So today, thank you very much for coming in and we've decided to do a little bit different approach this week An opportunity to get into a deeper dive with our experts our health care experts here with the state I want to thank secretary govay and his team for participating So we want to talk about health care reform efforts thus far and to present some very very preliminary and I want to repeat very preliminary observations on our 2017 Medicaid pilot which was built around the accountable care model So Al and his team have been working on health care Reform longer than I've been in office at least this office the governor's office Towards the end of the previous administration Their efforts had come around and led them to what is now known as the Altaire model As many of you may recall I was a bit apprehensive at that time and question I was new into the office and question how this would affect our Vermonters experience how would it address costs and how What Vermont's health care providers would think about this and so I was cautious and appropriately so Because after our experience with single-payer it was important to have answers to those questions Before declaring it the answer so one of the One of the very first briefings I had when I took office was from the group here today advocating for a pilot project between Vermont's Medicaid program and one care an accountable care organization the concept which is similar to the all-payer model is to pay providers participating In a set amount for the care of a distinct population So in February of 2017 Secretary go Bay and I announced this pilot would be taking place and as I said then We'd be monitoring its progress and that's why we're here today to share some of the results From this program's first year It's important again to note This is preliminary This is one year of data We can't call it a trend by any means But it does give me and the team here today some additional confidence Around the direction of health care reform and the all-payer model So with that at this point I'd like to turn it over to secretary go Bay who will be detailed the scope of the challenge And as well how the all-payer model can help address some of those issues. Thank you so first I want to Recognize Vicki who's in the audience from one care and say thank you for being here today Representing one care the ACO that's a part of this Just to take a step back The question comes up all the time What what was the purpose of the all-payer model? What was the thinking behind the all-payer model? What is the problem that we're trying to solve and how are we doing looking at it today and into the future and so What I would like to do is say that I think about health care in three buckets The first is how we collect the money The second is how we pay for goods and services and the third is how we deliver the care And it's important to understand the three buckets and how they relate to each other in terms of our current system And in terms of the reforms that we're trying to make So when we think about how we collect the money It's important to understand that that's done through a lot of different entities Medicare Medicaid and a whole host of commercial payers within the state And then when we move to the payment bucket they all pay in a in a myriad of different ways For the goods and services in health care and then providers respond by delivering that care in Varied ways based on the payment or based on Current science or both What the all-payer model tries to do is address some of the problems that we see in health care But before I talk about problems I want to also say that Vermont is a great place to live and get care We've been considered to be one of the best places to have You know to live due to health Outcomes and the quality of our providers and so when we talk about What problems are we trying to solve in health care? It is not to say Criticism to our provider community or the care that's being delivered to Vermonters. It's to say Health care currently grows at about two to three times the rate of inflation And that's over a long period and that is not sustainable the second point I'd make is that Care is typically delivered in Vermont and in the United States in an uncoordinated way and third It's important to understand that across payers There's different ways in which the care is delivered That doesn't lead to the best health For all concerned so basically I'm saying we think there's room to improve How fast health care costs grow? We think there's room to improve how well care is coordinated and we think there's room to improve health outcomes for Vermonters and when you look at the information we have before us You're going to see that that's happening in the document. We've provided under the Medicaid pilot But it's also happening at the federal level under ACO's What I'm going to do now is I'm going to turn to Ina Bacchus who's the director of health care reform And she's going to make some comments on where we're at today Vermont's all-payer model is a model that's based on Medicare's next generation ACO program and that's a program that's been in place prior to Vermont's all-payer model The model that Vermont has is a six-year agreement between Vermont and the federal government That allows for Medicare to participate with Vermont in a specific Vermont payment reform To pay health care providers differently The agreement is six years, but it's measured by five performance years 20 2018 marks the first performance year for the all-payer model Agreements between Vermont and the federal government However, we're here today to talk about 2017 results for Vermont's Medicaid program, which actually went first in implementing the alternative payment model arrangement Similarly, Medicare has been operating as I said its own next generation ACO program And it has recently received released results from 2016 that indicate promising early results for Medicare ACOs that are participating in the next generation from Program those ACOs have been able to maintain quality while generating savings for the Medicare program touching quickly back to 2018 and how the model has been implemented to date a 112,000 Vermonters are part of the Medicare all-payer model. Excuse me Of those 112,000 Vermonters Three major payer groups are participating Medicare Medicaid and commercial payers That's what brings together the all-payer model is participation across the different payer groups That means the incentives are aligned and the payment change is more uniform across the payer groups Self-funded commercial payers are also participating in the model the network includes hospitals primary care providers specialists FQHC's skilled nursing facilities Home health providers designated agencies and area agencies on aging all working together as a part of the Campbell care Organization one care Vermont that is the organization in this state that can accept this alternative payment model so I'm going to step in here and talk a little bit about Give it a little context for those of you that don't follow health care on a daily basis which We're in the weeds on a daily basis, but Diva Department of Vermont health access for the record identifying yourself Corey Gustafson and the commissioner of the Department of around health access and We are the state's publicly funded health care plan and so on a you know our fundamental responsibilities are to determine eligibility of Vermonters that apply to our programs and Enroll them in those programs and role providers in programs and then when the two come together We pay for that that have those health care services and just for the sort of financial context He we pay for over a billion dollars in health care services annually on behalf of our members and so this is obviously a big part of the The state's expenditures, and so it is important that we are continuously evaluating how We do things and this is a little bit of a next step given that context too. I think the other thing. It's important to Think about and recognizes that for Mon has been a leader. We've been leaders in in examining how we Interact with the health care system and how our members experience health care system I think the best example is probably the blueprint for health You know going all the way back to the the original 1115 waiver not flexibility that the federal government gave us to Cover services in a different way Has has led to some pretty significant forward progress and coordination of care, which is one of the issues. We're trying to can to continue to address and so I think in most recently the blueprint the hub and spoke miles another great example, so six years ago state of Vermont looked at the opioid epidemic and and determined that it needed to Address it in a systematic fashion that covered all parts of the state We have now done that and as recently as yesterday the human services secretary made note that MAT Medicaid assisted treatment, which the hub and spoke Provides to Vermonters is the gold standard and so to us the ACO program this effort is a is another Example of Vermont being on a leading edge of health care reform and so it's early and this is as he has said It's early in the process we today have some results to share with you as the governor said and You know from my perspective as the diva commissioner You know at the beginning. I'm a little bit like the coach and a background in sports And I'm thinking who's the best team for to address to take on this this project and so Early on the the the goal was to identify a team Michael Casa deputy commissioner diva is is Lead on it along with Alicia Cooper who is the director of our healthcare excuse me our payment reform team at diva and so The team was identified The next modest goal was to stand the program up There's definitive changes that need to be made and how we do things and how we pay for For services and how we track and measure spending some there were some clinical changes So in the in in the time between identifying the team and executing To today's date and having results for the 2017 year that team has has Basically on a daily basis thought about this and and step-by-step moved forward The last I think goal we had was to be patient and to not try to do everything On day one and so just take the problems as they come We knew there'd be things we didn't expect but we also knew that the the goal which was to address Fragmentate fragmentation in the system both on the provider side So lack of coordination among providers some duplication things that we've all heard about when we think about health care And this and the delivery system But there's also fragmentation on the payer side. We have multiple payers in our In our in our health that pay into our health care system and pay providers and the better alignment we can have The better experience. We think our members will be subject to as they have interactions with their providers and so Decreasing fragmentations one of the goals we've had we think we've started down that path The second is just the incentives of fee-for-service. I think the Secretary have mentioned the incentives of fee-for-service, but I'm say that the idea to remove If you do more you get more from the equation is is one of our fundamental goals And with greater revenue predictability our premise is if they we pay Prospectively to two providers they will have more flexibility to to address the health care needs of their their patients on the front end rather than Way till the back end and so they have more flexibility with the dollars they have through that perspective payment system and so I think we achieved our early goals our modest goals set up a team and and so on and Right now. We're here to talk about what the results of Of the first year are and I'm Michael's gonna kick us off with the With the basic results so as Commissioner Gusherson said that the leadership of the governor and the secretary Leadership As Commissioner Gusherson said with the leadership of the governor and secretary go babe They've said clearly what we want predictable sustainable and affordable health care costs while maintaining high quality and has challenged the department of Vermont health access to figure out how we do it While working with our ACO partner The report you have in front of you lays out our initial results from 2017 I think as the governor said it is far too early to call this a trend However, we've learned a few things through operating this program in 2017 number one We're capable of launching and operating the program successfully that required to focus on the fundamentals Can we pay differently giving health care providers a consistent capitated payment rather than paying them for each Service and test that they deliver Can we monitor quality and cost on an ongoing basis and can we analyze with those results? To learn things to improve the health care system on behalf of her monitors And so we think we've done that successfully at least for year one The second result is that the program is growing ACO based Reform is a coalition of the willing providers are not obligated to sign up They must choose to take part and serve for monitors in this way We began with four communities and around two thousand unique Medicaid providers in 2017 And that has grown to ten communities in 2018 and 13 communities. We believe in 2019 all while doubling the amount of providers participating Our third result is that the ACO program spent less than expected on health care in 2017 at the beginning of each year The Medicaid program and the ACO agree on a price for the health care of her monitors further the year 2017 that was approximately 82 million dollars and we believe that the ACO program spent approximately $2.4 million while caring for those for monitors the fourth of five results is that the ACO met most of its quality targets We have a score of 85% on our quality targets And an interesting story to tell there and Alicia Cooper our director of payment reform will get into the details a little more in a moment and then the fifth result is that Medicaid is seeing more use of primary care among people inside the ACO program as opposed to our beneficiaries who are outside the ACO program Again, this is just a first piece of data It is too early to call it a trend or to see whether it's statistically significant But it's a positive sign that the ACO program is allowing us to focus more on the relationship between for monitors and their primary care Doc as we think about how people get their care around the state at this point I would hand it over to Alicia Cooper. She and her team manage this Project on a daily basis as part of our payment reform team as we think about how to make more value based payments How to make sure we're paying for quality in the health care system Not just quantity and she's going to talk a little more about the financial results and the quality results Thank You Michael As Michael mentioned the agreed-upon price in the contract Represented what Medicaid believed it would have spent on the population of ACO attributed beneficiaries for the 2017 performance year the results showed that the ACO's actual spending was less than expected This is important because the model is changing provider flexibilities These flexibilities should allow providers to focus more on the kinds of services that keep for monitors healthy In order to really understand the program's effect on keeping for monitors healthy It's also important that we're monitoring and evaluating the quality of care and the utilization of services The quality results as Michael mentioned shows that for monitors are receiving high quality care in certain areas For example, the ACO showed performance that was above the national 75th percentile in diabetes control for this population of for monitors There was high performance in certain other areas as well The quality results also show opportunities for improvement the financial model puts Certain amount of incentive on providers focusing on quality as the program continues to evolve And so they will be areas where providers who are participating will keep paying attention and trying to improve as we have more years of program experience We also look at the services that for monitors have been receiving under this model And as Michael noted, we're seeing that for monitors who are part of the ACO population Are seeing more primary care utilization than for monitors outside of this model This is important because primary care providers can really help for monitors focus on staying well And when they need services, they can help them get those services in a coordinated way so that's Basically what we have to say we don't like to open up to questions on what we've presented So what what is the bottom line here are for monitors in the ACO? saving money and Are they getting better care? So I think the the first thing we have to say Want to apologize for not saying it earlier. It's congratulations. Isn't that the first thing we have to say? So then to answer your question, I think that And I'll open it up to anybody and we're gonna have to play a little microphone game here I think that this is one year and it's the beginning of an all-payer model and it's only one pair and It's only some of the providers and so when we're While we're cautiously optimistic about all this we want to be clear on what it is it's year zero just Medicaid and so you know the question you're asking is, you know, did it save money well When you set a prospective payment and you do the actuarial work to say is this what we think we're gonna spend on this You make the assumption that that's right and that's what you would have paid and so The answers It it was predictable payment. It's not about necessarily Saving money you want to fund it properly that the second thing I'd make at the point I'd make is that when it comes to quality in this model I Remember the moment at the Green Mountain care board where we saw the first quality results from the all-payer shared savings Which is not the same type of restructure as this where one of the doctors involved said this is the first time we could measure anything You know and that was only a few short years ago, and so these quality measures in here are really important and Having data on them long-tutedly it's going to be incredibly important to judging The efficiency of the system and and how well it does but do you does anyone want to add to? I'm just going to add as well I think it is going to take time To prove this out because when you look at what the the premise about the all-payer model is is Part of his prevention Trying to treat the patient holistically and look for areas of opportunity to do so so that you're not just paying fee for service You're paying for keeping the patient healthy So this may take a while to prove itself out is my point And it won't be in the first year may not be in the second year It could be years from now when we'll see the true benefit of this So again if we can save money along the way, it's all good But and an essential but it's the quality of care that we're giving in the for the future I think that is really I'm most enthusiastic about because in every regard whether we're talking about whether we're talking about Health care or we're talking about any other initiative with the opioid epidemic and so forth. It's about prevention So we need to continue to focus on that Al. How do you? Ensure that the savings are not that people are being denied care or not receiving the care that they should be getting So, you know, that's where the measures come in You know, in other words, if you just said we're going to change the way we pay, but we're not going to measure Anything at all you, you know, then you could say that that might happen Do you want to talk about what some of the measures are that would speak directly to this? Sure Thank you So thank you That's a great question and I think that gets back to the earlier point of the importance of monitoring both quality performance and the Utilization of services in order to make sure that Beneficiaries are still receiving services in a way that is comparable to how they had previously We look at utilization of primary care services in addition to utilization of emergency departments inpatient stays High-cost services like radiology Keeping an eye on all of that to understand how practice is changing when the financial incentives are changing Based on the first year of experience. We have not seen significant enough differences in Certain areas to be able to say what is driving some of these reductions Relative to what the extent expected expenditure was We also look at quality as the secretary noted. We have measures that relate to primary care utilization We have measures relating to screenings. We have measures related to The treatment of more chronic conditions So all of these give us additional lenses into the care that the population is receiving in order for performance to be Good on those measures the utilization of services has to be occurring So the the 2.4 million less that was spent in 2017 calendar year That now goes back to the providers that were in that Medicaid pilot So the program sets the price Upfront with the ECO in this case that was 82 million dollars It gets paid to the ECO and then the ECO has Agreements with its provider network about what happens if money is saved and it goes It's my understanding that money will float back to providers that system But one of the key things to know about ECO based reform is that the state is in the position of saying what it wants Particularly regarding predictable sustainable costs and high quality But it's up to the health care community through the ECO to figure out how to do it And that's how they do the savings in the program But the bottom line is the whoever the providers that were participating in 2017 in this pilot will get to sort of figure out collectively how to Yes, divvy up the savings. That's correct. And then so 2017 was Medicaid alone 2018 calendar year. It's expanded to commercial and Medicare. Does anything have you seen anything translate from that? 2017 pilot to 2018 thus far that tells you the expansion was a good step We'll know about 2018 at about this time next year Now, do you have any? feedback from from others who participated about any differences that they felt being part of this Was it more satisfactory? In some way or was it completely transparent nothing that the patients know this So I would I would turn to the team here. I Answer that So one of the things that we monitor are the calls that Both Medicaid and one care receive from the beneficiaries who are part of the model to see if they have Questions or concerns about any particular parts of their experience with care In the first year of the program, there were relatively few calls That were related to concerns or complaints I think on the whole since Approximately 29,000 Medicaid beneficiaries were impacted by the model that reflects that relatively few were having Differences in their experience of care that were adverse in terms of monitoring the experience of care in future We are trying to identify additional ways of understanding the experience of care so that we can not just be looking at Whether providers have whether whether beneficiaries have concerns But also look at what some of their more direct experiences are and how those experiences compare to individuals who are not part of the model and if I could just add I think Obviously, you know the patient perspective is the single most important perspective But I also think in this model because it takes willing primary care providers to sign up to grow and build an ACO What what I've been looking at is, you know are The roles growing or are the roles shrinking and so as we've come into 2018 as we've seen additional Folks come on to the program it gives me Sort of the feedback I need from the provider community that it's going according to plan as the scale increases And so I think that's also something we have to judge over time isn't it as a key indicator this sheet from CMS from 2016 notes that the number of beneficiaries per ACO ranges from 8,200 to about 65,500 in 2018 We now have 110 in our program does that make us one of the biggest in the country out of these projects right now Yes She is for excuse me for just Medicare. We have 112 across all pairs So these are just Medicare. Yes, so you could see we have about 39,000 Medicare beneficiaries in Vermont But today's data Reflects the experience of 29,000 Vermonters in Medicaid in 2017 How do you know that the quality measure? Data is accurate. I mean maybe this is a dumb question, but if the providers have a financial stake in those numbers being Good Yes, that's an excellent question the majority of the measures are calculated by looking at Medical claims data and the calculations are performed by an independent third-party analytics vendor a number of the measures also rely on clinical information information that doctors offices will have and one care works with its provider network to collect the information from those clinical records to support the Reporting on those quality measures. So some of the information is coming from providers But it's collected in a very standardized way with the set methodology And some of the information is coming from a third party that is separate from the provider So it's not strictly provider reported Are there any particular soft spots in the report things where you would like to see things go better in the next year? It's all good Well, I mean, I think the first thing is that our reaction isn't that it's all good I mean, I think our reaction is that And I think it's most people's reaction that that we have a lot of work to do on health care We have a lot of work to do on Access affordability You know distribution of resources in the health care system. I mean, there's none of us that think that this advancement is the final result we you know the Cori's point this is a an evolutionary step in a Lengthy process of Vermont being a leader in reforming its health care system It is not a boil the ocean idea that is fixing every problem That could be written down in the health care system. So this is focusing again on payment and delivery 86 cents on every dollar of health care goes toward chronic conditions This is an attempt to deliver health care in a way that addresses chronic conditions in a more coordinated way But it certainly doesn't fix all the problems of how we collect the money How all of health care is paid for or any delivery issues that anyone would run into so again, it's it's a You know for us, it's a huge deal. I don't want to Undercut it the team has done an amazing job. I can't say enough good things about them, but it is an incremental step governor, would you say you've gone from Skeptic to believer in this system I'm cautiously optimistic at this time with the results that we've seen over the last year But as I said, this this doesn't make a trend I'm looking forward to what it's going to say next year Because as we all know health care is difficult if it was easy to solve We would have done it long before now and it would have been accomplished by Throughout throughout the country in some way. So we want to do this in an incremental way We need to prove to Vermonters that we we can we can prove that we're making gains on this And we're willing to do the hard work in order to do it You can't just declare victory and say that we've we've solved it We have to prove this and and I think that the we're doing that as we speak Another report from the remitant care board shows that the ACO isn't meeting its scale targets for either Medicare or all payer The number of treated people in the system. How concerning is that to you as a state tries to me as overall goals with CMS? Yeah, so I'm not concerned about it at this point Because my main concern and and I said this when I was chair of the Greenmont care board was getting too much scale too soon the first thing we had to be able to do as a state was Talk Michael Costa and Corey and Alicia into doing their jobs Because they are so talented to change the way that Medicaid paid was such an operational risk I cannot state that enough and working on the measure such an operational risk to prove that we could do that to the provider community and To the patient community, you know in this room, you know that this report confirms that we did it Until we got to this point We we couldn't say we needed more scale. We needed to know that this it's incremental We need to know that this was working now. We'll work on scale We still have a lot of work to do in the way. We're doing this so does Medicare so does commercial You know every you know, you know the boss is sitting to my left You know, he's looking at this and saying prove it to me every single step of the way that this is working And is the right thing to do and if not We'll have a bad day. And so Saying that you want scale too early Would not be a good thing that said we still have to if we're going to do the five-year agreement get there And so that will be a priority, but it wasn't the first priority So were those initial scale targets too ambitious then? Because there's no punitive impact of them, you know, I just said you know when I when we were when we were looking at doing them it was a guess and You know the key thing CMS was saying to us at the time was don't grow too big too fast Get this right in every step and we'll talk about it. And so if we don't make them We've got to have a conversation with them, but it's not going to be a antagonistic one because their number one priority was that this was done well, so it didn't It didn't collapse under its own weight. And so I would prefer to be where we are with the scale issue that have it be the opposite way So that's about attractiveness, you know, so if we're going to go to To folks and say that's a good idea We have to again have done it all well to get to the point where we can say hey, this is attractive I would say that to any self-insured plan that was looking at it but with the way that it's going and the predictability of the trend and If we can actually show that it's improving health outcomes, then it will be attractive and it won't take Any force or any? Cajoling it'll just it'll be something that folks will want to do and that would be a goal We're not at that point at this point time that's right, but you know who knows in the future again if we can prove ourselves and Be more attractive, then they'll come that they'll want to be a part of it is Saving two and two point four million eighty two million dollar bill that'll 2.4 million is a lot to me But I mean were you this price So When we said we were going to go forward with this my conversation with dr. John Bromstead was You know if we end up 3% up or 3% down somewhere in there Is it is it worth it to do all the learning to build all this so it works? And his point was yes So he was willing to take the risk if he you know if it went the other way We were willing to take the risk if it went this way to get it stood up to see if the machinery could actually operate So to me it's not about the money because I actually don't think the way to look at it is that that's a savings It's that we paid what we thought it was going to cost and then providers Actually operated different differently when that happens you can't say what would have occurred in an alternative universe It's just you've changed the incentives so you've changed the behavior so you've changed the outcome Yeah, I want to reiterate it isn't just about the savings right now in this year next year the following year Which they're important, but it's the outlying years, you know with prevention and the way we're delivering health care We could save significant amounts of money if we do this right 10 years from now 15 years from now 20 years from now and and people will be healthier as a result Does anyone have what the the 82 million what the per person cost was based on that number and then what the reality was If we don't have it here, we can get it for you. Yeah, absolutely. We have it Yeah, but by the way this all this math was done by an actuarial firm for For HS and it was vetted by the Greenmont care board and their actuary so it's done through a through a two-step process to get to these numbers We have I don't know if this Jives with what people are talking about today, but we do have a shortage of primary care doctors in the state And it seems to be trending in the wrong direction. We've got a lot of old primary care doctors in the state Does this program bump up against that harsh reality at some point? So it would be my hope so first of all I don't disagree with your point But I would say that I believe we have the highest per capita amount of primary care in the country I'd want to verify for number one or number two, but it's pretty high And so we're not happy with where it is, but I wouldn't want to give Ramoners the feeling that we're number 50 And so but to your point we're all getting a day older every day And primary care is a pivotal pivotal to this my hope is that if you change the Payment methodology and you change the incentives and you change the way primary care is delivered We'll actually be a place that primary care physicians again are attracted to and want to come Because they won't be trapped in the 15-minute office visit turnstile that they will be everywhere else And so if this works again at this incremental step I'm hoping it also helps workforce because you're not wrong Well, and we should mention as well This is across the board in every sector. We have workforce challenges We have a shortage of people in this state And that's part of the overall goal to focus on workforce development and attracting more people to state in any way We can and and in this area. It's it's no exception different subject sure One And where are you from? Yeah, what do you represent Jason gives? You know, this is an incremental process and I know we had talked previously about why that that's a Delivered it deliberate choice and why that approach is valuable doing that sort of incremental change Sure No, so I mean so let me explain why I think incremental is important I would also say that you should ask providers why it is as well. So Changing the incentives and putting providers at risk You should not do that all at once in giant dollar amounts. I mean when you look at the health care Spend in the state of Vermont all in six billion dollars But just the hospitals over two billion you said hey, we're just going to change the way we pay and put you all at risk Boy, that could be a financial nightmare Which would actually hurt people doing it in small ways and so that folks can learn how the payments change How the incentives change and then change the care delivery model to make that work is really hard work Dr. Fred Niffin said at a meeting I was at Four weeks ago. Hey Al what you did with your team with the all-payer model, you know That you know, that was really important, but we have the hard work to do We have to go out and actually change the way we're delivering care and the way that we're coordinating communicating across providers and also get patients to behave differently so that they interact with the health care system differently, so Incremental is the only reasonable way to do this for a bunch of reasons But the financial one is the one that would scare me the most if you went too big too fast So governor today the health department came out with a water quality report that showed it was a pilot of 16 schools water quality for lead and showed that all 16 schools had levels that exceeded what the health department felt were Acceptable and safe levels and and they said every school in the state should be tested But I'm not sure they addressed how that was going to be paid for Do you do you accept that conclusion that every school should be tested and is that something the state will pay for? I accept that we have a responsibility to test every school for water quality in terms of what what our children Injusting and we'll figure out how to pay for it But but I agree that we should be we have to pay attention to that the health risk is dramatic Sure, so let me just add this that That when you look at the pilot program, you're correct identified 16 But the cost to remediate was between $250 and $500 per school And so when you look at the benefit to the cost, I think this is just something that just has to happen So it's money, but it's not you know, I wouldn't want to leave people thinking it's an incredible amount of money per school Well, is it the state's responsibility to I mean who's going to pay for this I Mean you have to pay for the testing itself, right? Sure, which is about a thousand to twelve hundred dollars Right. I mean, I just want to give scale to this because it's not you know Five hundred thousand dollars per school or something because I think people when we first started talking about I think people thought It was a huge number to like re-pipe and re-plum entire schools I just don't want anyone to leave with that on their mind So it's it's not an incredible amount of money per school But it's an incredibly important thing and as the governor said we'll we'll figure that out Do you accept that it is a state responsibility to pay for? Well, it's a society issue and so Regardless of who pays and we'll have discussions about who will pay for that At the at the end of the day We're going to get it done in some way and if the state has to do it. We'll do it But but as well we'll look for other resources Now that the deal has been finalized. How do you feel about the move of the inmates to? Mississippi particularly given that the facility that they're going to be moved to has Arguably questionable record when it comes to health care for inmates. Well, again, I think the good news is under the The previous agreement with Pennsylvania. We didn't have a lot of control Once we once we sent some of the prison population to Pennsylvania. It was under there under their system Dealing with with an outside contractor private contractor. We're able to make that contractual relationship work for us and and our offenders as well, so I I believe this will prove to be a better deal a better situation For the offenders and for the state some Democrats are calling a for-profit contract Well, this is you know, this is the fourth administration this wasn't started by a Republican this was started by Governor Dean and so Governor Dean and Con Hogan as a matter of fact and they sent there was a Number Greater number over the years than we have today We want I would like to see all the offenders housed in Vermont But that's going to take some change and we're going to be started that conversation last year We'll continue it to this year But but it can't happen overnight and I think you'll find some Democrats who would agree That this is our only Alternative at this point. We can't we can't do it overnight without jeopardizing the safety of our monitors and and and Just turning everything on its head. So you don't think that I think immoral. I don't see anything immoral about it Do you have any concerns about it? Well, there's always a concern in every situation whether it was in Michigan or Pennsylvania or Kansas And now Mississippi, of course we have concerns. We'll continue to monitor this We take we don't take this lightly and we don't take the move lightly But but again at the end of the day, we have to do what's fiscally responsible as well as What's what's Responsible for us under under the Department of Corrections Vermont's prison population has been declining over recent years and the out-of-state number has been declining as well I was wondering governor if there's any Particular initiative that you have in mind that you would support to further reduce the prison population whether it's You know reform on the front end or reforms in terms of when people can be released So uh in uh Last year's budget Most recently passed budget. There's seven million dollars for juvenile justice reform It's not juvenile justice that would not be in corrections It's actually goes up in years into the correctional population and so with that money the thought is how can you um Reform the correctional system Uh, you know to to improve all of these outcomes. So the question is what impact would that have I think there'll be a lot of talk about reform of cash bail But that's a criminal justice reform not a correction You know the the secretary of the h.s. And the commissioner corrections are not gonna You're not going to do that kind of do that kind of work. It's not our it's not our thing That's truly criminal justice. I think also though I would caution everyone to take a look at the prison population and who's in it in terms of why they were Incarcerated and look at who left over since 2007. It tells an amazing story of mr. Meaners No longer Extended time in corrections and being left with basically a felony Population and so how you lower that number from here Gets difficult and is a case by case individual by individual hard topic And so to underscore that I mean those some of those Situations the easier situations have been dealt with over the last Two or three years Or more to come to this this lower number and now those those they're felons Basically a lot of felons that are that are currently being Housed in some of the out-of-state populations. So it does get more difficult and I don't mind having the conversation But the public safety is the highest priority from my standpoint and and some some are Incarcerated for good reason governor. Do you believe that vermont is incarcerating people right now? That either shouldn't be incarcerated or don't need to be incarcerated Well, again, that's a policy question that we should we should debate I would repeat that I think some of those situations have already been dealt with over the last Two or three years and And some of those most I would say the majority of them now Are convicted felons. So I I'm I'm not sure that Those easier situations are there to deal with but we'll take a look And I would also add if you if you look at the facility report that we did last year That we still stand behind some people have written that we pulled it back or that we you know pan You know a candid or something, you know, we didn't we pushed that for every thing I pushed that for every single day of the lab slave session You know, I'll push it again today if they come back today But if you look at it, it wasn't a giant facility It was a bunch of small facilities to address particular needs You know, we need a new women's correctional facility if you don't think we do Let's go meet at the chitin county correctional facility We need better mental health group home like facilities and corrections Because we don't have that now. We're trying to build it in some of the facilities It's not the right answer. We need better a da compliant facilities and corrections We don't have those and so there's a long way we need to go in terms of rehabilitative and therapeutic Facilities for the department of corrections that would that we're in that report that need to be looked at again as well as transitional housing Sure, because that's uh That is proven to be Very difficult to accomplish But is necessary for those who are returning to normal life There is no Recidivism at that point. You're not discouraged with the reception that the Prison campus plan received at the state assets seem to get a lot of people thought it was a terrible idea Everyone thought the all-pair model was a terrible idea five years ago. I mean like this is the way it works You know you have to put out ideas Suffer the slings and arrows Stick to your knitting and keep trying to move forward I believe that that folks are beginning to see this differently that they're beginning to say Hey, maybe we need to take a look at why we put people out of state. We've done it for 20 years Maybe we need to look at this and say is this what we want to be doing You can't blame the commission the commissioner of corrections For something we've done for 20 years as a choice by the people of ramon You have to look at it as a choice by everyone and so if we don't like that choice change it So it was a bad idea last year, but it might be a good idea Again, I think you should Focus on as well why they thought it was a bad idea May have not been the the campus type approach There was a variety of reasons. They thought it was bad so Those can all be rectified. I mean, this is just the plan And when you get into the details and and I would say that some who may have disagreed with that approach Might by degree with us in saying we need to bring that out of state population home We want them to be housed in vermont. Well to do that We're going to have to find another approach because we have outdated Prisons at this point that needed need to be replaced correctional facilities So we're willing to have that conversation. So is the administration going to pitch another Proposal to increase capacity in the criminal justice system in the next legislative session We are going to continue to talk about the the plan that we put forward And we're willing to have the conversations about how we can make it more enticing and better for legislative Buy-in so you're going to work with the same plan Well, I mean there's a it's again. It's just a a plan It's just that a goal and if we can figure out what the goals we want to accomplish Then we can we can work with within those constraints. So I'm not I'm optimistic that we'll we'll come together on something governor.  Um, well you find out on october 2nd Uh, is is the republican candidate peter briggs being invited? Uh, I am not aware of who's invited to that event. Okay, should he be? I mean, he's he's a fellow republican Again, I'm not sure who's invited to the event at this point Your thoughts about the parent resolution to the Long-running nurses dispute again I think it's good news that there is resolution We can move forward at this point for all those involved for the nurses as well as the The administration of the hospital. So We need to it's it's long overdue Can we can we afford the the last best offer was upped last night to a better last last best offer? Is that something we can afford? Well, I did you know I cost increase in costs are an issue for us the affordability of vermont is something that That I talk a lot about At this point, we're going to have to so we'll have to figure it out, but Anytime that the costs are increased. It's a problem for us in attracting more people to the state One more question. Do you think the republican party your party is handling appropriately? The accusations leveled by professor blasey forward Against a supreme court nominee alleging sexual assault I can only tell you how I feel and I believe this is a lifetime appointment I would advocate That they should take the time necessary to make sure they get it right And and I believe that this should be Thoroughly thoroughly looked at so that we don't make any mistakes Does that mean you favor the idea of having the FBI do an investigation? I I'm just saying that it's in the senate's hands at this point But if they asked my advice, I would take the time necessary whether that's and in any way they think is they deem Possible to make sure that they're doing this and making sure justice is served And that everyone is treated fairly. So I think we should We should take the take our time lifetime appointment. This is the accusations I have to believe that they are I don't But but I'm not the I'm not the judge of that and I believe that they that's why they should take the time necessary To to to fully contemplate that. Thank you very much. Appreciate it. Thank you all