you for taking up this bill. Thank you for your support last year. And thank you so much for really making an effort to move this along. As you know, it passed out of the Senate with great support. And it sort of fell apart in the house because I think we were in the middle of COVID and everybody's capacity was greatly diminished. I'm hoping that if we can get to the house sooner rather than later, we have a real chance at passage this year. Jim's on and he'll share with you what got him interested. It's a very moving story. He reached out to me and shared this idea he had. And of course, I was all in. I remain committed to seeing this through passage and adoption. Jim and I worked together at Public Safety for many years. So it didn't take much explaining. The reason for this bill is obvious to the first responder world. We are in House Senate Health and Welfare. And I would say that the bill will have one technical change. We need to obviously change how we refer to the Vermont Criminal Justice Council in the bill. It's the Criminal Justice Training Council because that's how it was referred to last year. And obviously that's changed. So we need one technical correction. And there will be a request to make two additional changes. I don't know what the committee's response will be the language that we sent over this morning. Katie has it. But we're suggesting that in subsection B4, in the committee's charge, you'll see the number of things the commission, excuse me, the commission's charge. The commission is charged with, among other things, in B4 to educate the public emergency service providers. And we're proposing that we add language and their immediate families. At the end of that paragraph, we want to ensure that, in addition to examining prevention and intervention and the effects of trauma experienced by emergency service providers and law enforcement officers, that we include in the effect that trauma may have on an emergency service providers immediate family. In addition, we're going to propose a new section which will require a little renumbering in subsection B. And that section speaks specifically to some of the additional barriers that women, members of the BIPOC community, members of the LGBTQ community to include those who are non-gendered might experience in raising their hand to say, hey, I need help. So we've included language that says consider best practices that encourage emergency service providers to overcome perceived stigmas they may associate with addressing or reporting trauma-related emotional injuries to include emergency service providers who may identify as black, indigenous, persons of color, LGBTQ, female, or non-gendered. Those are changes we're going to request. Well, that's the language we're suggesting that they include in the Senate committee human services. So that's where we're at. I don't know how they'll respond. I'm hoping this week will take upcoming next week we'll take testimony. I believe former Rutland mayor, Chris Loris, will be testifying. I did speak with Chris. He's going to tell a very personal and pretty moving story in support of this bill. And then I don't know if there'll be any other witnesses, but I expect we'll take this language up. So that's the status. Do you all have any questions for me? Does anybody have any questions? I have talked to Senator Lyons about the language. So I'm glad you brought it up here because we will act. I mean, it will be part of the bill, I believe. So great. Thank you. Any, Senator Bartson? You are muted. How fabulous. I'm so well-disciplined by my chair. Should be muted when I'm not sorry. Anyway, Beth, it's great to see you too. Good to see you, Jim and Kay. But I have, Beth, it's great to see you back at you. I'm just curious why you limited it to the emergency services service providers because, as we know, trauma is experienced in the medical profession, in state's attorneys, in a number of areas around this. I'm just curious why Wellness Commission would just be limited to one sector when trauma is experienced in a number of professional ways and volunteer ways. Well, so we're really addressing a system, a particular system. The health care system is its own system. And it is not to the exclusion of their trauma. And I suspect that this work actually might inform others as to how to move forward. I'll let Jim speak to how he came to identify this, to work within this particular system. You might call the first responder world. And we certainly recognize, I'll be the first to tell you, that when I was a public safety, and general counsel, I was asked to help put together a peer support team, which was their way of trying to support their membership. And as part of my work with them, I attended a conference. It included an expert that public safety had brought in. And as I was sitting and listening to this expert describe PTSD and trauma related injuries, I recognized for the first time my own trauma related injury as a result of my time at the state's attorney's office and what I had born witness to. And the light bulb went off. I didn't have any association between what I had experienced and what word we were attaching to it until that moment. So there is no end probably to the lines we could draw. I think Jim can speak to this. But my guess is he tried and wanted to start with a world where we've made some progress. Let's get it right here. I suspect that gradually we will be adding and applying what is learned here potentially to other folks working in this area. Jim, I don't know if you want to jump in and add to this. I would, yeah. We'll just jump to you for that. And for whatever else you have to say. And Beth, if you have to leave before, please. Thank you for coming. And for sharing your story. Thank you, Senator. And again, thank you for the support again this year. And I got a comment on Senator Clark, not on the piece about expanding it, but I'll get to that in a minute, Senator. I do think this is probably the first time I've actually seen my good friend Beth Novotny in I think over a year and a half physically seen her. Maybe a year. Maybe we saw each other at the state house quickly. But Beth and I have a lot of history together. The reason why I'm bringing that up is when I came up with this idea and I'll walk you through how I got to where I am on this idea, the first person I called was Beth because I knew she had one of the best strategic minds of anybody I've ever been around. And I needed some help on an idea that was floating around in my head. And how can we do something about it? That's how Beth. And Beth has given up countless hours, countless hours over the last year talking with myself and other members of the first responder community about championing this process, this legislation. So again, for the record, my name is Jim Baker. I'm currently the Interim Commissioner of Corrections. But prior, this bill idea came forward prior to becoming commissioner. And as you all know, I work for the governor now with Secretary Smith between me and the governor. And I tell you that because the governor does support this legislation and has given me permission to speak in my role as the commissioner of corrections to support the legislation. And let me just tell me, especially for newer members that may have not heard this last year. You know, in 2018, I had the unbelievable honor of receiving the Con Hogan Award. It's an annual award given in Con Hogan's name. It's given to someone that has had public service and around the area of making a difference through data. And I was recognized primarily for my work that I had done when I was the chief of police at Rutland. And I was nominated for that award by someone who I have an enormous amount of respect for. And I was given the award. And along with that award came a pretty hefty stipend. And I guess I skipped over who nominated me. But it was Mary Powell. And Mary was the CEO of Green Mountain Power. And I consider Mary a friend and a mentor. And I was given this fairly significant spike. And some folks on the committee know that I had some medical challenges around that time. And I was in the battle of my life. And I was blessed to have those resources to pay off and support some of my medical expenses. But I set aside a certain amount of money because I felt like I was honored in the name of a guy who I had no business being mentioned in the same sentence as Con Hogan. And I needed to find something that I needed to give back. And I was looking forward to something I could pay forward. And as I was recovering from some surgeries, I gave it a lot of thought. And I landed on something that I've been passionate about for a long time. And it was around the suicide of police officers. Many of you know that in my career, I also worked for three years in Washington, DC for the International Association of Chiefs of Police. And one of the things that was in my portfolio when I was there was the overseeing and development of the Center for Officer Safety and Wellness. And I became very much involved in the conversation nationally about the suicides of police officers. And just to put this in the perspective of what a challenge this still is nationally, some of you may or may not have seen this. But since the uprising at the Capitol on January 6th, two police officers have killed themselves that were part of that, that were in that fight for their life on the ground at our US Capitol. One was a Capitol police officer and another one was a Washington, DC Metro police officer. And suicide is a complicated thing. And so I had a big interest in that. And as I was recovering, I gave it some thought and thought I could expand it. As I did research on suicide of firefighters in paramedics, I realized their numbers were at a proportion as well. And I had a pretty good understanding of trauma. As Beth said, you can't be in the business that I was in and not think back about situations where I was traumatized. I remember the first double fatal car accident that I ever investigated in October of 1978. And if you asked me to describe that scene right now, I can describe to you in great detail, including where the bodies were inside the car upon impact. And that's the kind of scene it was. And I've been very blessed in my career to be married to someone that was a registered nurse and Senator Clark, I'm gonna get to this in a minute because it ties in. And that understood what trauma was for a very long time and supported me over the years and I've been able to work through it. So I came up with this idea that I wanted to work with first responders in the state around providing support to all first responders who are exposed to trauma. And I started making a bunch of phone calls and doing some investigative work. And again, I had quite a bit of free time on my hands because I was doing some consulting, but not working full time. And I learned that the services provided to all first responders in Vermont were uneven. You could be a firefighter in Burlington and they have a pre robust program where they support their firefighters, Senator White down in your area. The Brattleville Fire Department has a pre robust program supporting their firefighters.  And I know in the law enforcement community is the same. There's not the programs that look like what the Vermont state police have. And corrections when I got here had started a peer support program a couple of years ago. And I will tell you another factor that drove me to do this was a suicide of a corrections officer who I was very close to in Rutland when I was the police chief. And after I left this individual committed suicide and the day he committed suicide, I got a call from the Rutland city officers telling me that he took his life. And I loved this guy and he was somebody that had a big impact on the success that we had in Rutland. But he had a very complicated life and a lot of trauma in his life and he just couldn't work his way through it. And by the way, his complication as life showed up in work performance on the job. And he had then become the subject of investigation inside corrections that led him to make the decision that he couldn't go on.  So in June of 2019, we pulled together a group of all first responders at the fire academy. And this is when I reached out for Beth and we floated this idea about could we put a working group together and put together a conference for all first responders which we did on June 9th of 2019. We had 250 plus people there. If I had to find, and that's what I put some of my resources towards to underwrite that conference. If we had more money, and I had some very generous supporters including Mary Powell that helped us put that on. If I had more money and resources, we could have put 500 people in that room. It was, I think Beth was there. I think she will tell you it was a powerful, powerful experience. The governor opened up the conference. This is before I guess I was auditioning for the governor at the time I didn't know it. Cause a month later, my phone rang offering me the corrections job but the governor was there. And I will tell you and I'll tell the story at the end. The governor said to me, I can do the keynote but I need to leave cause I have other commitments. Our keynote speaker was a trooper and I'll talk about it in a few minutes. His presentation was so powerful the governor couldn't leave. The governor would not leave. And I think his security staff kept motion until it was time to go and he didn't go. He stayed until the end. And so this is how we got to where we were. And coming out of that conference, what we did in the afternoon of the conference is what I would call a town hall where we just opened it up for conversations that we had. I don't remember the questions now but we had three or four probing questions that we facilitated a town hall conversation. But here's what's important for all of you to understand is that coming out of that fire EMS and police corrections was there. Unbeknownst to me that I would be the commissioner we invited corrections to come into the conversation. Across the board, we heard the same thing. There are not enough qualified clinicians to deal with this type of trauma. Insurance companies will not cover it.  And we heard stories about volunteers that committed suicide. That yes, they're your local plumber, they committed suicide, but it's that tied back to their service as an EMT for 20 years where they've seen countless tragedies or suicides wherever the case may be. And coming out of that and one of the things that we decided was that we were gonna try to put together legislation and move forward. And that's how we got to where we are now. So Senator Clark, I say all that to come back to your point. The idea in the beginning was the focus on one system. Now, ironically, I think we can all agree that the country is traumatized right now. I mean, I don't care where you are on the spectrum and it doesn't matter, but we are living in a very, very treacherous time. And then you lay COVID-19 on top of that. And these first responders are, you know, I have 18 employees quarantine right now in the Correctional Facility in Bowling with three positive incarcerated women. And this is what folks are facing every day. It's just not the everyday stuff that I faced when I was a road trooper or when I was the police chief at Rutland or any of my other experiences in life. Now we have this COVID-19 thing that's putting enormous stress on people. I can tell you inside my agency right now, my staff is very stressed. And to the point where I worry every day, I don't want something to happen on my watch. As a leader of the department, I've lived through losing troopers. I've witnessed, I've been involved in funerals of troopers that have killed themselves. And this is a very challenging time. And ironically, the bill cleared the Senate last year because of many of your support and I appreciate that. But this is an entirely different year this year. And I'll wrap it up by telling the story and then I'll certainly move on to questions.  And he has, and if you so felt the need, he would love to come in and testify. But his name is Kurt Wackenback. And on December, or excuse me, on April 8th of 2008, I happened to be the colonel of state police at the time. And I was with my family on vacation in River Beach, South Carolina with my phone ring. And I was briefed on an incident where a mom in a psychiatric crisis threw her two young children into a roaring brook and leaped into the brook herself. And Senator, if you remember this, it happened in Wardsboro. State police, as Kurt told the story that day at the conference and as the governor sat there and I know he was just couldn't move, as Kurt told the story. Kurt talks about getting the call at seven o'clock in the morning. He was playing with a small child before he signed on as a trooper at eight o'clock. And the dispatcher could tell from the tone of her voice that something bad had happened. And he immediately responded to the area with other ironically firing EMS and other troopers and other folks trying to make a rescue of these children. And he will tell you the story as he watched the child bob down the street. And he tried to get into the water to get to the child. And a firefighter grabbed him and the other troopers saved their lives. He talks about not being able to do what he thought his job was because to answer the question about why the first responder community, there's a stigma in the community that when you're called, there is no failure. And when you fail, it's a big deal. It's a big deal psychologically and it's a big deal emotionally. And it's a big deal because you didn't get the job done that you're paid to do. Kurt talked about this at the conference and I've maintained a relationship with Kurt for the, it's hard to believe I'm saying this, for 13 years since that incident. And I talked to him quite often. And he went back to the command post that was set up at the Woodsville Fire Department and soaked from head to toe and walked in.  And I'm sure it was because, what are you supposed to say? Hey, you didn't do what you were supposed to do. But he took that as failure. And in the business of peer support and best practices, the best way that should have been handled there, peer supporters should have took him off the side and done what's called a diffusion. And diffuse the situation. But from that day forward, he tried to champion on for the next four or five years as a trooper. And every month that went by, it got worse for him. To the point where he had to finally go out. And by the way, the other trooper that was with him, one of the last things that happened as a colonel of the state police a year later was we had a fight for him to get a disability requirement because he fell apart immediately. And had a lot of other issues in his life. And I've always carried this story forward because it's that and the loss of the corrections officer to a suicide and other traumatic events in my life. I always thought that if I had the opportunity to do something about this, I would.  And, you know, Kirk went out and because of the good clinical support the state police had, he was able to go out and the disability under the new law that post-traumatic stress syndrome is in fact the disability. And he's doing fine today and he's with his family. And he's been able to work through it. And I think that's what I want to see for all first responders in the state. And that's why we put together this effort and I share that story with you. So with that, Senator, I'll be quiet now and I'll certainly answer any questions that folks have. Thank you so much. And I am going to, and I know Senator Clarkson I know that there's trauma in other areas too but I'm going to limit the conversation to first responders here because in the interest of time and in the interest of supporting this particular bill I want to acknowledge that there is trauma in lots of other places, but this one is specifically addressing first responders. And I will, I'm just going to say one thing and then I'll ask if anybody has any questions and then we'll have Katie do a, I think a high level walkthrough because the details of it are going to be in health and welfare unless and committee members may not even need to have a walkthrough. So we'll see where we are. But I will say that as you probably all know our previous sheriff in Wyndham County had a near experience with suicide and he's been very open about it but and he did get professional help but perhaps had there been something like this in play earlier than that, he might have not gotten as close to suicide as he did but and that was just his help came only because he happened to be on the right road at the very moment that he was considering suicide. So with that, do the committee members have any questions for the commissioner or questions about the bill itself or whether we want to have a walkthrough of it or leave the details in the walkthrough with health and welfare. So committee, Senator Colomar. Thank you, Madam Chair. No, I don't have any questions. I want to thank Christian Baker and I guess Ms. Novotny has left us but for being with us today, Jim and I have known each other quite a while and some of that I'd never heard before. So it was extremely interesting. I don't need a walkthrough. I'm fully in support of this bill including the changes that Elizabeth referenced to include the families of these folks as well and the addition of the BIPOC reference. So I'm fine with the way it is. And again, I thank Jim. You're welcome, Senator. You're welcome, Senator. Senator Polina, I see you unmuted yourself. Yeah, that was very powerful testimony. I'm good with the bill as it is well with the changes that have been put forward as well. So I don't feel the need to go through the bill. Appreciate Katie being here in case we needed her but I don't really think it's necessary. But I read the bill and I understand the bill and I understand from the testimony how important it is. So I'm good with the way it is with the changes that have been offered. Thank you. Senator Clarkson. Oh, I agree.  So I hear the trauma, I hear it all the time.  He's a Woodstock firefighter. I think, I mean, this is critically important. I, the stigma around getting help is huge particularly in this community but the stigma exists everywhere about getting help on this. Jim, if you'd be willing or Katie or whoever, it would be great to just have some of the statistics in the last five years of sadly, some of the consequences of not getting help because our job is to advocate and paint the picture. And so it would be great for us to just be clear on in each of these areas, you know what the impact has been without help. I will get that to you. And Senator, to your point earlier, and I don't wanna take much more of the committee's time but it's interesting because I have a friend who works in this space in Vermont who is now starting to work with the nursing community in the emergency rooms because of COVID and the stress that's on the healthcare. And so what I'm hoping comes out of this is the research and the work that we do can be applied to other disciplines and other systems in order to support people because again, we are operating in very challenging times. Yeah. Yeah. Thank you, commissioner. I think that, and thank you, Katie for being with us. I believe that we're all set that we don't need a walkthrough because you Beth pointed out the changes that are being proposed. And I think everybody is okay with the bill as it is. So what I will do is send a note to Health and Welfare that we as a committee support the bill and the proposed changes. And then they'll have five more people on the floor absolutely in support of the bill. So if that is okay with everybody. Yes. Okay. Good. Yes, thank you. Senator Carson. So Jim Baker, I'd just like to say it's good to see you still in this position. Ask his wife about that. I know how she feels. I know, but I have to say it's wonderful to still have you leading corrections and thank you for your continued service. Senator, thank you. And I appreciate the support on this bill and everything that you support corrections on. I deeply appreciate it. And just going back to the Senator's comment, the fact that we've been isolated for a year and I work out of my former consulting office, which is a mile from my house, makes a big difference than being in water very every day. So my wife is being very patient. Thank you. Thank you, commissioner. And thank you, Katie. Thank you, folks. Thank you, Katie. Thanks. Bye now. Bye. So the next thing on our agenda was the EMS system and there was some confusion. I hope, Pat, that you weren't confused. There was some confusion about whether it was related to S42 or not. It was not related to S42 at all. It is, we are, I had a conversation with commissioner Gustafson a little while ago. And we, one of the areas within our jurisdiction is the emergency management system. And we have been working on trying to help make the system more sustainable for the past few years. And we've made a number of changes, just a lot of them administrative or regulatory or how often they have to be certified and who has to certify them and the education and the training and making sure that they have alternative methods just to licensing or certification other than onsite ones that we've been working with the department of health and with Patrick Malone who is the, he's in charge of rural health options. I think it's called at the University of Vermont. So he does the EMS system. So we've made a lot of changes. And then when, before COVID and then when COVID hit we made a number of suggestions and recommendations around their training and scholarships, stipends for them to get trained. It still is not a sustainable system. And so what we're doing now is looking at we're trying to continue the conversation and go in different directions. And one of the, I'll tell you why the two of you are here. We have heard that the cost of becoming a parametric at VTTC is close to 30,000. But the cost of the same parametric program at Greenfield Community College, which clearly is closer to us than Randolph is about 7,500. So we don't, we aren't sure if those are comparable programs or why the cost difference if it's the state underfunding of our state system. But so we need to have a better understanding about that. And then, and what alternatives there might be and how the academy is working with the, with other places for training like the career centers perhaps. And then Commissioner Gustafson, you are here because we want to continue the conversation about how do we reimburse them? And we're not talking about reimbursement levels or how much they should be reimbursed. But how do we reimburse them? What do we reimburse them for? Is it within our control or is it something that sets someplace else? How much control do we have? How much leeway do we have around treating them more as healthcare providers than, and we've been working toward changing the culture from thinking of ambulance services, EMS system as a transportation service to more of a healthcare service that they are really an extension of the hospitals and the doctors that they work for or with. So those are the conversations that we want to have. We don't necessarily expect any answers from you today or any, I mean, if you had answers we'd be very happy to receive them but we want to continue this conversation. So this is more kind of a conversation than kind of a testimony if that makes sense. So do either of you have a time constraint? And if so, I would be happy to put you first. And you're both muted just for your information. I only start talking when someone says you're muted because I think that's pre-rec for every Zoom meeting someone has to be. You're on mute. I do not have any time constraints. Yeah, I mean, I have a two o'clock, but... Why don't we start with you then? Well, so thank you for the phone call ahead of the testimony, Senator White. I appreciate that. I appreciate you recounting that again. That's what you had to put me. So in light of that angle of approach to the conversation, I asked for Sue Ellen Botigie. She's the director of our provider member services team. And so really, I guess the starting point for the conversation is what are the parameters under which the types of providers are reimbursed because I don't think the culture aspect of it is an issue from our perspective in terms of what we pay, how we pay, or what we do. I mean, I know there are parameters. If you wanna get into the details, I'll have Sue Ellen sort of talk to you about those of you have specific questions, but I will also say that what I told you on the phone is still true, that we have been in this process of professionalizing our reimbursement and payment methodologies at the Department of Vermont Health Access, and it's not limited to EMS. It's across the board. I'm not sure that EMS has gotten that review yet. I mean, there are thousands upon thousands of codes and services that we need to be professionalizing. And we've made a lot of progress, but we, I mean, I'd say we basically are looking for a benchmarking. We're looking for a methodology that's repeatable and usable, and then we're looking for regular review and intervals to be able to make sure that it isn't, doesn't require a legislative conversation when it comes that a code has been, or a reimbursement has been left behind for a long period of time. So just on like the actual rates, that is something that we're really going across a lot of areas. I don't know if EMS is in that space, but Sue Ellen and I have had conversations about some of the, this isn't a new conversation either, not to say that it's old, old, old, but it is something we have talked about. And there are some, I would say federal limitations on what we can and can't pay for that creates, I would say difficulties. And I mean, from a lay person to a few other lay people in this area, I don't think Medicaid can pay for a trip if there's not a patient. So then that makes, you know, but they still made the trip, right? And I believe, and you know what, I'll just stop and ask Sue Ellen to jump in and because I'm gonna go on the like, three or four that I think I can remember.  Because I think what we need to do, by the way, is to get to this of an endpoint of this conversation or a resolution or a make progress, we need to know the specific problems so we can come up with solutions. I mean, we are actively engaged in payment reform, which is different than just having a professionalized fee schedule that gets regularly reviewed. Immeraform is purchasing healthcare in a different format so that you have a different result. So we do now look to prospectively pay for healthcare. That creates a situation where the providers don't have to chase the dollars. They actually just have to make sure they're there when they're needed. And that changes the dynamic of how they end up performing healthcare. EMS, we'll have to look at it but we also have had success in this area. And so it's not, I'm not just talking about the all-payer model or the ACO environment. We have several other payment reform efforts. Applied behavior analysis is one that we've been engaged in for a while. We're buying, we've unstructured the reimbursement in a different format. And in order to get what we solve the problem, I won't go into the whole story but we've had success in a few places. Now within the agency, we have all kinds of department representatives coming to us saying, can you help us with payment reform in this area? And in this area, so the DEVA payment reform team has been very successful at creating, like I said, a methodology for solving what is the problem we're trying to solve, getting at it and producing a methodology that can better serve, in the end, we're looking to serve three parties. We're looking to serve the patients. So the patients are better solved, served so that the providers are able to be sustainable and preserve access to care. And then lastly, the taxpayer, right? We don't, the easiest thing to do is to just say, how much more do you think it would take? And then we just appropriate that money. That's not the goal. We owe it to the taxpayer to make sure that every dollar is spent as well as possible because every dollar is spent in one area is dollar that's not spent in another area. So balancing that is also part of our task and our responsibility. So if you want, I can ask Suelen to talk about some of the parameters that she has heard to be a problem. I don't know that we've had direct communication from the emergency medical service representatives in this current year regarding reimbursement. So I don't know if she's heard anything of recent, of late, but we've had a lot on our plate and as healthcare system in the last year. So maybe I'll pause there and see how you want to proceed. Yeah, no, that's fine. And I don't know that, I don't think we have any interest in setting reimbursement rates or anything like that. We're not, I think what we need to do is understand what the parameters are. Like you said, Medicaid can't pay if there's a trip with no patient. So does that mean we need to redefine what a patient is when we're looking at our EMS system as healthcare providers as opposed to transporters? And I don't know, I mean, that's not your question, that's... We can't pay a doctor if there's no patient either. Right, right, but in this... In a fee-for-service model, that's what I'm getting at. And so I think that... I mean, you're beginning the conversation of solutioning, but let's figure out what we need to do and where the pain points are for the providers. Right, right, no, I get that. I was just thinking because we talked before with EMS about how are they transporters or are they healthcare providers? So, I mean, I think that's a larger conversation too. And they all fit together and we need to have the conversations. But yeah, I think that it would be important for us as well and to understand what kind of what the parameters are that we're dealing with and without coming to any conclusions now about what to do about them, but just what they are. And I did see that Senator Clarkson had a question. Corey, it's good to see you. I actually thought of you the other day when they were talking about hockey issues. And I thought, oh, Corey, I haven't seen Corey in a long time. I haven't seen anyone in a long time. No, I know he was a commissioner until just now, so. Well, it's good to be. Eva, following Mark Larson. So Corey, on this transport issue, I mean, it's to me just a classic example. I mean, they are transporting themselves and they are actually caring for a patient and because it may be a successful outcome that they don't have to transport someone to a hospital because they may have intervened in such a productive way that there is no transport, but they transport themselves to deal with the patient. And yeah, it's just, it's a system that really does need review. So we'd love to have the EMS crowd on the radar screen for payment reform because they may be in fact saving us dollars and they need to be paid for, you know, rewarded and paid for that. But I think we need to understand what the parameters are so that we understand what we need to change in the EMS system and in the healthcare system to abide by those parameters because if they're set up for us, we can't change those. We can only change the way we, if we can. But why can't Medicaid be changed? We, let's find, let's first of all find out what the parameters are that we're dealing with and then start thinking about, because Medicaid, they have certain parameters that they have to work within and we need to know what those are. Is that fair? I think it's fair, but I don't think it's the final. It isn't the final, but we're just starting the discussion here. I don't want us to come to conclusions with 10 minutes into the discussion. Right. Okay. So, Sue Ellen, do you have thoughts for some words of wisdom around what are we dealing with here in terms of how constrained you are and therefore how constrained we are? And welcome, by the way. Is she here? Yes, she is here, but she's on mute and off-camera.  I did see her earlier and I see her name. Yeah, and she was just telling me, clarifying my comment too. So I don't know if she's- There she is. Thank you guys. I could not unmute myself. Okay. First of all, Sue, I'll clarify the non-transport issue because it's a little different than I think they understood, but go ahead, clarify that, but then also anything else related to are the restrictions that that relationship in a Medicaid program puts on us as far as flexibility. So certainly, I'll be happy to clarify some things for you. So the way Medicaid works right now is we enroll the ambulance providers. So the actual ambulance, if you think of it that way, we enroll them, they bill us and we pay for the ambulance company's services. So if an ambulance goes because there's a fall and they don't end up transporting to the hospital, we would still pay that ambulance company for that trip. We've always done that, we will continue to do that. I think what we're trying to understand here, or what I'm trying to understand here is are we talking about individual emergency responders billing Vermont Medicaid for their services? I think that's one of my questions that will lead to further discussion on understanding our parameters and can we even do that? I'm not sure I understand, but when we were the people that we've been talking to are like Rescue Inc. out of Browbro, which is an ambulance service entity emergency provider and the Rutland, well, the Jim Finger is the chair of the Ambulance Service Providers Association. He's out of Rutland, but he's the chair of that. And our understanding really was that if they didn't transport to the hospital, they didn't get paid for that. We have actually numbers. We've actually ran that information the other day and in the last fiscal year, we paid out $39,000 to the ambulance providers. So I'm wondering if maybe it's more of an education to the Ambulance Association telling them that they have this ability to do it? I mean, that's something that, those are the kinds of things we need to know so that we can work with the service, the system to help them there. So that's very good to know. So, okay, thank you. You're welcome. Yes, and I'm happy to give any of that background information, you know, run numbers or anything like that. Cause I think it's important that we have all the facts in front of us when we're making those, you know, having those discussions. Well, and I do know that I had talked with the commissioner at one point about a particular provider in my area who has a very high level of Medicaid patients and he was going out of business. And one of the problems was his inexperience in billing and that that's such a complicated thing. That wasn't an, right, that's a, that was an actual provider, correct? But I'm just saying that sometimes the knowledge about how to bill and stuff is really important for people. And in this case, the commissioner worked with the person to help him. And maybe the same is true with the ambulance services. Well, it was Sue Ellen that helped them. Oh, well, thank you, thank you, Sue Ellen. She knows all about it. Okay, all right, thank you. Well, you're very welcome, that's my job. And actually what I enjoy doing is helping providers succeed. So it's important to me. Good, thank you. Senator Caldmore, did you have a question? I did, madam chair, thank you. And it is great to see Corey and Sue Ellen and Pat. You just gave a figure, Sue Ellen, I just want to make sure I'm understanding. Are you saying that you paid out $29,000 for a whole year's worth of ambulance services? No, what we paid, and it was $39,000. Yep, $39,000 and $63 to be exact of services that did not result in a transport. So the ambulance services billed us when there wasn't a transport, a person within the ambulance that they took somewhere. Just for those services. Okay, and that's an annual figure, correct statewide? Correct, yep, from 7-2019, 7-1-19 to 6-30-2020, yep. Okay. Statewide of what was billed to us. All right, thank you. You're welcome. Senator Clarkson, sorry, Sue Ellen, can I just clarify that? I thought you said you paid $39,000 for one year of transport that didn't result in a transport to the hospital. That's exactly it, yep. No, it's not every year, it's not the same amount every year. No, the $39,000 was from 7-1-2019 through 6-30-2022. No, 20, sorry, am I going to do this way out? I was going to say, ooh, 20. Yeah. Great, okay, great, yeah. I didn't mean it was a repeating annual figure, I just wanted to make sure that that was an annual figure. Yes, thank you. I understood as well, thank you. Yes, I did too. The annual figure would be different every annual, but it's still an annual figure, yes. Senator Pulley and I see you. Yeah, I have a pretty basic question I think. Are ambulance providers considered healthcare providers? And they fall into the category of healthcare providers? We consider them transportation providers and that's a bigger conversation, I know. Yep, we consider them transportation providers, so we pay them with transportation codes when that day bill us. So yes, at this point, that's how it works. Yeah, so the reason why I ask is, as we move away from fee-for-service, we move towards capitated payments, those are for healthcare providers. And I just wonder if down the road, at some day there would be a pop opportunity to, I don't know what the word would be, but to bring ambulance services in as providers so they could be paid for on a capitated payment system as well. Obviously, that's just something, it's a brainstorm kind of thing. I'm not saying that's gonna happen anytime soon, but it would be one way of dealing with them. It's something we can definitely look at, correct. Yes, something that we can definitely consider as we look through healthcare reform. And I'm sure Corey's putting that on his list as we're talking. Yeah, I saw him right at town right away. I think we already talked about it. I think that's, you know, it's what we're talking about. It's purchasing healthcare services differently, not just healthcare, it's purchasing services in a way to get what we need. What we need is to make sure, I mean, whether they're healthcare providers or not, that's a, we can have that conversation or that. Now I have to look at what the parameters of transport versus healthcare. I mean, I think emotionally we all sit here and go, of course, they're healthcare providers. They arrive on a scene and do something, but that doesn't, the definition of it is different than what our emotional brains say to us about whether or not they're healthcare providers. So I don't wanna get ahead of that conversation, but in terms of payment, yes, we purchase all kinds of services, most of them in the medical environment, but we do purchase services and we are very, as I said off the top, we're very much interested in getting, understanding that how you pay impacts what you get and what we really want is access to EMS services across the state and in a way that makes sure that, oh well, specifically from my chair that Medicaid beneficiaries are able to get to medical facilities when they need to. Just seems like holding them in as healthcare providers so they can be part of a capitated payment system would be an idea worth looking at, as Sue Ellen said. We will keep this conversation going. This is not something that I think we will, in terms of legislative time, do anything that would result in any kind of passage this year, I don't believe because this is a longer conversation and I think we need to really understand what we're doing and EMS and DIVA and appropriations and the Department of Health, I think it's a very complicated conversation. Senator Markson. So to tag on to Anthony's question, which is so good because that goes to the heart of it, are they able to bill under a different code when once they've arrived at a scene, are they able to bill, is there a code for a service for a healthcare service once they're at the scene, are they able to bill under in a different capacity? I mean, is there a code for them? Is there a code for them currently that they are billing for their emergency medical, the EMS for medical, medical service? This is Sue Ellen, I can answer that for you. Currently no, and I do understand the question. So when they are doing the CPR on a patient, are they billing for that? Yeah, that's not a transportation service. Exactly. So yeah, at this point, no, the ambulance providers do not bill us currently for that. And it wouldn't be under the ambulance provider. Right. So there's no codes for that. There are codes for that, but they're not, the ambulance providers are not authorized code. Right, and this is part of the conversation we need to have, and it isn't just a black and white question. It's if a paramedic provides a service in an ambulance at a location that doesn't result in a transport then, or even if it does, are they able to, how do we get it so that they can be reimbursed for that service and the supplies that they use to provide that service as opposed to the paramedic in an emergency room who can bill for that service. And I don't know if it's because we're moving from fee for service to this capitated system that we need to go down that hole too far, but those are some of the questions that I think we need to address is how we define the services that are provided by, and I think that's less a question for Diva maybe than for the Department of Health, but I may be wrong. So I don't know if that muddies the water or not, but it is a complicated conversation. What were you going to say, commissioner? I'm sorry. No, I mean, I'm not, yeah, I'm not sure. I think that what we probably don't want to do is have us wait for a legislative mandate to engage. I think that we haven't, I think that we've talked about it. I think some of the other comments about EMS providers being reimbursed for medical services provided on the scene, but I guess we can look at that and what the limitations are there. I don't know that necessarily that solves the sustainability issue that feels like is underlying all of this, right? The sustainability of these providers. When you and I talked earlier, that was the, I think the word you used was they're in dire straits. So wanting to understand that more was a big concern, but as we know, I mean, we have other providers in the state of Vermont, not in this space, but we have other providers in the state of Vermont that have said, we need this. And it's been through a legislative conversation say that we've said, okay, well, this is what we'll do for you, but it hasn't necessarily solved the issue and that we're right back again. So like really understanding the problem. And I'll just go back to where I began. And we were understanding the problem. I don't have, I don't think there's, unless there's like a, there are, we should just get into our assessment of what the rules are about transport versus healthcare provider. But I don't know that being able to bill for medical services by EMS providers necessarily is a solution that we might hope it is in this conversation. It comes with administrative burden. There are volunteer, there are volunteer responders that not part of the ambulance services that go on scene. And a couple of them have said to us, if I had to enroll to get to be paid by Medicaid, you have to enroll in Medicaid. And if enrolling in Medicaid and doing billing was part of the deal. First responders have said, no, thank you. We wouldn't do it that way. And they used expletives too. So like it does come with you, right? So I don't know, I think as they're all parts of conversations that need to be had probably not in a hearing setting necessarily, but there needs to be some conversations back and forth. Maybe, you know, a study committee, I'm probably the first commissioner to say, I think a study committee at the, the first one to say it this year, I know it'll happens at the end of the year and they're trying to not have a bill passed, but I am saying it probably needs some investigation. If you feel you wanna have something on the books with a timeframe to come back, that's usually the way to do it. But I think we will be, we can generally engage in these conversations all the time. So having it on the radar now, understanding the problem, it'll be good for us to delve into it, whether there's a bill or not that comes forward in the future. My preference is that it would be done without a bill, that we don't need necessarily a legislative fix. I think our role here is to get everybody in the conversation and to make sure that the conversation goes forward. And if the conversation is going forward and they're look like there are potential solutions, then we don't need a bill. If it looks like nothing's happening, then maybe we need a bill to put some fire under the feet of whoever it is. So, and I think that you're right that the, even if the paramedics were reimbursed for the service provided, the same as they might be in another setting, that isn't the solution. There, what we've found over the last couple of years there are many little solutions and we've tried to tackle them. One of them is the workforce issue, for example. We get people all trained in paramedic positions at rescue or wherever, and then they find out, wow, they could work at the emergency room at Brattleboro Hospital and make more money and not have to be on call all the time. So there's many, many issues around the sustainability of this system. And I don't, we're not certainly not looking at the reimbursement as the solution. We're looking at it as one little part of working toward the sustainability. Yep, clarity around the problem we're trying to solve is will be a great contributor to figuring out what to do. I really agree. And you are the reimbursement people. So we're talking to you about reimbursement. Dan Basty, well, not now, but whoever is taking his place if they ever get one, and Pat Malone are kind of the education people and Pat Moulton. So we're talking to them about that part of it and the regulations that were in place by the Department of Health, we've made significant changes in those and those made a difference. So we're just trying to tackle this piece by piece. And I know that there are people out there who are very impatient and would like us to solve everything right away. But we heard from the emergency management people the other day that the changes that have been made have been very positive in terms of helping them become more sustainable. So. Okay. Thank you. My two, if I could say it, my two o'clock is it's 11, 15 waiver stuff.  Oh, just you go by. You probably should. Yes. You probably should. Good to see everyone. Senator Callumar, Senator Ramp, everyone, Senator Polina, Clarkson, White. So I would say that we've kind of raised some questions and that we will have some more conversations with probably Sue Allen and the EMS people kind of at the same time we can have the conversation again. Does that make sense, Sue Allen? That makes perfect sense. Yep, I'm happy to engage. However, you need me to. Okay. Thank you so much. Thank you. And thank you for being here and thank you for helping out my provider. At any time you're notifying me. Thank you for adding me. Thank you. Bye. Bye. So President Moulton. Hi. Hi. Hi, everybody. Happy New Year. Great. So I'm going to, I just thought of this the other day because I got a call from somebody who's running as a UVM trustee who is not a legislator and the very first person who was ever nominated as a non-legislator was Pat Moulton by me as I left my position because I was so upset that people think that it has to be a legislator. It's a publicly elected trustee, not a legislator. And so Pat was the very first person that was nominated and for a couple very bizarre reasons she lost by six votes. Yeah. That was a bad campaign. My first and only. So. So anyway, I've been thinking about you. Well, thank you. So would you, do you want to just give us a little more background on this case? I don't know if you, if we talked about this before, but there's, we don't know if the programs are similar. You were here when we had the conversation with Drew, right? This wasn't last year about the kind of the difference between the fees at VTC versus Greenfield Community College. Yeah. And what constitutes those fees and why there's so much difference and how we can help VTC with this program and the relationship with career centers if there is any and the training center at through Pat Malone. And so just a general conversation about that. The one thing that might be helpful is, I had been wanting to ask maybe like, does this help solve a problem and that we're low on EMTs in general or just let the training is onerous? Okay. Both. I mean that, we're super low on. We, I think he gave us statistics last time, but we are, our EMS system is in dire straits, financially, workforce, in probably in every way. Okay. I didn't quite make a gravity until now, so that's really helpful. Yeah. It's a system that is hanging on by its teeth. And a huge retention, huge retention problem. And hanging on by your teeth, you know that in Vermont, we do not do well with healthcare from the neck up. So if they're hanging on by their teeth, you know it's serious. Okay. So, Pat. First of all, good afternoon. It was great to see everybody happy new year and congratulations to all of you for your election. Senator Rahm and reelection, everyone. It's great to see you again. And someday maybe in person, right? Pardon my attire, it's Flannel Friday here at Vermont Tech. So I got my Vermont Tech, my Vermont Tech Flannel, so my Flannel company on. So it's what we do. It looks like a nice blazer from what I can see. Well, then that's how I'll fake it. So good. Thanks. Okay. So I'll dispense with the, you all, I think know pretty much about Vermont Tech and who and what we are, but our program is a paramedic program. It's not an EMT program. It's the next step up. It is a certificate program. It's approximately five years old. We offer it currently in Bennington in Williston. It is a three semester long program plus an internship. We get 100% placement rate of our completers.  And this year, thanks to the legislature and Corona Relief Funds, we were able to provide a substantial scholarship to Vermonters to the tune of $18,000 a year, which I just wanna thank you very much for that. And that has doubled enrollment in our program. We have 27 students in the program this year. We had, well, close to doubled. We had approximately 14, I believe that completed last year. So it's had an impact for sure. And why is our program so much more expensive? Well, you nailed it, Senator White, in large part because Vermont's 49th in the country for its public support of public higher education. As comparison, Greenfield Community College gets 59% of their revenue from the state. We get 17% of our revenue from the state. So that's a biggie right there. The other piece is it's a three semester program. Our program is 39 credits. Greenfield Community College is two semesters. It's 29 credits. I had a chance to compare the curricula between the two programs. And our curricula really goes deeper into what I heard you talking about before, the sort of medical care provision. We go deeper into things like anatomy and physiology, airway management, EMS management, medical emergencies. There are similarities in a number of areas, but we do OBGYN and pediatrics, which I do not see in the Greenfield Community College. A few other classes that are not part of the Greenfield paramedic program. So that in a nutshell is the basic reason why in my humble opinion and from what I've been able to research, you brought up earlier, are we looking at alternative methods of delivery? I mean, suffice to say Vermont Tech is looking at alternative methods of delivery and new modalities for all our programs. Namely, how can we open it up to more adults? How can we decentralize delivery similar to what we have with our nursing program? How can we make it easier for students to access? And one of the few bright sides of COVID is that our faculty have learned that distance learning and technical education is possible. It's not ideal to have the same amount of time because students are not in the lab in the same way they've normally been, but our faculty have recognized that this is not the end of the world to do this work. And in fact, our School of Engineering and Computing is going to be delivering all of its first year courses, synchronously and asynchronously to any adult that wants to enroll starting in the fall. So I think those kinds of opportunities can exist with paramedicine. You brought up linkages with Career and Tech Ed Centers. That's clearly something I want to do. I would like to look at Career and Tech Ed Centers as possibly being labs for our instruction where we provide telemedicine or distance learning, telepresence or lecture, et cetera. So we make sure our property, appropriately credentialed faculty are delivering the class but that we might have a lab tech at the site of the CTE. Right now we deliver in Williston and Bennington and we do something similar. There's broadcasting of lecture and then students are in Williston for the hands-on. So it's a combined sort of a hybrid in some cases and we think we could do more of that. That does involve expanding our expenses potentially in terms of lab tech, et cetera but also potentially reducing in terms of not having to purchase additional equipment and things like that to do that kind of education. So I have not started that investigation as it relates to this program. We've had general conversations but the nitty gritty of getting into, okay, how do we make this work with CTE is still to be discussed. So that's roughly what I can tell you at the moment but I'm happy to answer any questions you may have too. Well, I just, I have one to start it off and then I'll call on the other committee members but it's in terms of career centers, I wondered what the relationship was in terms of feeding, not using them necessarily as part of the program but feeding from the career centers. And one of the things that I thought we heard was that whatever they did at the career centers was not transferable into the, it didn't, the VTC program didn't build on that. And I wondered if that was something that could be addressed. And then I know that there was a two years ago, I think maybe we gave a grant to VTC as a pilot to work with some career centers around the state to try to figure out how to expand some of the programs between the career centers and VTC and wondered if this was one of those and if that was successful. Okay, I'll start with the first. I mean, the point of a CTE as a feeder is a definite possibility. I don't know right off the top of my head how many students we have coming in that come from career and tech ed. We often find issues with some of those credits transferring in and that has everything to do with our accreditation requirements and assuring certain content is taught at a college level. Some of that potentially could be overcome through dual or concurrent enrollment. I mean, that can be analyzed. So, but yeah, I mean, we have lots of CTE students that come here for all kinds of programs. I just can't speak to paramedicine specifically. On the, yes, two years ago, we were the legislature provided funding for us to investigate offering associates degree at career and tech ed centers in part driven by then chancellor Spalding's recommendation and Governor Scott's excitement about that. We started digging into that. We sent an interim report as required into the legislature that identified a number of obstacles, a number of opportunities. We never heard anything back from anybody. So had no idea how that was felt in the legislature. We would have had to then expand another pot of money to continue to investigate. It chose not to. I think we spent about $30,000 out of that whole 200,000. So somewhere there's 160, $170,000 sitting that we have not touched in part because we felt that we needed to pivot and then COVID hit and the world as we know it changed. So that model assumed we might be using high school faculty, might be using CTE faculty, the center would be the actual deliverer of the degree program. That presents all kinds of concerns from an accreditation standpoint. The model I'm thinking of now is more, it's our faculty teaching distance learning and the lab concept at the CTE to avoid those accreditation issues, to avoid having to pay additional salaries, faculty salaries, to enable students from anywhere to still access without having to physically come here. Another opportunity that we're looking at is low residency options where we could again do the distance learning and students could come here to our labs for weekends, one week, whatever the case might be. And those are models that we're considering. In fact, right now we've got a whole group looking at those new modalities and those new opportunities for all our programs. Our parametric faculty is, one of our key people is also a nursing faculty. So she doesn't have a lot of extra time to investigate these things. So we're trying to do this on our own and in collaboration. But so ultimately, Senator White, we sort of shelved that associate's degree at CTE idea because of the obstacles and felt some of those same opportunities could be met through a different delivery model. So I had a really brilliant question but it went right out of my head. That money did assume we were gonna start a couple of pilots and we didn't think we were quite ready to get to the pilot stage that we had a lot more work we had to do. Then unfortunately, Lyle Jepsen went and took a job somewhere else, gang him. And so we've had a little bit of turnover plus COVID and really said we need to pivot to a different way than looking and having the high schools actually be delivering our content, if you will. I just thought of my brilliant question. In developing your curriculum and your delivery systems, do you work very closely with Pat Malone? I know, not yet, because we haven't gotten there yet, really. I mean, we've been having individual conversations around things like construction management and some of our manufacturing and even auto programs but we haven't really said, okay, now let's get into the nitty gritty. And I apologize, there's so many Pat Malone's in the world. He's the director of rural medicine at UVM and he's in charge of the EMS system and he's very creative in terms of trying to come up with alternative ways to train people and even looking at some of the things that might be some of the education that currently exists that may be better done in a different direction, something. So I would suggest working with him. Yeah, I'll get my, I mean, our academic dean and the director of our program, Inga Smith-Lews, yes, Smith-Lews, is the person who would be getting into those details. But yeah, if we don't have to reinvent the wheel, amen in hallelujah. So definitely we'll be in touch with him. Yeah, thank you for that. And I know Inga has talked with him because I know I've heard her mention his name, but I have not directly.   That's our favorite phrase of 2020 and 2021. I know I'm trying to be good about and also I always started to print things and when he prints things, it's right next to my Thank you, Clark. Pat, hi. I despair at thinking that you submitted a report on workforce and the CTE centers and that we didn't address or didn't respond to. I'm sort of, and I apologize on our behalf. I don't know where it was sent, but I assume it was sent to education or to send an economic development and I am embarrassed that we did not address it. So I apologize. I was sent to the legislative, the statutory required recipient. So it was agency of education. Let's see, a whole slew of folks, but yeah, but we didn't hear a peep. Yeah, I'm sorry about that. Just given how important these issues are. And so that's all I was going to say and we will get on that and other workforce issues ASAP. Well, it was kind of a no harm, no foul because in looking at this work and realizing, geez, that path seems more bumpy than other paths that can achieve the same outcome. Well, but the silver lining of COVID is exactly what you said, which is your faculty is happier doing remote learning, teaching, your students are now more used to we're all now more used to it. And so remote instruction zoomed into CTE centers that can be labs is a great model and one that I think we should, yeah, and that's great. Yeah, it's to your point, I think we've all gotten used to it. There are still students who do not do well and that is not a modality they would pick, but there are many who would. So from a affordability and access standpoint, let's crank it up. And that's really the philosophy we in the system are following. We particularly hear it from on tech may not be great for our bottom line. Sure, we'd love that room and board, but if it means it captures more students and some of that 40% that don't even go on to any education past high school, bring it on. So that's what higher ed needs to be doing. And so it's, you know, and for us as a technical college and applied hands on and particularly paramedicine, you can appreciate that you got to put needles in arms and you've got to do compressions and simulation is good to a point, but until you're actually out there practicing it, it's not great. And that's what we do with our nursing programs.  But this fall we were able to get like our nursing students back into clinical, our paramedic back into clinical. So that helps a lot. So, but yeah, I think that's the way we've got to go. And that's the emphasis that I'm gonna be looking at as the whole system transforms and we'll see where it takes us. Do you know, Pat, if the certificate that a paramedic receives from VTC is the same certificate that they received from GCC and would it qualify them for the same positions? I believe it does. I had the GCC website up a minute ago. I'm looking at, I know it's accredited by the same entity. I don't know, I mean, there are certain like all the, well, it's a certificate. So you're not really required to do general education courses. I've got to, yeah, I've got to look, I'd have to look a little deeper to see if there were significant differences.  We lose students to cheaper places to go. And as we heard a couple of years ago in this committee and we've heard from all the EMS services because we unfortunately had to end our fire science program which was also where we taught EMT.  We do a lot of EMT training now through our continuing education division. Not a lot, we do some. It's in part a moneymaker for some fire departments. It's a pain for other fire departments. So we've tried to step into those places where the fire departments really aren't equipped to set that up and Maureen Hebert could give you chapter and verse on that if you would like. So EMT is pretty good, but it's getting the deeper into the paramedic piece. But let me find out about that license, that certification and the similarities for you. I think Kasia had a question. Yeah, I just wanted to follow up on that one first. The reason I asked is because I wondered the difference between the 10 credits. I know when we were doing the dental therapist bill we looked at the difference between curriculum at BTC and the curriculum at University of Minnesota. And there were things in the University of Minnesota curriculum that weren't necessarily geared to like office management. And I just wondered if there were things in those 10 credits that you could have two steps, a 29 credit one and then the full one. I don't know, I just thought of that. We'd have to look at that. I mean, we looked at whether or not we would expand to an associate's degree program and haven't chosen to do that because that, according to Inga, that is the associates you can get into that higher level. Providing that more in ambulance health care, on-site health care than necessarily we can do now. And I'm probably misspeaking and if you'd like to have Inga come back and talk to you, I'm happy to have her do that with you. So it's just, she's sometimes hard but of course classes start Monday. So hard to get a hold of, but I'm just looking for, yeah, I'd have to get back to Inga. No, yeah, it's not, it's just something to think about. Senator Rahm, did you have? Well, I mean, I'm just offering this because it sounds like the situation is getting very close to dire and that that might increase the possibility that money could somehow come back to a program that is training AMTs who are highly needed and there's sort of like a possible revenue stream if they're trained for free, but go off to do work after that. My good friend, Melvin Carter, was a city councilor in St. Paul. He's now the mayor. And when he was a city councilor, he created a really intensive EMT program and we're not supposed to share links, so I will do this later. But the St. Paul Emergency Medical Services Program is an intensive tuition free EMT certification program for low income, underrepresented and women residents of St. Paul between 18 and 24. They earn an hourly wage during training. It lasts 240 hours over 10 to 14 weeks. It's largely targeted for diverse, linguistically diverse and culturally diverse students and they've graduated over 200 young adults. It's a collaboration of their fire department, their youth job corps, their public schools, their community action partnership and the federal government. And it's such a great program. I went and visited it. I looked at everything they were doing and they were facing a similar situation that was very dire and really just created a targeted, intensive program. So at some point, if there's too much of a cost to trying to keep EMTs, then we have to spend money to get enough EMTs into the pipeline, it sounds like. Yeah, I just wanna stress EMT is different. Different, very different. And EMT is an easier, shorter-term program and yeah, I would love to know more about that program because it's very likely we could access federal dollars to help set that up and provide that tuition. Kind of like we do with our Strengthing Working Families Initiative that is targeted at custodial parents and teaches in industrial trades, but it's free. We even provide wraparound services such as childcare, transportation, et cetera. And that was a $4 million U.S. Department of Labor grant that's been enabling us to do that. So that idea, I love it. I'm excited about it. So I'm just looking to- Let me make sure I understand those. So EMT is different than EMS. EMS is the system. EMS is the emergency management system. And EMT is an emergency management technician, emergency medical technician, and a paramedic is a step much above an EMT. Okay, much above. Quite often you have to have your EMT to be in the paramedic program. Yeah, this program does EMT and then firefighter awareness. So I think they tried to start building modules on top of EMT to get- Which makes perfect sense. EMT is part of our firefighter program because the firefighters will tell you 85% of their responses are medical. And so it's having that medical, and that's part of why the fire services want to have paramedics too, who have that next extra level. So, and I will ask about the 39 versus 29. I know there's a reason we set it up for 39 credits. And probably I know this program was driven heavily by the EMS providers around the state. In fact, we had paramedicine on the cut list at one point because the enrollment was so poor. And I got an earful from our EMS friends about don't do that and we didn't do that. And they've worked hard to hustle up the enrollment, but really a big thing that's made a difference is that scholarship. And that's one of the things I talked to Dan Batesy about, and we talked to you about, is that if this is a priority, is there some way to have that scholarship continue? The CRF funds were great, but boy, it was a scramble and a half trying to figure out how to fit the December 31st deadline when it's a three semester program. We punted because the department had some other money. It turned out the deadlines weren't extended. The department had other state funds. They squirreled away that they could cover the tuition. And now, mercifully, the CRF deadlines are extended. So we can use every nickel of their CRF funds to cover all three semesters of scholarship. So it was a great thing, but it's not that particular source of funding is not sustainable. I would just, in terms of setting up any kind of a new program, I would make sure that you work with Dan, I mean, with Pat Malone and Dan Batesy and Drew Hamilton, who's the chair of their education committee because the state is working on new programs for EMTs, but they're also working on a new level called the first responders. And these really are very first responders. And according to what we've heard, I think, committee, is if we can get that first responder system set up, we can go a long way toward our workforce issue in the system. And then once people get that, then they have a sense of whether they wanna go on to become an EMT or not because it's a, as we heard from Jim Baker this morning, it's a, there's a lot of trauma associated with in this field.  I can see her. Margaret, Margaret. Margaret Lagos. Oh, yes, yep. Yes, as a volunteer. And so I think that what we don't wanna do in my mind is set up a lot of competing programs here that are competing with each other for dollars and for students. So I would suggest that any, looking at any new programs that you work with them. Oh, absolutely. Drew and Dan were part of the team we worked with a couple of years ago when we were considering possibly cutting our program. So yeah, and I would just comment too. I mean, I think it was a couple of years ago, Senator, we were in the committee and I can't remember whether it was Drew or who it was. We've talked about, like 50% of the paramedics do not renew their license after that. Right. And then another 50% of those that stay off are gone a year later. I mean, Jim Baker's testimony was compelling and you think about what those people are dealing with. No wonder. I mean, the trauma is huge. And so, the whole idea of the wellness commission takes a lot of sense.  I have a lot of healthcare providers in my family. Well, my sister-in-law is a medical examer here in Orange County.  God bless that they do the work they're doing. Those rescue people see our lives are very worst. Alice, Senator Parkson? I think that the other key thing with this as we look at this system of training are emergency medical professionals is the ladder that the nurses have for their encouraging, bringing people in at the beginning, just like we have this EMT training. And then not viewing it as a disaster if they want to upskill and keep upskilling and upskilling. Because retention in the EMT and EMS system isn't just about the trauma, it's because they're paid so badly. And so, which is what we've heard repeatedly from Drew, how poor the pay is. So for me, this is yet another opportunity to actually also look at bringing in our marginalized communities and our people, our BIPOC community and our new Americans into a system where they get trained relatively, affordably, hopefully, and then get into a system where they are able to get better, more training and upskilling and upskilling. And it just seems to me that this is a win-win if we can get this right and make it affordable.  So much better. And that doesn't require any more training. It isn't a career ladder. You don't have to, so other than asking people to go, it's like, anyway, we need to make sure that people are paid. Yeah, our website, admittedly, it's 2018 data from Bureau of Labor Statistics, but median salary of a paramedic is $34,000, whereas the median salary of all occupations is $39,000. So you're already starting, and it's kind of like our veterinary technicians. I mean, they do it because they love it, but they don't make any money. And I think a lot of people go into this field because they're caregivers and they want to, but you can't make any decent money doing it. I mean, it's, has COVID taught us nothing else other than our whole pay system in this country is backwards. We pay the essential workers nothing and the athletes and actors, gazillions. But I'll get off that soapbox quickly. Well, at least people are spending more time watching Netflix than maybe being at Walmart right now. I mean, so it's like, really? But right, there's a paid disparity that's unbelievable. Although we're probably paying the Netflix people a lot more than we're paying the people at Walmart and they're losing their jobs because... Exactly. Well, they're losing their jobs because no one is going there. So anyway. Well, online purchases. I know. No, no, no online purchases. If you can't purchase it in person right now, you probably don't need it. You can wait till the stores reopen. Well, those of us who live in Randolph, and there's no such thing as at home delivery, where do we go for groceries? I mean... You can go to the grocery store. I'm a, yes, I'm a huge fan of buying local as you would imagine. Yes. Yes, me too.  Just curbside pickup. That's not fair. Curbside pickup from your local merchant is different than online purchases. Oh, gosh, yes. Yes, you're at least buying online. Yeah. And I find a lot of my locals do that, but the chain's not so much. I know. Shaz does curbside pickup or anything. All right, any more questions for... So my delivery is back to you. Is the certification the same? And have we looked at some sort of latter approach, i.e. 29 and 39 credits? And yeah, and clearly as we seek to figure out this new delivery modality, Pat Malone will be one of the first people to talk to, so. Yeah, good. Yep. Any more comments or questions or concerns? I mean, this is an ongoing conversation, and as I told Corey and I think hopefully the committee agrees that a lot of this doesn't need a legislative fix. It just needs an ongoing conversation and holding people's feet to the fire to make sure that things are happening, which is why we're having people come in here so that it's a conversation that's alive and moving.  So hence the point of trying to get at those students who don't pursue education post high school. But the other issue is, I know you're not the education committee, but students are less prepared coming out of high school than they used to be. It's just plain and simple. The math and the science and the writing isn't the same. And it's only gotten worse in COVID, as I'm sure you know. So, that's the other challenges. Some of these programs are hard. It's hard work to become a nurse. It's hard work to become a paramedic. But I'm grateful we fill up our nursing program mostly. Every year there's a couple of Brattleboro, Bennington are always, Bennington particular challenge to fill up, but I hear continually from faculty, they're just not the same level of student. It's, you know, it's an old conversation I know, but it isn't getting any better. So, but- That's discouraging. Yeah. So I just want to make one comment about the, kind of the ladder for healthcare people. So, AHEC runs a number of programs, MedQuest Camp and different things. And one of the things that they used to do, and I think they don't do it anymore, but I'm not sure, is they had a program for like seventh and eighth graders to just kind of feel out the medical field and see if they might be interested. And they called it blood and guts. And the boys loved it. They all, seventh and eighth grade boys signed up for it right away. And some of them, some of them ended up thinking that was a profession to go into, but- AHEC does a great job on healthcare education, educating students about opportunities in healthcare. And it's, it's huge. So, great. But blood and guts, yeah. Blood and guts. Speaking of Netflix, right? I appreciate your time and I will get back to you. And thank you very much. And y'all stay warm this weekend. And I'm sure we have this conversation. I think we'll try to make sure that we have Pat and Drew and people here so we can kind of have a more roundtable discussion. Yeah, and next time I'll get Inga to join us as well. Okay, great. Great. Thank you. Bye-bye. Thank you, Pat. Bye-bye. I'll see you.  Does that make sense to break it down that way? Did anybody have a chance to look at it, Brian? I was just wondering whether we could take a five minute break. Oh yes, that's. And then I don't think that this will, this conversation will go very long, but I would like to have it. So, okay. So no, let's take a five minute break though, because I for one would be very happy. So. And what are you wanting us to work off of? Your email. Well, I'm wanting to, I'm wanting to see if the way I tentatively organize the elections conversation makes sense. I kind of divided it into checklist, ballots, tongue clerks. Right. Does everybody have the list? And then I put the things under there that I thought made sense. And obviously they could go in many different categories, but the email titled elections issues, right? Right. From two hours ago? Yeah. So the first one is the checklist itself. And that's the idea of purging, having one statewide checklist, and I'm putting all the ideas on here that people sent. Somebody suggested not having the tongue clerks through the checklist, which I don't think will go anywhere. And then purging. And I'm not sure how much we have to say about that, but I don't think that whole conversation will take a long time. Because if there are, the Secretary of State will be able to tell us what we are legally allowed to do to purge the checklist, because a lot of it is under the Federal Voters Rights Act. And then under ballots, I put the things on there that we talked about that were pretty seemed pretty self-explanatory. That the ones that you see that seem new here are mainly ones that came from Deb Bilodeau from the Republican Party. I guarantee paper ballot. And I think that we already do in statute, but I put it on here because it was on the list and put all of these under here. And I'm looking to see what she meant clearly by the issue of mail ballots, mail to nursing homes. So I'll have more clarity on what she meant there. So that has to do with ballots itself. And then town clerks. There's a lot of ideas under there. And again, the ones that you had not seen before were limit the early processing to one day to the day before and report the total votes cast at the close of the polls. And voter ID required and authorized multi-party observers and same day voters get a provisional ballot instead of the regular ballot. Those all came from the Republican Party. And they're on here because we asked for those. So that's day one. Do you think that's? That's a lot in day one, yeah. It is and we may not get through all of them, but. Yeah. And then day two, we put candidates, primaries, general election and miscellaneous. And Kasia, your thing is under candidates. Yeah. I'm happy to rename it to like defining residency. I had put out an idea that seemed to be different than what you had put out was problematic in your like letter that you didn't mean to have be a letter. But I mean, a lot of what I've heard back people have said, what, you know, a lot of people have given me feedback since they heard it was the topic yesterday and it's been either get rid of the requirement or make it 183 days each year that they live here. But I don't know, you know, I'm happy to stick with just the idea that I have that I think is actually the least expensive and allows you to be abroad and still demonstrate you care about Vermont, but. Well, we'll take that up. I don't want to get us into the 10 hours of conversation around this issue before. Right. And it was probably 10 hours. I was struck by the Secretary of State's office saying they still get questions and don't feel like they can answer them because that makes young people, it feels hard, you know, to know someone's, I mean, when I first ran people were like, well, do you know if you meet the residency requirement? And it felt very somewhat xenophobic, ageist, you know, all kinds of things that I think we should have a standard definition. So that's why I raised it, you know, a lot of us have had an experience where someone questioned our residency because we're brown or young or, you know. But they questioned it from Molly Gray too. So it isn't. Yeah, it was a question for a lot of candidates, not just five of them. So I just feel like it's, you know, I'm sorry I wasn't here for all that testimony, but it just feels like I was trying to build on what I saw you had already learned. We could try to have the conversation, but I really, and everybody has a definition that they would like to see. 181 days, that's half a year. Right. Does that mean that if you, your car broke down when you were on your way home from Florida for the winter, and so you were only here 179 days, you're not eligible? Or I really, really think that the only way that the courts are the only way that this is gonna be resolved, because we can't get rid of the requirement of the residency because that's in the constitution. Or we could have a constitutional amendment, but not this year. Yeah. So we can't. I think given the robustness of the conversations, both the one that stimulated our long conversation and the latest ones, it's at least worth seeing if there's been any new thinking from the Secretary of State's office on this or from anybody else. It just keeps cropping up. So it's something I think we should address. Okay, well, and we will have the AG's office here because I really suspect that they will find almost anything that we do could be considered unconstitutional, but. Okay. I mean, I hate to be so negative about this, but I do remember the conversations before and they were so long and protracted that when I bought my state house book, that really beautiful book, what's her first name graph? Did the writing in it? Yes, Chris's wife. Yes, Chris Gaff's wife. She, they all signed it for me and she did not sign her name. She signed it Garrett's mom. Yeah.  That's helpful context. I didn't know I had gotten that emotional, honestly. It is because how can you force people to vote? Can you say 183 is the right number of days? Can you say that you had to have been here physically present all the time when Brian goes to Florida and signs in, is he a resident or isn't he? Do you have a historian speak to the original intent when they put in residency or? Well, they don't, I mean. We don't have anybody that was around when they put it in. Right. I just didn't know if there was, you know, people who went back and tried to study the intent of the framing of Arbremont Constitution. Well, we did hear from Peter. We did hear from Peter and Paul Gillies and Giuliani who are the three people that we usually, and that's the enrasque who are the people that we usually ask for constitutional opinions. So, but we will have it. I just want to, I'm going to keep it very brief because otherwise we will have everybody from across the state weighing in with a different idea for a residency requirement. And that's the only one you have to be a resident. So, I appreciate you having a little bit more conversation happening about it. So, that's what, so candidates. And then I put on there also the miscellaneous, or the corporate contributions and the public financing and translation services under miscellaneous. I just heard from Beepirk today that they are already asking places like Burlington and the Secretary of State's office if they're translating ballot information for a town meeting day, if they're going to have that interpretive and ballots in other languages and things like that. Well, we'll have that conversation. And then day three is the permanent mail out question. Does that make sense? Yeah. Okay, great. I think you organized it really well. You, it was a, I think you did well, Jeanette, thank you. Well, I just, I don't want people coming in and talking about nicknames and then in the same conversation talking about why we should permanently mail out ballots because it just gets too, too cumbersome. So, okay. Great. Anything else? Are we going to go off the record at the moment? Yes.