Thank you, Maria Royal, your legislative counsel. So I'm going to be walking through S193 with you today. And this is a bill that relates to some rules that you authorized last year as part of the Barad-Ban bill Act 79, specifically Section 25. You asked the E911 Board to adopt rules that established protocols for the reporting of outages, system outages that are applicable to wireless service providers and VoIP providers and electric companies. So the 9-1-1 Board did adopt those rules which have been filed with Elkar. And I believe they're on the agenda for later this month. So I just wanted to give you a little bit of that background because in the bill itself, you'll see on page 2, subsection D, it says that a person who violates a provision of a board rule establishing outage reporting protocols shall be subject to an administrative penalty of $25,000 for each day of non-compliance and proceeded against as provided under the APA. As used in this subsection, the person means an originating carrier that provides voice service as defined by board rule. So this is essentially a penalty provision that's applicable to these new board rules recently filed with Elkar. And I believe you're going to hear more about those rules. What are the rules aiming to do? So based on the charge and the rules themselves, the idea is that these outages that would affect wireless service, VoIP service, and electric companies that might impact 9-1-1 availability. And the report goes to the 9-1-1 board. And this issue came up in relation to VoIP providers that might lose electricity. And therefore, you don't have your traditional phone line that could still be working in a power outage. And so in order for there to be a kind of.  Is that, I know we addressed that issue. That's what brought this on. You addressed that issue in two places. One, it's addressed here to ensure that 9-1-1 is aware of the outages. It's the outage where there might be potential disruption in 9-1 service. That was fine. There's also an open investigation, which you, I don't remember the deadline, that has to do with those backup power requirements. And we ensure that Vermont consumers are aware of what they are. Yes, it's separate matter. The Shrewsbury, the Shrewsbury has one. That no one had ever told them. They couldn't, they called the cable providers. There was one place in Vermont where you could get the battery and they were out of them. Yeah, we're out of them. Yes, I remember that. We adopted this provision so as to try to get a handle on how often is there such a problem? Because nobody had any idea. We talked to the 9-1-1 board, no one cared. Nobody had an idea. How many times are Vermont unable to dial 9-1-1 because of a power outage, a power down, whatever the case may be? And so the goal was to get something in place. Now, I gather that what's happened is some of the carriers, the larger carriers were having difficulty because what we wanted them to do was if there was, if they were capturing the information in some systems, such as the ones that they had to do periodic reporting to the federal government, rather than to impose something that required everybody to jump through great hoops, is capture what you can. And so we modified it a couple of times while it was still in progress. And I gather that over the summer, the 9-1-1 board has been talking to the various carriers and that there are still some issues in terms of how you capture the data and whether or not the data that's been captured for the feds is sufficiently granular to meet our purposes. And so that's what this is all about by way of background. Okay, but this bill essentially just adds a penalty for not reporting and a pretty stiff penalty with the rules, once they're on it. Not a penalty for being out. No, not a penalty. For not reporting. They'd given the potential we get up and I still am today, no one controls that. Hi. So is it commonplace to put administrative penalties in the statute or is it sometimes put in the rules themselves? It can be either, if there isn't a penalty provided or one authorized, you can certainly put it in statute, you can do it. You could have put it in the rule specified that there will be administrative penalties and even suggestions now. Could this rule have put the penalties in the rule as their authority to do penalties within the statute? Or does it assume that there's a authority? So the 911 board has rulemaking authority and has, I don't know if it has authority. I'm gonna have to look to see if it has authority to impose fines for violations of its existing rules that if it does, then the board couldn't have put them in here. I just have to check. And maybe Barbara Neal is scheduled to pay for this and so she might be able to tell us if she does it every night. Okay. So that's our, that's a simple one to walk through compared to insurance yesterday. This part is simple. Yeah. I think this one may cause a little more controversy though than the insurance bill yesterday. Okay, Barbara, come on up. How are you? I'm fine, thank you. Do you want me to address my thoughts on S193 or are we talking now about the rule itself? Let's talk about both. Okay. That's you sitting here talking about the rules. Well, let's start with 193 and then we'll talk about the rule. That might, I'm gonna trust Faith. Okay. Set this up for a reason. Okay. So for the record, I'm Barbara Neal, Executive Director of the Enhanced 911 Board and on S193 specifically, the board really does not have an opinion one way or the other about the penalty or the amount of the penalty, whatever is deemed to be appropriate is something that we will work with. We had consulted, I believe we do have the authority to put a penalty into our rules but I will appreciate Maria's double check of the statute to confirm that. But as we were developing the rule, we did so in consultation with our legal counsel and came to the conclusion that the general remedy that we have, which is to go to Washington County Superior Court would be effective. And when S193, when I became aware of it, it made me think back on the 20 years of reporting that we have required from Vermont's regulated wire line. That's a traditional wire line telephone service. Excuse me. And I could think of maybe a few instances where we had to go to the telephone service provider and say, we're aware of an issue here. Where is, excuse me, where is your report? And when we've had to make those calls typically, the instances that I'm remembering, the outage report was produced within a matter of hours, not days. So I would say historically there has not been any significant issue that would have caused me to consider. I would say you needed a very strict penalty because in general, they've been very strict. Why? They have. Now, keeping in mind, we're talking about the regulated wire line telephone service providers. So however, if the committee or the legislature deems that it's appropriate, we'll certainly implement, we'll implement that and include it in our two blocks. So. When you get notified. Pardon me. When you get notified, does that change your behavior? What can you do? If you know the electorate's out, if you know the cable's out, do you have a remedy? I know last time we talked about having a duplicity of work around, I mean, is there something you could do? When we get a report from a telephone service provider, this would be the regulated telephone service providers right now, we evaluate that report, and we also notify our public safety answering points where 911 calls are answered. So for situational awareness purposes, really, so that they are aware that there's a community that they answer 911 calls for that may have certain telephone customers who don't have service. They in turn have been asked, the PSAPs have been asked to notify the local responders. And in some cases, the local responders may have particular protocols that they implement in those cases. We don't know the specifics of each and every protocol at the local level, nor do we have purview over it. So, but it's really a matter for us of situational awareness and passing the information along to those who can or might be able to use it or at least should be able to. I'm still gonna pick up my phone and not be able to call it. Now, here, I'm in the big city. No, my phone's not working, my phone's not working. So I can't call. I couldn't call it outside my service area. So that is the issue of isolation, which we spent a lot of time talking about. And isolation is a particular kind of telephone service outage. It's kind of a subset of the outage reporting that we get now. That's the isolation that we have been discussing is related to host remote isolation and a wire line network. And it's a situation where the caller still has dial tone, but they can't call outside. Their local exchange really is the easiest way to describe it or off network. So if I'm in the big city, I can call my local fire police department. You could. But if I'm out in one of those more rural towns where my local fire police ambulance, they usually call in the same building. Services, I might not, if I call 911, I can't get through.  You may not have a fire department or a dispatch center that's man 24 hours a day. 24 hours a day. We didn't have exchange. But even if very town services pretty much, their ambulance pretty much the whole area. If I live in very town, I can probably call the ambulance. If I live out in callus or wood, I don't know if they go as far as Woodbury, but I'm pretty sure they go as far as callus. If I don't know that that 911 calls, no one picks up though. So I know no, I can't get through. Right. That's the experience that happens with a host remote isolation. If there's no 24 hour number within that. And nothing here changes that. Nothing here where in the rule? No, we'll go on. I've got one more witness on the penalty. Okay. And then we'll go on to the rules. And I've got a question about having had a disturbing experience with not having an address. Okay. Only a very obvious, it was within sight of the ambulance. And it took, it seemed like forever, but it was probably 15 to 20 minutes to get the dispatcher to dispatch the ambulance. So I would need to know the details of that. And then it would be happy to look into it. Yes. Because I'm sure that there are cases in an emergency where you don't know the address. Well. You don't know the mile locker on the interstate. And just how, what the work around is for that. Well, there are a number of tools and resources that are available to the call takers in every PSAP. So, let's talk about that. I wanted to talk about that because it was upsetting. Certainly. It seemed like there were really two instances that brought this discussion to a head last year. The first was the isolation situation. And it's in particular related to Alberg and Grand Isle. That's right. In which there were two instances in which two separate instances in which there were emergencies and they attempted to call 911. And as a result of an isolation problem, they were not able to do so. So that was item one. The second in particular was the Shrewsbury incident in which an entire town lost their phone service for at least, as I recall, two weeks or more with, again, no one having a handle on the reporting of the entirety of the problem.  How big a problem is this? Because nobody seemed to know. And so this is kind of an interim set of reporting to figure out how big a problem do we have while we then try to figure out, well, what if anything, are we able to do about it? Yeah, and I think it may just be those two instances. We don't know. We don't know. Well, we have had reports of isolation events. I think there were two or four, I can't remember the exact number in each of the years 2017 to 2018. So they are not frequent, but they do occur and obviously it's not an ideal situation. So we do know to some extent when those isolation, those particular isolation events occur in a wire line network because we get reports from the wire line companies. But you get nothing from the wire ops. We do when it reaches a certain threshold at the FCC, the rule that we wrote was meant to address defining thresholds that we thought would meet the legislative intent of section 25 of Act 79 and perhaps be more appropriate for Vermont and align with the reports that we've been getting for the wire line, from the wire line companies for 20 years. And I am happy to talk about that when the time comes. I have handouts. Ah, do you have a copy of the board? Yes, I do. So the first is the packet of the filing, the actual, all of the documents that went with the filing to the Secretary of State's office and LCAR, I don't expect you to read it, but or to read it right now, obviously, but I might refer to sections of it. So if you take a look at that document, you'll see in the upper right-hand corner, there's some numbering in red. So when we need to turn to certain pages, if we do, I'll be referring to those. This document is just the rule. You'll be happy to know it's much shorter. This is the packet I get in the mail. Right, when the rule. No, but the committee chairs of jurisdiction get a packet and this is a small one. Some of them have been huge. So going through the rule itself, do you want me to go section by section? Is that how this is done? I think that's what's going on. Do you want me to go to section by section? Do you want me to go to section by section? Do you want me to go to section by section? Well, I think the purpose section will tell you. It really, what we're, what we meant to do here is to establish the protocols for outage reporting for certain originating carriers, as defined in section 25 of that 79, which was the wireless and the fixed non-line powered services, which are your VoIP services. We also incorporated into this those existing rules for wireline companies that I referenced earlier. So that we would have one rule. One rule that. Yep, for outage notifications from originating carriers. And the purpose as you'll recall of section 25 was to create these protocols. So we would have the data to make an assessment of how these various outages impact the ability of Vermonters to reach 9-1-1.  Section three goes through all of the definitions of the various types of originating carriers, what an outage is for an originating carrier or wireless carrier under the electric power outage. We define voice service. Section four says that all facilities based fixed voice service originating carriers. So facilities based fixed voice service would be wireline and VoIP, not wireless. Those companies are expected in the rule. It requires that they report an outage to us when 25 or more of their subscribers are unable to complete calls to or communicate with 9-1-1 and that situation lasts for 30 minutes or more. And then it lists the information that we want to see in those reports. Requires them to notify us when service is restored. Section 4.2 outlines the requirements and they're a little bit different for wireless service providers. If they have an outage that meets the definition in section three, they are to notify us, and last 30 minutes or more, they're to notify us of that outage. Madam Chair, I have a question. Can I ask why the cutoff is 25 subscribers or more? Why does it start there? It starts there because that's what we've historically gathered from the regulated wireline companies. So that threshold was in place. It's been in place for a long time. I don't know where exactly it originated or when. Does anyone do less than 25 subscribers? I don't know. There may have been in the olden days when we were cranking up phones, very small, local, but- Well, you could have an outage that impacts fewer than 25 customers. But then they do not need to report that. Right. But you could have an outage involving a single apartment building in Burlington that has more than 25 subscribers. Oh yeah, sure, we could. So then a telephone wire could break in a storm involving one building and then you have a reporting requirement. Right. What year did you say the 25th threshold was established? Humanly. When was it established? I would have to go back into the historical donk. I would say early 2000s. That's a guess. We went online in 1998. It was 20 years ago when we first- We've been receiving reports from wireline companies for 20 years. And so just to clarify, so then we don't have any requirements for reporting when there's an outage under 25 subscribers. Not to the 911 board? Okay. I would encourage you to talk to the public service department to see if there are certain requirements for, or maybe some of the folks here now know, if there are certain requirements for reporting, like how quickly they repair outages, not outages, but interruptions to individuals and whether or not that would meet what you're asking about. The 911 board does not have those requirements. We're also the issue of wireless charters. There is no reporting in the company other than what we're doing here. There is no rule in the state of Vermont for reporting specific to wireless or voice. Yeah, and what I understand that you're trying to do is you're trying to get a uniformity of rules. But I guess the question that comes to my mind is that wireless charters are different than regulated wire charters. In other words, if you have a particular outage from a wireless provider, is it more likely that a larger number of people would be involved for that single incident or that single problem that would be the case with a hard wire carrier? So the numbers may be very different. Yeah, I don't know the answer to that. It would depend entirely on across the outage and where it happened. I think it might be helpful if I went through kind of how we came to the thresholds that we defined. It speaks a little bit to the 25 level but kind of in the opposite direction. Why are we not satisfied? Let me back up a little bit. Many of the national carriers wireless and voice have given us lots of input and public comment on their recommendation that we accept the FCC defined thresholds for outage reporting. We did not accept those in our, or we did not implement those in our rule. We implemented much, much astronomically lower thresholds for reporting. Because we thought it meant the intent of the legislature and it better serves Vermont. So we know that section 25 originated from a number of sources which you just reviewed, isolation events and also the concerns that were stated by many citizens in some of the most used areas in one town. And so as we developed the rule we looked first to the existing outage reporting requirements for the wire line companies and those companies are required to report 25 or more of their subscribers out of service within two hours of that event. And then let us know when the service has been restored. And as I mentioned before that information is passed on to our public safety answering points for situational awareness purposes. There are no specific rules in Vermont right now for wireless and voice. I will note though that when we start talking about FCC thresholds, the regulated wire line customer or companies that are reporting to us at 25 or more customers also have to report to the FCC when they meet the FCC defined threshold. So they are bound by that as well. Here's- Can I ask a question? Yeah, sure. Is there a difference between an outage to connect to E911 and just a general outage? What our rule requires is reporting if the ability of the caller to reach 911 is impacted. I understand that. Is that ever happened with the general outage as well? I think that you could have, we've gotten reports that, yes, I think it can happen that way. I'm not gonna be able to give you a specific example. I know that there are times when we will receive like the voice part of a call, but not the Annie and Allie, not the data that comes along with the call. So that's a 911 impacting situation. I would have to research, I guess, to know if there was ever a time where you couldn't reach 911, but you could call, I think you can. Subscriber to subscriber might be able to call, but they might not be able to get outside their network. Actually, isolation is kind of an example of that as well now that I'm processing this through, sorry. So, yes, there are situations where you have no access to 911, but you may have dial tone and the ability to reach certain other places. So here's why we don't think that the FCC thresholds meet what you intended in this section 25. In the simplest of terms, these carriers, and we're talking about the wireless and the VoIP companies are required to report to the FCC any outage that impacts 900,000 user minutes. So 900,000 user minutes means 900,000 subscribers are out of service for one minute, or 100,000 subscribers are out of service for nine minutes. But to get this down to kind of Vermont numbers, it means 30,000 subscribers are out for 30 minutes, 10,000 for 90 minutes and so on and so on. And so to get to the 25 users that we're currently getting reports on, they would have to be out for 36,000 minutes or 600 hours, which is like more than three weeks. So bottom line is we would not know about this. I would say you would know about it. Or we would not know that this had been out of service. You wouldn't get a phone call from them. Well, that's true. So if you go to a more maybe common place then, let's say that there's 1,000 subscribers of some service that lose their telephone service. That service would have to be out for 15 hours to meet that 900,000 user minute threshold. So we would not, if we accepted the SEC thresholds as appropriate for Vermont, we would not know about that for 15 or potentially 17 hours because they have two hours to report it. And that's probably a large number of towns, definitely the more isolated towns. Right, so if we go back to Shrewsbury, there's about 1,000 people I believe that live in Shrewsbury. You know, not every person has a phone there, right? But so we looked in the 911 data, there were about 650 sites there, so that aren't outbuilding. So their residences are business and they would likely have a telephone. I can't really do that math. So let's say 500, it would be 30 hours before they would need that 900,000 hour, a user minute rather, 900,000 user minute threshold. Given that the kind of the genesis of this section 25 was concerns like that, accepting that threshold just didn't make sense to us. That threshold is there. So if that threshold is okay, we don't need to do rules. But what I think what I'm saying, I know what I'm saying to you is that that threshold is not necessarily okay. No, I think that's not, yeah, I mean we would need to do nothing if that were okay. But I think that means that a significant number of communities in Vermont would have to be out of service for a significant amount. A lot of people can have heart attacks in 30 hours. So just to clarify, because there's a bunch of different, well there's actually I think three different technologies that we're talking about here, right? Wireline, we're talking about the non-line powered, like VoIP service, and wireless. So as this relates to wireless, they are also at that 900,000 user minute threshold. And the SEC has a calculation that these carriers use to determine how do we figure how many users are on a tower at any given time. And so that calculation is run through, it varies for different companies based on how many customers they have, nationwide or worldwide or with some calculation. But to use the figure 1000 user minutes, her wireless tower is generally accepted as a good estimation. So the same would apply, we would have one tower down, for it would have to be 15 hours before it became recordable under the SEC thresholds. In some towns that might be okay because maybe there's overlapping coverage, and if there is overlapping coverage, those other carriers, if they're technologically compatible will be able to send a 911 call on it, that's fine. However, there's a lot of towns, and I don't have hard and fast data on this, but I think that we can all agree that it is not unusual for a single town or portion of a town or community to be served by one tower. And when that one tower goes down, they have no wireless service. We're still dealing with towns that have no wireless. Correct. Well, correct. And we're not even that, this is just if the tower is there. Right. Hopefully. They have landmarks, if they have no power. Correct. So that's why the argument has been made or the comments have been made that the FCC has established these thresholds and they did consider whether or not it was appropriate for rural community states to have these thresholds. And they determined that it was, but I would counter or I would add that they determined that it was appropriate for the purposes that they are gathering the data. Not necessarily from what we are gathering the data. I mean, they need to know when the national emergency or half the new England is blocked out. And that's one thing. Yeah. We're interested in getting emergency services to people before something worse happens to them. And our role in that is to ensure that the notification about the outage gets to the public safety answering points and then ultimately to emergency managers or emergency management. We're working on new protocols, by the way, to ensure that emergency management is aware in a more formal way than they have been in the past, in the past, on these outages. So, wait, is that one more slide? Madam Chair, a couple decades ago we had said 25% thresholds for notification. Is there any preemption of the federal government of our ability to change that number? No, that was number 2587. Since we can, after 20 years of experience, are you ready to make a recommendation that that number should be changed into what number would you make as a recommendation? The rule outlines that we believe that the wireless company, these national companies should be reporting at the more granular 25 subscriber or something of an equivalent, depending on the technology level. So, I would recommend leaving the reporting at the 20th at that more granular. Recommend lowering the 25. From 25 to whatever. You know, my understanding of how that came about was, you know, we wanted to be hearing about instances where there was a public safety concern on more of a community-wide basis. My question is, I understand what you first did. You did the reasons. You did. 20 years later, when you had a chance to take a look at it, would you recommend it be changed? No, I'd recommend it stay the same. Not raised up or stay the same. Great. Thank you. When you were, in your various discussions with the larger carriers, did you find that they had the ability to provide you with the information you needed? And if not, what were the impediments? Well, they did describe that there would be some technological changes, an IT change that they would have to make in order to meet these reporting thresholds. I don't have specifics on what those are. They express that those would cost money for them to do. Again, I ask, but we don't have specifics on that, but I'm sure that they are willing and able to let you know what those obstacles might be. They will. One thing I will note is there have been occasions, of course, where we become aware of an outage, let's say, in one of these carriers network here in Vermont. And we will make a call. The 901 board IT staff will make a call to their technical people. They're knock, they have what have you. And we have always been able to get the information that we need from them in that kind of real-time conversation. So I think that the information is there. It's a matter of them needing to develop whatever they need to develop to mine that information and get it out to us in a proactive way instead of us calling and saying this is going on. Can you give us any information? So you should basically only let me know when someone can't get through and they call someone else or trot over to the neighbor with a landline and say I can't get through. Can you dial 901 or can I use your phone? And I think one thing that hasn't really been brought into conversation, so I'll do it now, is we talk about the impact of outages on the regular public who need access to 911. And that's obviously very critical piece. But there are also responders out there who are using these telephone services, wireless, wire line, and all the various services. Police departments, response agencies, dispatch agencies who are reliant upon the various different services, which is another reason why I would recommend keeping that threshold low so that as we're doing those notifications when we receive a report, those entities have an opportunity to be aware of it as well. You might not know that you, EMT, might not be getting the call to show up to answer the response. It certainly accrues all kinds of potential communications concerns. The way I read the violence in 2003, you have no options as to whether to impose on 193. Yeah, and it doesn't even say up to, it's pretty hard. Doesn't give you any discretion to, it's the first time or if there was a, in any given circumstance, is that the way you want it, if you have to impose this violation rule? Well, I would just comment that this is not something that we asked for, but when we became aware that it was there, we don't necessarily oppose the idea. As I read it though, it says, shall be subject to an administrative penalty. So I would need to check with my legal counsel to know, does that afford me any flexibility? I would say the plain reading says no, we shall have the proposer come over and tell us what the process is intent. But normally you get things about May and up to. Up to, right. And because there could be mitigating circumstances, like they've got alignment down under a tip truck and they're working to get an alignment out. That's where their focus is at the moment. Or the major crisis, they're dealing with the crisis and not with your crisis. Right, and I think. So it's passed up to with May. Up to with May, I think. I think one thing kind of speaks to that is the focus should be, and the 911 board agrees with this, the focus should be on restoring socials. Even as it relates to notifications to us. So we say in the rule, tell us about the outage if it meets these thresholds within two hours of your discovery of it, or as soon as reasonably possible. So it is not our intent to slow down the restoration of services that needs to be, we agree, the first priority. And so having said, I think I would not disagree that having that same approach in the penalty might be an appropriate thing to consider. Okay. When you're supposed to press that out, I want you to look at that section. Two hours or, what year is that? That is in, you go to section four, 4.1. So that first section there reports any known outage lasting more than 30 minutes. That limits or prevents 25 or more subscribers from completing calls to or communicating with 911. The OC, that means originating carrier, shall notify the 911 system provider and the board within two hours of discovery of each occurrence or as soon as reasonably possible. So is the intent there, which ever is sooner or is it essentially, as soon as reasonably possible governments ever, could be put together. I think that we need to let the companies, perhaps determine in individual circumstances what is reasonable, reasonably possible, given that we want them to fix the problem. We want their first priority to be to fix the problem. So the intent there is to, could be a day under that circumstance? Well, I'm not sure, it depends on the circumstance that that would be reasonably, yeah. Yeah. If it's a day and there's just we didn't get to it then you've got a $25,000 fine. Right. But if, how do I say, major visitor ice storm and their core facility has no power and no phone service then they may be physically unable, along with the rest of us, to notify anybody of anything. And in this day of strange weather, I don't know who had what coverage during I read or for how long major carriers were down. But I think we want them putting the bulk of their effort into getting communications back up. Well, we do, but we also wanna keep in mind that public safety piece that we want people to be notified. So there's a balance here. And I can tell you from historically, from this 20 years of collecting the information from the wire line companies, I think the wording is the same in the existing, for as soon as reasonably possible. And we have not, as I mentioned at the beginning, not had event after event after event that's not being reported in the expected amount of time. So it's not been a problem historically.  And the purpose of this right now, since other than notifying people with the phone services down, is trying to just understand how often, how many people, how big a problem is this. Right, so we plan to take this data and analyze the data, get the data also from the electric power companies. And I should mention, they have a different reporting mechanism in here. They are going to be reporting to us on outages lasting a certain amount of time, monthly, not on a real time basis. And I just want to say why we did that. Okay, because we did the law last year, I remember telling them to report, so that you knew then that folks relying on VoIP might, they didn't know about batteries or couldn't get them. And we should be getting those reports now from the VoIP telephone service provider under this rule. But one of the things that we're going to be doing is when we receive these reports, we will check the publicly available outage reporting map to see if it looks like an electric outage might be involved here. And then when the official data comes in from the electric power company on a monthly basis, we'll analyze it after the fact to see if it lined up with the information we had at the time. The reason for that is I know there was a lot of focus on the battery backup issue in Shrewsbury and other towns. And I understand the concern, but the 911 board does not see a direct correlation between a power outage and the loss of access to 911. So, because there's so many variables involved, these non-line power telephone service providers are required by the FCC to make backup battery options available to their customers, so those customers may have purchased that.  They also may have their own generator in their phone, in their phone, in their home to keep telephone service and other service working. So, because of that, we didn't see the direct correlation, whereas when you lose your telephone service, when something happens and it's gone, that does impact your ability to call 911, but that should be covered in the rules for originating carriers. And then we'll take the information from the electric companies after the fact and analyze it against the outage reports that we've been receiving. If we need to adjust that, we can, but it seemed like a reasonable place to start giving all of that, at this point. Okay, okay, hang in there with us, okay. Okay, so now I'm gonna go to Ben and Erin, everything. Thank you. And I, yeah, I'll go ahead. So, Madam Chair and Honorable Members, my name is Ben Erin, I work for CTIA, CTIA is the Trade Association for the Wireless Industry. We represent carriers, such as AT&T, Verizon, T-Mobile, U.S. Satellar, Sprint, handset manufacturers, Samsung, Apple, HTC, LG, chip makers like Intel, software companies, app providers. If it's part of the mobile ecosystem, we have members of the association that are interested in it. I am here today in opposition to Senate Bill 193, as well as to purge for some amendments to the rules that Executive Director Neal just presented. Let me start with S193. Senate Bill 193 proposes to apply a $25,000 fine for violations of a novel set of rules that are in effect, not in effect today, they haven't been adopted yet, and they're also novel insofar as they're not in effect anywhere else in the nation. These are Vermont-specific rules that are not tried, no one has any idea if these are gonna work. So with that background, it seems to be an excessively punitive approach to immediately move to impose a $25,000 penalty for violations. Not only has there not been any, but there's no way to know if they, A, can be complied with, or B, if there will be scoff laws. I suspect not. There's also a proven alternative, and I'm gonna talk about that, but I wanna urge one point, and that is that Executive Director Neal's job is to address issues regarding the E911 system for Vermont. One of the responsibilities of the legislature is to look at a little bit of a bigger picture, and one of the things I ask you to consider is whether imposing these very stringent rules that are novel, not in effect anywhere else in the nation, makes it an unattractive proposition to continue to invest in Vermont, to continue to deploy wireless networks further into Vermont, and whether those are good results for Vermont, and whether there are less stringent alternatives that might be considered, and might need the requirements of the desires of the 911 Board, in comply with the requirements of Act 79, which was the Act from last year that kicked off the requirement for there to be rules from the 911 Department. So I'll also pause there to thank Executive Director Neal. This was a very open process at the E911 Department. We expressed a lot of opinions. Executive Director Neal was a very good support about meeting with us and talking through a lot of these issues. We have talked her here about. We're not at a point where we want to be, but that's not because she didn't listen. So we really do thank her. We appreciate the dialogue, but there's still work to do. Executive Director Neal's understanding of the NORA system, that's the Network Average Reporting System, that's the Federal Outage Reporting System, is I would say at best misleading. The standard for reporting an outage in Vermont, single-tower outage was the example that was given. A single-tower outage in the most rural part of Vermont, the most rural tower in Vermont, will be reported at the exact same time interval as a single-tower outage in Boston, in Providence, in Manchester, and Concord, here in Montpelier, anywhere in the nation. A single-tower outage, same time interval, anywhere in the nation. And why is that? There's a calculus, it's not really all that important to go into it, but there is a calculus as to how you figure out your expected user minutes. And the FCC decided that the fair approach would be to spread this out, so that rural states like Vermont and rural towers get the benefit of adding on user minutes that would be focused in city centers where you'd expect more traffic. So that you have a reporting interval that's common across the nation. Now, another thing that Executive Director Neal is probably not aware of is that single-tower outages are actually fairly rare. When you have an issue that knocks a tower out, more often than not, it knocks a lot of towers out. If you have a single-tower outage, you might have an equipment issue at the tower, you might have a line that's down somewhere. These are small issues that affect single-towers, but they're not all that common. The more common issue is to have a big network impact that happens somewhere at a switching center, a large trunk was lost, somebody didn't call before they digged, not in your yard, but on a state road or something, and cuts a big data pipe. And that big data pipe takes down a lot of our towers. That's the more common type of scenario, or you simply have an issue at a switching center. One of the things that this avoids, this approach of having an averaged-out number attends not to report single-tower outages. The approach that Executive Director Neil wants to take, the non-1-1 department wants to take, is that I'll have a half hour of downtime. I now have triggered the requirement to report. If this is a single-tower outage, maybe I'll have a bad power supply that's hooked up at the site, and I have a two-hour window to report. It might take me an hour and 15 minutes to fix this, but I already have to report about an outage that, in all likelihood, has already been taken care of. Single-tower outages are not rarities, but they're not as common as you might think, and they're fairly easy to restore, usually. She's not wrong. I don't want to mischaracterize this. She's not wrong that a single-tower outage will take a while to become a reportable event. But having said that, it's, again, not the norm. And it's not true that it's reported differently for rural towers than it would be for urban towers. It's reported the same way, same time interval. What is the time interval for a rural tower? It is every tower, every wireless company takes their entire customer base. So, publicly reported numbers indicate that 18th team Verizon are somewhere over 100 million customers. I believe T-Mobile is in the 50s or 60s millions. And I forget where Sprint is in the U.S. cellular. Okay, so you take that? The big ones, yeah. You divide that by the number of towers nationally. Right now, there are approximately 300,000 macro towers nationally, so you take your 100 million, you divide it by something in the neighborhood of some 100,000, we don't exactly know, those are highly proprietary, and we have the association that will receive it. But you take that, you divide it, you come up with something in the neighborhood of 1,000 minutes, 10,000, whatever the number is, and that's a sign for each tower. Okay, but, I mean, we're talking 25 minutes. I think, I can understand you have a system in math, I can also understand that maybe the FCC has different needs than we do. We are really trying to find out how often we have people. And we don't have a significant number of people in a lot of places in the state. How often they cannot reach emergency services and how long. So in that case, the difference between 25 minutes and 24 hours is major. The difference between 25 minutes and three hours may not be as major, except to the person that has a massive coronary during that three hour session, but we're still dealing with large sections to Vermont, especially if you're in an automobile that have no communications. So I think- Well, if you take the math that you've been talking about with respect to the national calculation, it would be fair to say that a tower located in Vermont that has the same mathematical number of users as a tower in Boston, that we have a much larger number of users than we have people here. Right. So you're getting that benefit. In terms of then if a tower or group of towers went down, we would probably notify it a lot faster than we would be based on population alone. Absolutely. So from that, are you able to tell us that if a tower or typical group of towers based on the way connections are made in Vermont, how many people, how many people minutes, if you will, might in fact be involved before we would be notified? So I can't do that. I don't have the math against the criteria, but one thing that didn't occur, it did not occur during the Enon11 board's deliberations was an inquiry for what the carrier's numbers were. There was no outreach, there was no effort to find out how long would it take 10 towers to report? How long would it take 20? They have the ability to issue discovery requests or data requests. There were none. There was no effort to discover that information. You didn't volunteer? We, again, the association doesn't have it. You are right that the members. I mean, it's a 203. We gave what we believe to be a good, not too very good example, but one of the things that was never explored was what about a number beneath 900,000, but higher than zero? Now, you've heard about sort of old technology and old rules and that was 30 minutes in 25, I guess it was, customers. The rationale that I heard Executive Director Neal share with you was we don't want to hear about two blocks not having service. That's not what we view as a public service, public safety issue. I would contend that a tower out for 30 minutes, right? May also have that same impact, where yes, people are out. That in and of itself is a public safety issue, but it's not denial. It's not denial. However, if a tower is out for 30 minutes and comes back on in minute 31, the volume component, the volume metric, 900,000 user minutes prevents you from sort of over-reporting these smaller outages that are perhaps not that impactful and pretty much resolve themselves. If you have a volume component, you avoid that type of 30 minutes, 25 customer report where all right, two blocks were out, do I really need to solve for that in that period of time? We understand and we take extremely seriously our obligation to keep all of our towers on all the time. It's difficult. I believe Madam Chair talked about Hurricane Irene. I mean, this was a massive disaster. It washed out highways in Vermont. It turned towns into islands. Not as bad as the ice storm. Not as bad as the ice storm, but a lot of people in Vermont might have lost a lot of things, but they still have their cell service in those instances. We are a lifeline, we get that. We take that seriously. We wanna offer that service to our customers, but it is a massive sprawling network, even just in Vermont. It is highly technical. What goes on with it? And like I said, a single power supply that goes bad for it just as a for instance, at a tower site that's fixed very quickly by a tech doing a truck roll to the site, taking a look and fixing it, isn't that roughly equivalent to your 30 minute 25, two blocks are out? I would contend it is. I would contend that if Vermont wants something below the 900,000 threshold, that should be explored. Those numbers were not explored. We ended up with a one size fits all rule of the minute reporting in full that frankly may result in reporting of outages that are fixed before the two hour report comes in. That's what gets taken care of by the metric. One of the reasons you have that metric is, hey, if you get there and you fix it pretty quickly, do I need to know, right? What are the point of fixing it? I think our problem is there aren't 900,000 people in the state of Vermont. So we're, these are numbers we don't even comprehend. We're trying to find a reasonable way to ascertain when a significant number, and for us a significant number is somewhat smaller than probably the rest of the world of our people do not have access to emergency services. And I think we're open and if the carriers have information that would help us find a reasonable number, I think we would most certainly be interested in hearing that. What I'm trying to hear is, because the testimony we heard was, well, if we hear Shrewsbury's not getting cell phone, and I would say Shrewsbury was somewhat more vocal and we're without service somewhat longer than most places, I don't know why, but they definitely had all of our emails and got our attention. But that got our attention. And it sounded like, because when we asked the electric companies to tell us when they put it, it's a phone call. So I think we're trying to figure out for you is it more than a secretary, you know, I say, well, we got a report, call them and tell them it's out. Is it more than that that you're being asked to do? Or is it more complicated than that for you? So I'll offer a data point that might be helpful, partially in response. But first let me answer your question. I believe Executive Director Neal, and she would know better than I do, but I do believe Executive Director Neal knows who to contact from the carriers. I would hope if she doesn't then we should definitely get with that information. Yeah. Well I think most of their lobbyists are in the room. I'm sure they know who to contact. The carriers are very willing to work with the public safety community to make sure that they have the information that they need. If we were to receive a call from Executive Director Neal or a PSAP, you know, I'm hearing that there are some issues, they're going to answer those questions. I mean, I would hope, I wouldn't think that there would be any difficulty there. It's not the ability to work individually to solve some of these problems. It's just the, what we look at is a really, really low trigger for outages that should be examined and increased. The number that I said I would share with you is this, and we did share it with Executive Director Neal in our comments. In a five year period, we looked at 2014 to 2019, five years, there were 39 reportable outages. Reportable outages reported to the FCC, federal government, four Vermont, 39 in a five year period. Now, there's no obligation to report to Vermont, was not no obligation to report to Vermont, so Executive Director Neal did not get those, to the best part of it. But why would 39 reports in that period not have been enough? 12 of those, just to give some more detail here, 12 of those were Vermont only. They were not regional or national outages that affected Vermont. They were outages in Vermont, and that's a four, you know, five year. Right, Vermont specific outages that would have been reported under the FCC's rules, 39 of them, and how broadly they went into other states, you know, did they go from New Hampshire to Maine, or was it just a little bit over a state line? I don't know. But 39 that impacted Vermont, 12 that impacted only Vermont. And that's under the FCC's rules that we're hearing from the 911 department that are just unacceptable for Vermont. To us, that's a fair number of reports. It gives situational awareness. It does give visibility into, you know, these issues. On the other hand, if the sense of it is that that number is still not enough, I still contend that somewhere between 900,000 and zero, there's probably a reasonable, yeah. I think that's what we're trying to find is, because what we don't know is how many people were impacted by those 39 calls, how many other not, I mean, how many people have to be impacted in Vermont before there's a report? I think that's what we're looking for, because until the carriers can tell us that, or a rough equivalent of that, we don't know if it takes 5,000 before reports made, that's a good portion of Vermont. All right, that's half of my county. Not quite, but probably half of Santa McDonald's county. All right, so. We don't have half enough. It has made people to actually report. You don't have electricity, so don't worry about it. Don't even get the service if we're going to report. He doesn't have a stoplight or electricity. But I think that's what we're struggling with is we're trying to define the problem. We know that there are times when people can't get 911. And as the note that just got passed and we said, this isn't the apartment building. I was in New York City, or I was in Boston for the 1960 whatever, blackout. But I got into my third floor apartment, but neighbors were coming down the hall with candles passing out candles. And I could go next door and use the landline or we didn't have cell phones in those days. But here I can't, it could be three miles to my nearest neighbor in weather like this. So we're trying to just get a handle on what's a reasonable number that you can deal with that makes sense to us. If it's 300 people in your outage, we might be able to live with that. If it's 13,000 people before there's a, that probably is too much for us. So I think that's what we're looking for. I'm sure when the witness came in and told us we should feel assured we were being treated equally as people in New York and Boston, it just demonstrated that you don't understand what we're talking about. In those cities, when the outage hits those cities, they know it and the people who would go to repair them those problems know it. In Vermont, that doesn't work. They don't know it and maybe it's just, you don't want to be treated equally to them. And secondly, what is it about keeping a log of when the power is out and communicating that when it's possible that it's brought so many people to this room? What is it about our system that we don't want to have reported? What's that, why would the people who wake up every morning fully committed to fixing any outage as soon as possible and think about that on a shaven and have a breakfast? Not why should Boston know when something isn't out? Why? I guess I would start by saying there's never been an exploration of whether the federal standard would work for Vermont. That the step one was zero. Step two, question. But you're asking why don't we want to report? The answer is we report all the time, all the time. But Vermont is not looking at whether the existing reporting would work for Vermont. Vermont's taking the standard and going to zero and saying that that's a project that's going to 25 more weeks. All right, I'm gonna, no, you're two different numbers. I'm gonna start, I'm watching the clock, we're 15 minutes behind, we've got one more witness and then I'm assuming Dr. DeNicola is waiting in the hall somewhere. On the phone. On the phone, okay, can you let him know? Yes, we let him know. Okay, thank you. Yes, doctor's time is hard to get. I think we're gonna be looking at the utilities to see if you can help us figure out when you do report what size outage somewhere between 9,025 pick a number, but help us to get a handle on what size outages you are reporting and we'll go from there. Okay, Mr. White. Good afternoon. I give you an A for courage for coming up. Senior Director of Regulatory Affairs for Comcast, some members of the committee. First, I'd like to address the rules, the E911 Board's proposed rules and had compliment barb and the E911 Department's comments say we're very cooperative as we expressed our views a couple of rounds of comments we've talked on the phone. Some of our concerns have been resolved. And then I'll talk about S193-5. One of the difficulties for companies like Comcast is we certainly know what we have outages at a certain point in the network. What we don't necessarily know is if a particular customer's modem is out.  A car could hit a telephone pole, went down the road. We don't necessarily know that. At a high enough level, customer would call in and they've got a trouble call. Police and fire would know just as quickly as we do if there's a very local outage. So one of the issues in the underlying statute, it is section 25 of Act 20, 79, it includes within the definition of an outage the lack of function of telecommunications subscribers and backup power equipment. That could be a backup battery, could be a UPS, it could be something else. I mean, it's so many. You don't know that. You don't know if I have batteries in my phone that are backing up. We know, so part of the last year in the St. Claude Benville, the legislature required the PUC to do a workshop on backup batteries. And that report was issued on December 13th. And it's certainly there for everyone to read. It concluded that the void carriers had indicated their compliance with the FCC's backup battery rules and recommended it against a Vermont one minute standard. So really backup batteries are made available so that the Comcast has them. People want to buy them. We ship them. We have them available. We ship them to them. Very few people do that, to be honest, that we have a cost. The Shrewsbury said they would send to a hardware store and run one. That's because they, that's a different carrier. Ah, yes. There is a different carrier down there. Different carriers. So, and not only that, all the void providers, you're right. They operate differently. They're different backup batteries. Ultimately though, customers make choices about their phone, you know, what they want in terms of the phone. Most people in their homes have a cordless phone. When the power goes out, that cordless phone is a good work. Unless you're plugged in when you get back in the wall and over a line powered network. A lot of people make use not to take the backup battery because they have a cell phone, whatever. But in any event, we don't know when there's an outage at a very, very granular level. That language is still in the statute. So we'd recommend that that phrase, defining an outage, black. If that could be removed now. Okay, so there's 25 people in the state. We haven't replaced the batteries. There could be, well. But then, yeah. The, Barber Neal, I mean, they have taken account of our issue and commented that we would not, carriers like us, would not be responsible for reporting with respect to customer premises equipment, which would be a battery or something, or things that would be on our controls. That's fine. That's in the comment. We support that. We prefer that we're in the rule because when it gets to the fine, I'm sorry, yes sir. Actually, I don't know my question was directed to you, but why are we talking about the rule that hasn't been promulgated yet? I think it's been promulgated. B. This is totally an aberration from the L-Car procedure. L-Car conveying passes judgment on a rule and we don't get them all before that word passes. Sometimes we'll revisit a rule if we don't like it. We think it's beyond the scope, but to do it before the rule is promulgated, it's fine. It's all over the board. But I think part of it though is legislative intent. And they're going, when that, I'm going to get a packet. So that's a legitimate answer. If you're looking for some advice from this committee, how to respond to that package. I think everybody is. And I think I'm going to get one of these and I'm going to have to sign off and say it's either what we meant or we didn't mean. I think what's come up during the rulemaking process is questions about how granular did we want to get and had we didn't have a lot of this information. We just knew Shrewsbury didn't have phone service and Alberg had trouble getting out. And we knew they'd been at least two instances where towns could not reach 911. We didn't know how extensive or how often that happened. And so we put in somewhere in the process, I'm not even sure it was this committee, it may have been the other body, put in asking that rules be written so that the wireless carriers, the hard wired carriers have to report outages, right? At 25, we asked that the wireless carriers also report at 20, I mean we said, am I right, we said report. Well, in section 25, you did not define what the threshold should be. And that's what one of the conversations has been. And either we're going to hash it out here or some people in Elk car are going to hash it out for us or we're going to put in a rule that. Like strike the rule, project it here because it's undefined. Right, so it's probably better for everyone if we have this discussion with the carriers because I don't think we want to put in a rule that is unreasonable or we'll put a large administrative burden, we're really looking for information because it's going to be expensive to work around some of these problems. Is this insurer's way of fixing it here? I just wanted to add one comment that the purpose of section 25 was to create a mechanism for the 9.1 board to assess the impact of these various types of services on access to 9.1. We need to have a level playing field to do that. Right now the wire line companies are reporting at this very, very granular level which we think is appropriate and has served the state well for 20 some odd years to say that that's okay for the wire lines to continue to have to report at that level but the wireless and the void can report at this astronomically higher level does not seem to me to be a level playing field and I would recommend that whatever the threshold is we're recommending as we've got it in the board there be equitable for all of these carriers which would mean, in the past eight years we've got 240 some odd reports of outages telephone service provider outages from the wire line companies lasting anywhere from a minute to 12 hours or more. If you apply, well, I was able to determine what the user minutes involved were for 145 of those because I had enough data. If you apply the SCC thresholds of 900,000 user minutes we would know about four of them and none of the others. So, so. And I think what we're struggling with is we've been told that depending on the carrier and the number of people and the number of cell towers that calculation may be more complicated and I think what we need to hear from the carriers is using the FCC for you and you can fudge it so we can't calculate back to any, if we were to find any business secrets. But how many people is that plus or minus a reasonable number? I'll be coming just a couple of other points. Yeah, no, you're fine. From Comcast, right now the rule for reporting by regulated wire line carriers refers specifically to network outages. Talking about things that have the woman not at the customer premises. Right, no, I don't, yeah. That's our issue. If online comes down in my backyard. For example, Comcast is across the state, 25 people, there could be 25 people who have an electrician of the house in 25 different towns and there's no way we would know that if you're reporting at a network level perhaps. Okay. Perhaps it would be, it has to be based on the network. Okay. So with respect to the fine we would, we understand the intent that reporting is a serious obligation. We take that seriously in order to connect to the 911 system in Vermont. Each carrier has to have a contact or contact endeavors to the 911 board staff so that we don't think that's an issue. We would certainly think that allowing the 911 to collect information over the next couple of years to see how, what types of outages are being reported. If there's a reporting problem before moving to a system of fines, even then they'd have to be graduating based on some type of showing opportunity for explanation. Yeah, I'm not quite sure why that bill was put in, but if we made it clear, I guess told the board where we should be in process, has it been filed? It's been filed as required by Act 79 with the Secretary of State's office and LCAR. So it's, it's final proposed. It's in its final proposed language. I, who need to, Maria's shaking her head. Yes, I, I. Can they amend it? It's final proposed right now. LCAR needs to review it. And now it has scheduled review at possibly the end of this month. So if you would like to give the input. We've been talking about post-collection on bills. Maria says, hold up on it while we. Yes. I'm sorry. I had the septic rules in LCAR when I chaired it and they were still an active bill in the other body and we treaded water, no pun intended, for weeks. Just offer one final. But I think I just wanted to clarify. If we made it clear, which should be just the clarifying amendment and the rules that we were talking about network outages that you would know about in a reasonable amount of time that that would work. And I understand that the, the fine as proposed without any uptos or maze, it sounds somewhat punitive because this might happen on a holiday when you didn't have staff sitting in your office to make the phone call or you might be having a tornado or ice storm where your caller person was. I felt last just one last point in that the PUC has now opened a workshop on the effective electric service reliability on telecommunications networks that could generate additional information. So there's certainly, maybe not from our line telephone service to regulate the company, but for board there is a very high correlation between whether electric power is available and whether people can use their cordless phone, whatever, you know, so our quality that would be more information. And we can use them for a while but eventually you gotta charge them. That's right. But thank you, thank you. Okay, thank you. That was just a wait everyone. I think he's here. I think he's here. Dr. Nicola, are you there? Can you hear? I can hear you yet. We may all eat on audiologist after that feedback. I don't know if you heard it. I can clean my ear though. Okay, this is Anne Cummings and I've chaired you with the Senate Finance Committee and various members of the public are here to listen and we are looking at S245. This is an act relating to eliminating cost sharing requirements for primary care. And the floor is yours. Okay, I know some of the people on the committee and that's good, but for those that haven't, now I'll give you a two minute summary or less of who I am. I'm in my 44th year of practicing medicine in Vermont. I can't hear. It's a little pediatrician, 1976. I was in private practice for 17 years, initially by myself and then with two internal medicine docs. Then I signed up to give her medical center. I was medical director at Gifford Medical Center for about 10 years, went back to do a pediatrician and then I finished up for about three years being medical director again. I'm semi-retired, I still work on weekends once a month to help out and cover the nursery and stick kids. That's my history. I've also been very active to work member of the Vermont Academy of Pediatrics chapter and I'm also a member of Vermont Medical Society. I have read the bill and I've also read a very recent article that was actually just published a couple days ago on this exact issue. So I'll start by saying I strongly support this bill and I'll say as written, I'm sure there's some improvements that can and should be made. My biggest concern with my experience in Vermont is that there is a declining number of people in this setting, this setting adults, but it's happening in pediatrics too, who are going in for basic care depending on the age of pediatrics, they can be up to a couple months for infants and after about the age of five it's yearly and the numbers who are coming in has dropped off. This study that was done by the Anderson Internal Medicine and this study had no affiliation to primary care funding sources, which I think is important when you're looking at a study, basically found that there is significant drop off about 24% and they studied the years from 2008 to 2016 and they were sort of in private business in primary care with the same basic people that they were looking at. Although there were probably alternatives I mean the correction, there are probably many reasons why that's happened, one of the things that appears to correlate with it if you look at the curves that are in the study is as the what people call co-pay, the money they have to pay out of their pockets to go through the primary care as that goes up the number of visits go down and that to me is a concern. The reason it's a concern is that in pediatrics and in adult medicine we know that if people come in and the tradition, the old tradition of a checkup is you get your blood pressure burned, you get a couple other things done, maybe you're hiding weight in two other things. Checkups nowadays include everything from social determinants of health, to BMI, to history about smoking, drinking, drug use, many many other things and in many screening tests that we didn't have five since 15 years ago, for me very important it's a PSA which I probably would not have gotten if I wasn't going on a regular basis to the physician and I actually ended up in a prostate cancer and that was picked up at that surgery and I'm doing well.  And I think because you're the finance committee, our biggest expenses are for chronic diseases or illnesses that are caught too late which is really treat properly. The other thing that's kind of wrapped up in why people may not go to primary care docs and this is very important to me, especially as medical director, I'm still involved in screening for our organization. And by the way, we're an FQHC and I was as medical director for that also for the last three years. If we will be at the number of primary care docs in Vermont right now, it's dwindling, I've heard of two more pediatricians who are at least leaving one area in my house and where else they're going. And so the number of primary care docs is dropping, the access to care may be dropping off but even with, if you control for that, the number of people who are going to the primary care doc for routine checkups and routine healthcare is dropping open at a alarming rate. So, in the middle of all this, people are going to urgent care centers, not necessarily for the yearly checkup, but mostly that's not what they're saying, they're going for the sore throat, for the headache, for the rash, for the fever that they might have. And there's a cost to that that in many cases could have been handled in their school primary care office or if the primary care office has set up properly, some kinds of even a phone or electronic medical record message, but if they're not connected to the primary care doc, then it's very unlikely to happen. So that's my quick tell and dirty of, and I'd be happy to talk about any aspects of the bill or any questions that you have about me or about why I believe that getting rid of the co-pay for your primary care doc will actually improve access and improve health and over time reduce costs. Okay. Senator Ballant has a question. Thank you, doctor. I just wanted to go over, when you said there was a big drop off 24% in the visits to primary care positions, you were saying that was over an eight year period, is that right? Correct, correct. And so you alluded to the fact that in another part of your testimony that some of that may be due to visits to urgent care, was that factored into that data point there? No, the overall was the 24th percent, 24th point something percent. And during that time, the urgent care centers were kind of, that's when they really started changing off. Yeah. But I think the key here is, if you look at how urgent care centers work, they're basically the way I look at them, because there are many emergency rooms, and people are going in for acute care, often preventable if they had been to the primary care doc. And in the study of 50% of people did not see the primary care doc even though they had a primary care doc during that time period. Definitely, Winnert has this study and sure can get you to look at the details. Any other questions? Okay, thank you for taking time and I'll be here to have a question. I have a question. Thank you for your testimony, Dr. Senator Pearson from CHICNN. You said you were medical director at the FQHD, is that right? Yeah. Thank you for that. So you have a, help me just to make sure I'm right here that you would therefore have a bit of a larger view of the whole sort of hospital system as opposed to just being an expert in pediatricians, right? Correct, there's no question about it. I had to do reviews on every one of the employees and because they didn't include the subspecialists and include all the primary care docs and I had to do reviews on the adult docs, I had to do, I'll just, you know, a whole variety of people. So one of the concerns that's been raised here is while most people seem to agree we need to do better by primary care, whether it's reimbursement rates, et cetera, is that the premise of this bill could sort of have a punishing effect on specialists or maybe somehow impact their reimbursements. Do you have any concerns along those lines or jack up or that's right, the chair reminds me, or one way that the insurer might balance it all out is increase the co-pay to go see a specialist. Should we be worried about that or guard against those kinds of ripple effects? Oh, I think we should, but I think it's very important to understand that if the, and this is only one of many, many, many studies that show if people have a primary care doc, or by doc, I'm including nurse practitioners, P.A., if they have a primary care provider that they identify with and they go to them at least once a year for the checkup and then they go to them when they have the problems or follow up with their diabetes and things like that, their overall health improves dramatically. And at the same time, they're much less likely to go into a walk-in clinic where they're not down or shelf in the emergency room. And I think that pointed out in this study because 50% of these people did not see a doctor at all. That may make up some of the numbers that it showed up in the walk-in clinics. And again, what typically happens with walk-in clinics, they don't know your history. They don't have access to your records. They don't know what meds you're on. They may know what you tell them, but I'm lucky I'm on one med. If you're on 10 meds, you often can't even remember them. So there's a disadvantage in doing that. As far as the specialist are concerned, I think if anything, and I don't have any paper to back this up, people who go to primary care docs on a breakthrough basis are more likely to get appropriately referred to a specialist. Most insurance companies, I shouldn't say most, many require a person to go to a primary care doc before they show up to be a golf stick and a knee replacement. They are more likely to have someone who knows them, who can guide them to the specialist at an appropriate time and willing to back to get the care that they need. I don't see the numbers there. Now, your point about insurers, yes, insurances, well, Ginny, we're gonna lose the money here and I'm not gonna talk politics, but the insurer's making much more money than they need. If they say that I'm gonna raise by $10, $15, whatever, any cocaine, cocaine, those things especially, to make up for this, that's your job and I think it's allegedly a job to really talk about that. And so, yes, it's a concern. I think it's certainly not a reason to not do this, to do this still. Okay, I think Dr. DeNicola, we can't control all insurers, we can't control all those self-done. So what we're looking at are basically the ACA, gold, bronze, silver, and they are required by federal law to keep an actuarial value. So when we take away a cost to the consumer, it has to get added somewhere else and there's at least six bills that I know of and I'm on health and welfare that would limit or do away with co-pays. And any one I think is a good thing. All of them taking together could have some major hit. So we're trying to work through and figure out where we do it. We have one on insulin, there's one on contraceptives, there's one on, what do we do this morning? Chiropractors and physical therapists. Oh yeah, there's a couple more. So that I think is what we're looking at. The bottom line is the cost of health care is too high. Our health, yeah. And I understand that completely. I just keep going back to my, who said the pediatrician, if kids get really good pediatric care, they're gonna have left health issues, whether it's obesity, diabetes, or hypertension, or even bad access, who knows. Whereas if they're not going, they're much more likely to develop problems that are gonna cost the overall system more and the insurance need to look at that this way. And that's to improve it over and over again in the need of the country, where people have medical care, excellent access to primary care, and I believe in other countries where there's excellent access. So in the end, of course we have to look at it, but I think that based on the foundation or finance, how should I put it, to improve in climate reform, in medicine has to start with primary care. And I have good friends that are specialists. One of the biggest problems we have in this state is we have a very good growth time getting primary care done. That's gonna get worse and not better. We also have some problems, we respect, especially in some specialties, and I can think of three, which are really at risk. However, again, if we keep coming back to where we started, because we started with the foundation, get everybody to have easy and appropriate no co-pay to their primary care doc, they're gonna be healthier. And yet, there has to be a balance. So the balance really has to be looked at more long-term. In the end, if I keep one, two, three, four kids from getting morbidly obese or getting diabetes at age 15, I've saved the overall system dramatic amounts of money. So I, and as an withdrawal, if I'm seeing a 20-year-old with a chronic problem, and I know them very well, the likelihood of them eating hospital care, eating kidney transplant goes down. It doesn't go away, but it goes down. So. Okay. Other questions? Thank you very much for taking time to talk to us. It's been helpful. Finance doesn't get to deal in health care a whole lot. Well, I'm happy that Stephanie knows me and if you need to talk to me again, I'm happy to talk. And I hope it's doing better where you are. We're having an increasing rate here. I don't know what it's doing out there. It's gray and it's wet. Thank you, Dr. Liu. Take care. Is that Mark? Yeah. That's Mark. I'm Mark. You are gifted. He has been quiet. I listened to Dr. Liu. You are unique. Okay, thank you. It's your heaven here more often. That's right. Can you talk on what Chip said? All right. Where are we again? I'll call in Robinson. You know where we came from. Thank you very much. For the record, my name is Colin Robinson, the political director at Vermont NEA. We're pleased that we're able to testify here on the MS-245 on behalf of 13,000 members. And Vermont NEA has been involved in supporting broad systemic health care reform. We're all Vermonters, so everybody can access the care they need. When they needed it at a price, they can afford it. And we believe S-245 will do that. I want to touch base on a couple brief points about why we think this is a positive step forward. One thing that we know, obviously, are members who work with students every single day. And when students aren't able to access the health care they need or their families can't access the health care they need, that impairs their ability to learn. And in order for our educators, our teachers, to be able to be effective at their job, they need to make sure their students are able to be successful learners. The other thing is, obviously, the issues impacting educator health care across the state have been a topic this committee spent time on the past couple years. It's been a topic other committees have taken on. But the reality is the issues that were coming up in the context of educator health care are reflections and mirrors of broader systemic reform issues that are impacting everybody. So obviously last year you all in this committee took action on the debacle related to the third party administrator issue. And we appreciate that. And you might remember we spoke in this committee about a survey that we presented to educators across the state whether they're members or not. In the late, late in 2018, we received 2,000 responses from educators across the state. And this is at the end of the first year the implementation of the new VHI High-Deductable Health Care Plans. And what we found in that survey, one thing that really jumped out was, and it was sad but not surprising that 46% said that during 2018, they did not go to the doctor when they needed a medical, when they had a medical problem. They skipped a medical test treatment or follow up recommended by a doctor or they did not make an appointment with a doctor or other provider because of cost. So that's 46% of educators. And we know that that, once again, is not unique to them, but we believe it is reflective of- They are also not amongst the more poorly paid-in-care models. Exactly, exactly. So if that's a cost barrier facing our educators, let's think about how it impacts others. And so along those lines, it's specifically talking about VHI, obviously the health care plan that school employees have. This bill wouldn't impact the majority of the VHI plans. About 8% of individual school employees enrolled in VHI plans actually would be impacted by this because they're in HSA non-compliant plans, but it would impact 8,000 retirees in the VHI system. And we believe any number of remoders having positive impacts related to being able to see their providers when they need to is positive. Is the general fund paying for the teacher's retirement health care? OPEM costs are part of the general fund. Okay, so what I heard long and clear this morning was if we do away with those co-pays, then the cost is gonna go up. That money will have to be made up, and I assume here it would have to be made up by the general fund. Well, I think obviously it was spoken to earlier, and I'm gonna mention it just a minute.  No, no, what I was gonna say is actually VHI's, I mean, we do believe that, but specific VHI did an analysis of where their spend is, and 5% of VHI's spend is on primary care compared to 50% on hospitalization and 18% on prescription drugs. So when you're talking about what is actually having the biggest impact on, and of course the trends of VHI I think are probably reflective of trends in others' settings as well, is that we're talking about 5% of the pie and making sure that remoders are accessing that early care that has impacts down the road. There are other parts of the pie that there might be levers to impact that would potentially address, I think, what your question was driving at. So, you know, VHI, I think it is important to illustrate that with 5% of the spending on this, there is, it's a cost-effective way to incentivize the right care. The sort of final point I wanna make is that per Act 11, the bill that created the new statewide healthcare education bargaining structure, VHI cannot offer any new plans until the first year of the second agreement, and we believe that S245 could help facilitate positive conversation about the development of future VHI plans and what that could look like in order to make sure that educators are able to access the care at the right point in time. So, there are other additional comments in here, but I will leave it there for now.  No. No, I didn't think so. No, of course. Okay, so that means you're on the exchange? No, it's an inter-municipal, it's its own thing. All right, so you're not stuck with the same actuarial value, you're kind of neither fishing or following that one. Okay, so disrupting. Can you explain a little bit more about why HSAs take them out for the purview of this law? Why is no cost-sharing in HSAs? Yeah, there are, and I would defer to the Legislative Council on this, but per IRS regulations, You can't sit down. Yeah, it's IRS regulations. Basically prohibit. Sure, it's not about profit pressures, and you've got them all covered in the deductible already. Yeah. So, none of your... You can't carve out certain things in order to be an HSA compliant health care plan. Okay, can you speak more toward it, too, if you want? So, we can get the federal government to change that. Maybe have a different conversation. I don't know what to do with that one. Well, didn't I hear you guys back to us in health care? That's what some said. The best. So, if this were to pass, and you say that future contracts, may take this into consideration, how would that work if you still maintain a right to not do plans? So, the bargaining about educator health care is separate from the plan development and administration. They are totally separate and segregated entities. V High is over here, the bargaining is over here. The plans that are being bargained over are the V High plans. Right. The V High plan plans are designed by the board in consultation with Blue Cross Patio, and MISBIT, and all the other various partners. And like any plan, those redesigns happen at various points for various reasons. My point about the redesign is Act 11 prohibits V High from changing their plans until the first year of the second agreement. So, it's possible that the V High board, at some point in the next year or two, will have a discussion about what plans could look like. They may decide the plans will be exactly the same, or they may decide they will look different. But they can't, yeah. There's bargaining agreements here. They're setting, you can't do anything. That was per statute. Yeah, that was per statute. Okay. All right, any other questions? Okay, thank you. Great, thank you all. Margaret Lagas, let's give these guys a little more and more, I'll come in a moment. Why not? For the record, my name is Margaret Lagas, and I represent America's health insurance plans. And so, first off, I'm talking about 245, the no-cocay cost share for primary care. What is America's health insurance? It's a national association of health insurance companies. So, you know, like the SIGNAs or the MVPs, or whoever they have an access to, it's a trans-associated. Exactly. So, obviously, as you've heard, it's gonna be an overall cost shift if we aren't spending, you know, if our member plan owners are not spending money on primary care of their own pocket, and that falls to the insurer to make the metal levels work, that money has to go somewhere.  It's no, this really isn't any different than some of the things that have already happened, like the Medicaid cost shift. We already know that Medicaid's not being fully funded, and so that cost shift goes on to insured folks. We're seeing these kind of cost shifts all over the place, and everybody has their pet thing that they want to work on. Primary care is a very important point of access for folks in the healthcare system. I'm an EMT with the Heart and Grisly Squad. It's the third question that we ask people. Your name, your date of birth, and who's your primary care doctor, and when was the last time you saw him, or her? And I will say that everybody has a primary care doctor. I've yet to go, unless you go to, you know, maybe some older woodsman or farmer or something, and they have never been to the doctor in their entire life, but they don't have a primary care doctor. But most people do, yeah. Is he a physician's assistant? Yeah, I would refer to him as a primary care doctor. So the purpose of this doesn't matter. Yeah, yeah. So primary care doctor, it can also be, I believe, a nurse practitioner. It can be there are many different certifications. That's it, yeah, so, yeah. And what we do find, which is good news, it has changed over the 10 or 15 years that I've been an EMT, is that many more of our chronic disease folks with hypertension, diabetes, obesity, do now have a primary care doctor, and do see them on a very regular basis. So we do ask that question when was the last time you saw them. It is often within the last two weeks or a month. You know, certainly more than the average for mantra that goes once a year for a checkup. I think one of the other reasons that we worry a little bit about this language is that there aren't enough primary care positions out there already. And so you think that somehow the costs of going to a primary care doctor is keeping people from going, and this is gonna allow a lot more access. Where are they gonna go, and who are they gonna see? When I called for my annual physical this year, I called in June, and I got an appointment in December. You know, that's just the way it is. Even if you're sick, you're probably not gonna get in for a couple of days. So, yeah, so, I mean, I think that there's as much of an access problem as there is a cost problem. So I don't think that you can equate that people don't go to see their primary care doctor every time they should, with the fact that it might cost them money. It might be that they know when they call, they're probably gonna be all better by the time they get a chance to see their primary care doctor. And your primary care doctor will tell you if you've got a sore throat or if you've got, that needs immediate attention. People are gonna go to the walk-in clinic. They tell you to go to the clinic. Yeah, and so they go to the urgent care, and the doctor on the phone talks about, you know, well, they won't have a med list, et cetera. Every single person that we go to pick up in hard-to-rescue, we ask for a med list and we're handed one. Generally, if you take medications, you have a med list and it's readily available. We don't have any trouble. And maybe that's more for chronic care people that know that that's a question that gets asked of them all the time, and those maybe are the people who call us more often. I think that this bill would cause a fairly significant metal level challenge that you've already heard about, about the 60-40 split or the 80-20 split that's required in those metal levels. Where does that go? The testimony that you just heard was that I think it was for the educators, 5% of their money gets spent on primary care and a significantly larger amount gets spent on specialists. So if this money gets transferred out of this bucket and into that bucket, it just exacerbates what you're gonna spend elsewhere. And for that patient that actually starts to need to see that specialist, that's probably a bigger hit to them than the few times you might have to go to your primary care doctor for a cold or the flu or tonsillitis or whatever it is that you have. If you have to go and see that specialist more often and now that co-pay is significantly higher to make up for your free primary care doctor, I don't know whether that's better overall for a Vermont person. So, and the other thing. Yeah. I'm sorry, I. No, just one last thing is just to make sure that you don't apply this until we're already in the middle of rate setting and so it'd be really helpful to not apply until 2022. I'm gonna go into that much. I got it all morning. Shocking. Okay. This bill is based on two basic theories. One is that out-of-pocket costs do act as a barrier for people seeking, okay? So does the America's Health Insurance Plans agree with that theory or is it different? It's sure they do. I mean any barrier for you to get in, getting to see your doctor is a barrier. Okay. So the second one is that access to primary care is the best way to prevent bigger, more costly, more dangerous health problem down the road. Correct. You guys agree with that? And that's why we generally have the lowest co-pays for primary care physicians versus specialists. So if we agree on the two theories that make this come together, how is it that all of the professions, all of the insurance coming and then don't get us to or all conclude that this will cost us more? That doesn't make sense to me. If we agree with the premise that you get into primary care and save money, costly treatment down the road, how can this notch over time be at the smart place, et cetera? So you're right in that if you have a chronic disease and you wait and wait and wait to go to your primary care doctor, then it may be more expensive to treat that chronic disease because you'll be at a kind of farther down the road and where it is in its progression. That is true. To try to quantify what that cost is to a system might be difficult. I don't know that you can always say, oh, this person waited six months and they came in six months earlier. That might have saved us $1,000, $10,000, $100,000 over their lifetime of treatment. That might be very difficult to quantify. I think we all agree that everybody should have a primary care physician, that they should see that primary care physician on a regular basis. But whether or not making that access entry point free of charge is something that is gonna make a big difference is a question that I don't believe has actually been answered. And the resulting change in where the money is spent in the system is also a question point for us. As I said, if you do have a chronic disease and now you've got to go and see a specialist on a regular basis and you just bump that cost up by $50 a visit and you're gonna actually see that person more often than you're gonna see your primary care doctor, that's difficult. I think the issue where I'm gonna channel Senator Kitchell and we did it in here when we looked at providing medical care for children with autism because testimony was, I believe financial, well then it was a bishka. Finally agree that if we could get care there now, these kids could go to school with, many of them could go to school without having to have a special aid and they could function, but it took a huge amount of effort and input at this early stage. The problem was, and I know Senator Kitchell has said this, right now I have to pay, the system has to pay for that early intervention, the primary care, plus we're still paying for all the residual, you know, debts out there. So in this year and probably in the near future, it's not gonna save, it will save us money over time, but this year there is a base cost to the healthcare and what we're doing is dividing it up and the tendency in this building and I got this big time in health and welfare and we're talking about trying to make sure we do this. We had the chiropractors and the physical therapists in. One of the interesting things was this article here in the New York Times, it was in our packet, which essentially says that preventative care doesn't save money because as a result, people live longer and ultimately consume more things than programs including healthcare, which is interesting. It was true, I mean that's one reason that we, I mean social security was set up on the concept that you died within three years of 65. That was the lifespan. The life span. Now, yeah, and now it will be long enough to get Alzheimer's so, you know, the future of healthcare is out there, but for this year's budget and for this year's bill and if the cost of health insurance gets so high that employers stop providing it and people can't afford it at all. So we're really walking this game, but this morning it was the chiropractors and the physical therapists and, you know, we're talking about setting their co-pay at a set point. There's one to stop co-pays for contraceptives in the house. We've got one to stop out-of-pocket expenses for insulin. There's I think one or two others that get thrown out there, but any one of them is good. All of them taken together is going to be a much larger cost shift. And it's trying. I also think the biggest challenge is really behavioral change. You can go to your primary care doctor, they'll tell you what type two diabetes you need to take X, Y, and Z steps to get that patient to go home and change their habits in order to try to make themselves more healthy is really, really difficult. It's a big challenge and it's not, you know, and it's not just for diabetes, it's hypertension, it's obesity. There's all these big cost drivers and it is very difficult. And I think what you will see is that through health insurance plans, you now get $300 a year or $600 a year if you wear a step, you know, a step tracker, if you join a gym, if you, you know, there are all these things to try to get people that to put these practices into place because, you know, that's the thing that will probably save us the most money in the long run. The long run. Healthier lifestyle. Yeah. We don't get a lot of exercise. Sitting here. We used to on the farm sitting here with our computers. In fact, I've been told that health insurance is more expensive for tech people. Very scum folks. Okay. I think I'm next. You're next. You wanted to sit here because now we're gonna do water pocket expense for every time. That was very clever of me. I'm here. We don't want you to get any exercise. That's right. Don't stand up and sit down. Okay. So now I'm gonna talk to you about insulin, capping the coque on insulin. So just to start for myself, I just feel like it's necessary to lay it out. The bottom line is the market is just plain not working with regard to this drug and EpiPens and a couple of others. This is not a novel new drug. It's not a small group disease. It's not a drug that took 20 years and tens of million dollars to create. The drug was discovered in 1922. Patented in 1923. And the patent rights were sold for a dollar so that most people would have access to this drug. The biggest change in the insulin market happened in 1996 when Humalog came out and four years later, Novolog came out. Those are the two of the most popular used drugs with regard to type one diabetes and some for type two. Those at that time, 1996 and 2000, cost $21 of aisle which was about a month's worth of this product. We are literally talking 19 years ago, not late years ago. In a working market with competition when Novolog came out and certainly plenty of people in need, lots of people with diabetes and that's certainly not a shrinking population. It's an ever-growing population. The price should have been about stable. Good competition, a good healthy, robust marketplace. That's not the truth. Today, those same vials cost about $290 a piece and it does vary, you know, somewhere higher, somewhere lower. But in general, yeah, so there's a wide variety but I guess kind of on average, it's around new $290. How is it possible that especially those two drugs have marched in lockstep from $21 to $290 over the last 20 years? And in the last five years, their price has doubled. That doesn't sound like a healthy marketplace to me. Something is really seriously broken in that marketplace and it's really no different than the EpiPen problem. You know, now in the back of an ambulance, we're literally drawing up Epi and a vial because we can't afford to use EpiPens in the back of an ambulance because they're too expensive. We used to leave them at the scene with families. Had a child that obviously was new to anaphylaxis. So today, there are 30 million Americans who are about 9.4% of the population that have EpiPens. This is a healthy, robust marketplace and yet we've got these prices that are just going crazy. This bill, although I 100% understand why you want to do this and why it is important for diabetics to have wonderful access to insulin. You do not want people rationing this product. It has very negative health effects. You know, we go to see diabetics over and over again and the first time we go, they're missing one toe and then they're missing three toes and then they're missing their leg up to their knee. These are horrible things to witness and they're happening every day. This bill, although it certainly reduces their pain, which is a very good thing, does absolutely nothing to the pharmaceutical company. They're still getting their $300 or whatever it is that they want to charge. Right, because now just more Vermonters are going to pay to help ease the pain for the diabetic patients. There she is, there you go. That's what I said, you know, maybe this will all be moot in a couple of months anyway. We've got an election coming up, who knows? But for right now, for right now, this is what we're dealing with. So, you know, I guess if you have to do this and I can certainly see why you want to do this, the first thing we would ask is that it's $100 of prescription and not $100 to cover all of their prescriptions. We do believe that it's still a significant reduction in the cost for them and it's less of a cost shift to all other Vermonters.  We would like to see some kind of transparency language in this law. Right now we have a transparency language that deals with the most expensive 15 drugs that are out there and it goes to the Attorney General's office, et cetera. Can you just translate this? It's true, but I also think that you should put them on notice that you want to know when these drugs are going up that they're gonna have to report that as well. I mean, you may think that it doesn't mean anything to them. They fight against it. They don't like it. They don't want that out there. You know, no company wants that bad press, even if they're putting a lot of money in their pocket. Do we find out how much is sold in China? You don't have to go that far. Well, no, my son lives in Canada. I live in Derby. Well, that's a question of the drugs. These are brand-name drugs by and large, I think. Yes. Are they, in fact, cheaper in Canada? Many of them are cheaper in Canada, yes. That's a horrible thing. Significantly cheaper. I don't know what the, I've never gone up to price them. It's one of the ones where there isn't generic competition for, so the pharmaceutical companies have also very cleverly used some laws that pass in order to keep their products to basically to keep the generic alternatives off the marketplace or the, you know, yeah. So there have been those things. Well, remember the young man who was in here the last time on this bill and he was mentioning the huge prices.  I don't know whether you use that, but I sent him off, A, the name of a pharmacy and a phone number where he could price what was available in Montreal, and secondly, the name of a physicians group that will see Americans immediately in order to write a new prescription. And did you hear what the price difference was? I haven't heard yet, but I suspect it, if it was not a generic drug, I suspect it would be considerably cheaper. Yeah. Yeah, I think we, and then there are the pharmaceuticals companies here that my family, my brother, who was $1,500, and he ended up getting it for 30 because his doctor had a connection with this unity pharmacy. Right, and Hartman Health Center has the same thing. And the FQHD has access to that. Yeah, but that's not, that's- But this overall truth in pricing as far as, and also in effect, the right to shop, the availability of pricing is very difficult and pharmacies now, often you go in and you ask for the price of the drug and they can't tell you the price of the drug unless you give them the prescription so that they can fill it through your insurance company as opposed to really clear, transparent pricing systems. And if we were ever to do something legislatively, I think that would really be a key thing. So the Monarch can see, not just for pharmacy, but also for common medical procedures so that you can go out and shop. That's in fact the line. I think Blue Cross has testified that you are one of their policy holders. You can get on and see the prices charged for procedures, or for procedures and pharmacies. We have both a pharmacy app and a medical app. It's a little bit of work to find- To find, okay, but it's out there. Yeah, the pharmacy stuff is typically priced just at least in my experience, the same throughout. However, there are some stuff that I take, I know significant differences. And then there are also these things like good Rx of being the folks who have negotiated prices and they can be substantially less. Oh yeah, I don't think that's- But in short of people doing trial and error through long list of things, it's almost impossible for people to price that and that's something I think we should do something about. And it is more than, it's the very few pharmacies, because we did, we called them all. They're within $10, $20, there's all kinds of prices. But $1,000 differential is beyond any kind of normal market thing. And so if you find the right place, but most people when they're sick, don't do that. And when your doctor tells you this is what you need, you do it. And I'd like, yeah, and I hope you are on this committee. We spent several years doing a lot. We probably gave Andrew Gray hair doing it. A lot of trying to get a handle on pharmacy prices. Yeah. It was challenging. It sounds like Maine, because we did a lot of work with Maine. It sounds like Maine is back on the active status again. And we might start trying to do it along with- Florida, doing an importation bill. Yeah, we're trying to do that. I think there are a lot of states that have really come to that breaking point. It is a breaking point. I mean, that is one of the driving costs. And I don't know how you tell a mother with a kid with cystic fibrosis that we're not paying for your medication. And that's a new medication. And I don't mind paying for that, but when you're paying almost the same amount for insulin, that's when, or an EpiPen, both of them have been around forever. 1920s, both of them. Yeah, you know, that's when it gets to be just unconscious. I understand. Did you say earlier that the pharmaceutical companies changed the laws? No, he did. I didn't say that they changed the laws. No, I said they cleverly used the laws. Okay. Yes, I know Mike is up next and we've got 10 minutes. So I think we've gotten into bending our screens. Senator Schrockin, you do have a specific question. So you have to get up. I can't see. The blue cross machine, like you said, I went to one pharmacy and I wanted to charge $900. And my doctor told me to go to this pharmacy and you can get it for like $36. It's the community pharmacy. So it turned out to be true, same job. So my question is for the normal person who has not medication, but just commercial insurance, and there's a co-payment on the drug, is it subject to a allowable expense under your plan for the pharmacy bill above the allowable expense, George? If you're buying the drug through your insurance, they should not be charging you more than the co-pay. Some of what's happening, and Brian Murphy can explain it better than I can, is that you're buying the drug without using your insurance and taking a rebate directly from the manufacturer, and then there's a different scenario going on in that situation. You're not actually using your insurance coverage. You're purchasing the drug without insurance. Yeah, I had a constituent tell me that I had health insurance for pharmaceuticals. Went in, got like $300 bill, and he said, oh, I can't afford that.  Well, how would you do that? Well, we've got coupons and it's like you go to the grocery store with your coupons and we've got, maybe we should do, we've got pharmacists from Brattle Barrel, I think that loves to do this, but Brian is really good. Brian's a bill of one, I can explain some of that. And far better than I can. Yeah, I mean, he is just really good in the basis. Your pharmacy really has about as much control as you do in a lot of these things. They tell them what they can charge and they tell them what they're gonna pay. And that's it. The European systems that have coupons. Mike Fisher, health care advocate. It's pretty unusual in this world to actually think that there's a new idea out there. And this concept came to us in the middle of the hospital budget season and we've done, the health care advocates office has done a great deal of work researching it, making sure that it's legal and that there's no case law against it and that it could actually work. And on a high level, the idea is to, well, let me just describe, I don't know if you've spent any time understanding 340B. No. But on a high level, 340B, the difference between the retail price and the 340B price is a... What's the 340B? And the 340B price, I believe, is set by the federal government. Is... What's with the vet companies and FQHCs all have access to, is that right? Yes, there's a number of providers and they're trying to fly very high here. The difference between the retail price and the 340B price is a revenue stream for a certain set of providers. And that revenue stream is very important to those providers. Providers being doctors? Those providers being hospitals and FQHCs and a few other. Okay. And I am focusing on hospitals here. And I want to remind us that we have a whole set of hospitals in here in Vermont who are not in great shape, who are struggling. And so I have a very... I'm posing a very narrow, very narrow slice of using the 340B price as a reference for the what is allowed to be charged to the consumer for insulin only. If the 340B price applies and there's a lot of details behind that statement. Be the right kind of provider and has to be the right medication, has to be the right pharmacy. If the 340B price applies, then the consumer can only be charged what I'm proposing, 150% of the 340B price plus a reasonable dispensing fee. So to give you an example, Victoza is an insulin product that costs 295, the National Average Drug Acquisition Cost is 295.57 a bottle. $300 a bottle. The 340B price is $15. And so I'm proposing to limit the amount you can charge the consumer for their plan for that matter. The 340B price plus a reasonable markup for the provider and for dispensing. A much less expensive insulin product, Blantis is $27 a vial, $27.24 and the 340B price is $0.03. $0.03. I believe it is set on a national scale by the federal government and that hospitals, that drug companies, that certain set of drug companies are required to participate. And is it, on Tiva, I know every time we look at it, Diva says, do not touch our drug prices because they do have some connection with 340B. I believe that in many states, 340B prices apply to Medicaid, not Vermont. Not Vermont. Because Vermont has argued that they can do better in the, maybe they have. I mean, all I know is every time healthcare looks at it, they tell us, just leave us out because we're doing very well. So. Oh, this will get people in here. So I recognize that. No. I think this looks like great. I don't know, I'll email to you. And it's probably on the website. It's on the website. So, I don't need to remind us, you guys have heard great testimony on how important this topic is. We had calls at the healthcare advocates office about people who are not taking their insulin, who can't afford to take their insulin. And I wanna, and so this comes sort of a little bit in desperation. Where do we go to make this work? And I really, I wanna caution us. I think this is an interesting idea if done right and very in a very narrow fashion. The hospitals, Vermont hospitals report in their 20 budget expected revenue of 62 million, 62.8 million in 340B revenue. And that's what they're buying it for and what they're charging patients within the hospital. This is a ball 340B drugs. This is not insulin. So they aren't selling them to the public. They are, that's what they're charging me. When I go to the hospital and they get me an aspirin, they generally charge me what I would pay for a bottle of that. So again, I wanna make a disclaimer that I've been studying 340B and I've learned a lot about it. And if I get something wrong, somebody who knows it's gonna, should wave at me. David does do 340B price. If you want Medicaid does do 340B, that's what you say in 340B. Oh, okay. Okay. Thank you. That's, yeah. Thank you. I always told us don't touch it. I am proposing this for a commercial payment. I think this makes sense for a commercial loan. This is for people who have. But can commercial buy it at 340B prices? Are you telling the insulin companies that they have to sell it at? So I think it's a really important point for me to make. I am not proposing any change to the 340B program. It's a federal law. We can't touch it. It's federal law. I am proposing that Vermont hospitals charge consumers a rate that is reflective of the 340B price. But some name hospitals don't participate in 340B. They don't have pharmacists. I understand that. Do you say that all in Vermont? Vermont hospitals participate in 340B. They don't sell pharmaceuticals to the public. I can't go up. At least I don't think I can go up to CVH and get my prescription filled. So I'll be the first to recognize that there's some flaws in what I'm suggesting here that there are people who get their insulin from a community pharmacy that doesn't participate. And that this. Well, they can't participate. This price wouldn't help them. Okay, so you're only talking about hospitals or pharmacies that purchase through the 340B and make the 340B price. And sell to outpatients. Actually, if you go back to the history of the community, the idea would get these drugs at low cost prices to the hospital to get them to their patients was to benefit the patients. But the people who were selling it in the pharmacies or the hospitals didn't pay attention to what they were paying for. They charge retail. But if I'm paying $600 a month now for insulin, even if I'm told I could get it for $30 or $45 a dose, maybe $100 a month, if I had to quit off to UVM Medical Center or to a local FQHC, that would give me an option. Might not be the most convenient option. But it would be an option. Okay, I'm gonna have to close this. You have done this bomb in the middle of the table. We'll see where it goes. But the treasurer is standing in the hall and I have a feeling we might need, can we do a break in five minutes? There's your answer. Thank you. I don't know if they told you, but I am, I assume most members of the committee are getting letters. Yes, they say you demand. We demand that we fix and we are wasting and their petitions about to be a stranded asset. I'm not sure how many people actually know what a stranded asset is. Sure. Not a problem. I don't remember that from accounting class, but yeah. There you go. So for the record, best people to stay treasure and I want to thank you for the opportunity today as opposed to tomorrow, it's gonna be a rough day. But as we're all talking about, it's apparently the Senate is open, but I don't know how many people are there to be here. Well, we've got a big meeting scheduled for about 40 tomorrow, so we'll see how that goes. So the topic is, I'd like to switch it around and talk about environmental, social, and governance and how the investment fits into that. So back in 2013, 14, 15, we had a lot of discussion about the divestment issue in terms of fossil fuel-free investments and we did a study. My staff did a study with the time our investment director as well as NEPC, the England Pension Consultant who's our advisor and I want to point out they don't get money for saying, I got you a big deal here, you do this investment. They are an independent fiduciary to the fund.  They do not- No, they don't manage your investments. They advise us on investments. They are not getting paid by the coal company. They're not getting a commission for sending- Absolutely, absolutely and they're not getting commissions on management investments as well. So they wouldn't get you a short-term investment that's great, great and then a problem down the road. So we did a study, they did a study. Our studies were very comparable in terms of result, not separate process and we thought that something in the area of $9 million per year is what we came up with. I don't have the figures in front of me and I apologize. So $9 million a year for what? The cost of doing divestment. The cost of doing divestment, okay. Yeah, and I don't have the number exactly in front of me. I'd have to look, but it was several million dollars. I believe it was nine. It's been a while since I looked at it and I apologize. It's been, I was out of the state for two days and then we've been doing a wild committee to committee today. Okay. So is that based on the mechanics of moving the money or the depletion of the, you know, the weaker returns if you were not invested possibly? There's transaction costs those are one time, but this was really on the selection. For instance, right now we have a lot of things that are in, there are two issues. One, if you, we have things that are in co-mingled funds and if we were to move those to others it would be more expensive than the co-mingled fund. And if we're trying to direct the co-mingled fund on what to invest, we would not be able to stay in those funds. We also have a number of funds that are essentially, I'm trying to think of the term, apologize, neutral funds or that are basically do not have any fees. So we do the S&P 500 for instance. If you were to add to that a level of additional either a negative search or a positive search on it you'd have additional basis points on those and those would cost money. In addition, we thought that restricting the types of it and restricting it out of certain classes of investments would have an issue in terms of risk and concentration risk as well as diversification risk. So at the same time, there are a number of studies by advocates that had a different story. And what we said is that we would like to get past this dueling studies and have someone else take a look at it. And what we offered to the environmental community and we had a series of meetings which are on our webpage and listen to the audios if you like. We set up a scope of what kind of study we would wanna do and we had very large participation. VPurg was there, Sierra Club, Clean Yield, trying to remember a couple of the others but we had very good representation. And we came up with a scope and we said you pick three pension consultants, not environmental activists or not the coal industry on the other side or the fuel industry on the other side. I went like this, okay? I went like this. And so we said pick three and we'll do an RFP and many RFP and we'll pick one. So we ended up with Pension Consulting Alliance, PCA. They're a national firm, they've done work on this issue and in fact they put a very good listing of the biography of the various sources on this before we even met them. They're very proficient in this area. So they did a study and they met with both people on the fossil fuel side and representatives who were there and they also met with 350, oh, I'm sorry, 350 was the other one. So 350, VPurg, Clean Yield and in Sierra Club. This was back in 2017, okay. It all meshes together when you're doing all this stuff. I understand this, what day is it? Yeah, exactly. So in 2017, and I stepped back and my staff stepped back. We were a resource that people asked us information but the deal was if Andy sent information to PCA, he also sent it to 350 Sierra Club and so on. If they sent information, they shared it with you. We stepped back and said, we've set up the scope, we're having an initial meeting with you folks and I don't want, I'm not gonna be involved anymore. And my staff, the staff did get requests for information.  And I think it was around, I know it was Christmas Eve when they came out with the study because I- Maybe why we missed it. No, I was at the cake with my son. I was having a seafood platter just for the record but it was very good and they came out with it and it basically supported our, they didn't put the number of dollars but they said substantial dollars in losses, diversification risk and they recommended that we not divest. So then, but they did have in there, a number of ideas about how you can lower your carbon footprint until you can be a better citizen there. And we adopted a policy, a five point plan which is on our webpage, a letter from me to VPIC which is the Ramp Pension Investment Committee asking them to endorse these five policies. And those are included now in something called Environmental, Social and Governance which is on the front page of my, of my, of our, not my, of the Treasurer's webpage. And if you look in here and we try to find the page we go through all of those points and we talk about what our progress was today on these. So there we go. So a couple of things. For instance, there was five recommendations. So if you go to page, page number, page 15. And you go through it. So the first one was to develop a policy. So when we do investment manager search, we've required them all to come in with environmental, social and governance policies and risks around those and said that we recognize these and they would not be considered in isolation and would be part of our decision-making process. And we implemented a policy. Clean Yield helped me write the policy recommendation to the VPIC and the VPIC adopted that. So we did a good job on that one. If you go to, and you see a series of entries in here. So if you see this on page 16, the ESG integration. So this is now something that any PC does when they're doing a manager selection search for us and they're looking at these issues and they're scoring them on these issues and providing a summary to us along with a package from the prospective manager of their, of how they integrated. So basically a review of that. You'll see that based on that, we've had a couple of things based on page 17.  It's called Acadian and they work with us and they put in, they essentially put in the presumption there will be a carbon tax into their model, looking forward. And what they do is they essentially are decarbonizing by virtue of that. So that what they're looking at is putting more of an emphasis on that by virtue of that they pick up more firms that are energy friendly to be very candid. And if you see that they've reported some improvement in our portfolio, but then because of that. If you also see- I'm sorry, I'm sorry, Trevor. Are you watching on that? Can you go over that? Sure. So we'll back the page 17. So you see that Acadian applies, what they do is when they're looking at a company, they assume in the metrics a carbon tax. And when they do that, it's gonna be the potential to a more of a low carbon economy. If you look at the end of that, we asked them, how are we doing? And they said, according to the benchmarks and where we are, our combined, we've reduced certain benchmarks in terms of our energy, our carbon footprint. So there's measurable results. Okay. It's the short answer that because we are invested in mutual funds in commingled funds, we are not out there alone buying. We are buying in mutual funds, which is the safe thing to do. That we went out with all the environmental, the major environmental groups, including Be Perg and the Sierra Club, chose a consultant to help us evaluate where we were, what we were doing. And we have $9 million is a lot of money to take out. And again, that's my memory of it, but it's in my range. But it was millions, right? That there were some fiduciary concerns with that. And what we are doing now is we are working to, as we make new purchases, move ourselves in to greener investments. The last part about purchases, we don't purchase directly, we buy the managers, we contract with the managers and they make the purchases. So we don't make individual investment selections. But I would say that they are greener in their approach. We are asked our investment managers to be greener in their approach to where we invest our costs. One of the things that we did in here, so we have a five point plan to lower our carbon footprint to be citizens there. And they're all listed in here, the progress in all of them. One of them is not so much progress, but four out of five I think we've done a very good job. And the other thing that you should look at is on page 55. We asked each manager to give us their position on energy issues, climate change, how they're making that into their investment process. And I would recommend saying to you that divesting that save $100 million from somebody when they have $20 billion of investments or $100 billion investments. If you can move the company to think about this, rather than divest your 100 million, you make a great deal of progress. Now, what we get is sugar. I've heard you say that for years. And that we can petition fossil fuel industry to be a better. Is a complete slap in the face of the science which recognizes that you've got to leave it in the grant. There's a reason for that campaign. You cannot keep burning it, burn it or gently. The goal is not to have Exxon Gold will be more responsible is to shut them down. And what I don't understand is that is the, you know, coal, are we still investing in coal? Not to my knowledge. The, what's the big one called, the index fund? Well, the big one that we can specify. You have a term for it, the coal mingled fund. None of those are coal. I don't know what's in the coal mingled funds. We don't have any investments. So direct investments in any coal, to my knowledge. Right, you've done a nice job with our direct investments. But the coal mingled fund is the bulk. Coal, as they've been going out of business, cited in its reasons, this works. And what I don't understand is how our analysis is different from the Rockefellers. It's pretty ironic. They've divested from the Catholic Church, from Remount and Power, from university, from the Cal Retirement System, the University of California, from Harvard, from New York City's, that's the country of Ireland's message.  Why is our analysis so different? Why do we face roadblocks that these other people have either figured out how to get over or just have they just shrugged off losing 9 million bucks a year? I find that really hard to believe. So what I would say to you is that I understand the coal industry. And when we had a piece of coal of an investment, we talked to those folks and said, why? And we went through that process with them. And in one case, there was a company that was transitioning out of coal and we stayed with them. It's not real, how to say this, it's not, there's some gray areas and let me be very, so I'll take TA to tell investments in France. They're on the dirty carbon list or they have been. And they own 60% of a solar company. And when that solar company, and by the way, one of the vendors in the state uses their product. When that solar company was in trouble during 12, when the market wasn't, I think it was 2012, they gave them a billion dollars of cheap financing. So, you know, what do we say to tell? You know, in the process. So I think there's some issues there. I am not convinced, I am not convinced that giving up that your shares is going to cause divestment of the fossil fuel industry. Number one, and number two, when I give up those, I think I'm walking away from the table and I'm saying, it's your problem. Go forth and I've left it and somebody else is gonna buy it and they're not gonna be as activist as we are. And I think that's a mistake. I think you're walking away from the problem. I think that divestment is the easy way out and not the strong way out. And you know, by virtue, we're talking to the agencies, we're working, I mean, the investment managers, we're working the problem. And I think that when you walk away- What's the endpoint for ExxonMobil? Where do we convince them to go? Okay, they're doing research. You don't watch TV. Well, I'm not gonna get into it. Don't you watch the lawsuits? They're, they are, they're a back-up of, you know, we didn't decide, we would play nice with tobacco, see if we could, they cost cancer and now they've been spending- I hate to bring this up, but- Millions of millions of dollars- But what happened with tobacco was that the VPIC did an analysis of the cost and made the determination. That's called procedural prudence. They do their job. We did our job with procedural prudence and substantive prudence means that you followed the results of that. We had somebody independent of my office do this. Somebody that deep earned, somebody that the Sierra Club- I remember the process. And yet other people who have a similar new share of responsibility arrive at a different conclusion. Divestment was very effective in South Africa. That's the last time the legislature stuck its fingers in a domestic way. I would argue also that New York State has not digested. Others have no