Welcome back. This is the Task Force on Affordable, Accessible Health Care, Representative Lippert and I are Senator Lyons. Our co-chairs and we are very happy to have Mike Fisher, our Chief Health Care Advocate with us this afternoon. Mike, thank you for being here. Good afternoon. Good to be here. Do you want to share with us what it is that your office is doing? Sure. Yeah, so I'm Mike Fisher. I'm the Chief Health Care Advocate, a position that defines state statute. And before I and I do came here prepared to talk about a project that we're in the middle of, really to give you an update about it, a medical debt storytelling project. It really is very well timed for the conversation you are in for the purpose of this committee. But before I started, I guess I just wanted to make a high level comment. I've been a student of the challenge of how to bring consumer voices to the legislative table appropriately for a long time. And there's no really good, easy answer to it.  And so I guess I wanted to sort of recognize this moment, recognize the challenges that your committee has with five meetings to find the limitations, the very clear limitations of that. And I think, you know, part of my statute is to bring consumer voices forward. And that's what I'm doing here today. It's not a replacement for real life human people. But it is a step in the right direction, I think. So I appreciate your thinking about that. Yeah. So I will go ahead and share my screen and get it on the right mode. I hope I've turned off all of the messaging services so that you don't see my advocates who are sitting in a hospital budget hearing at this moment and maybe chatting about it. I do have paper copies of this if anybody would like one. I would. Why don't we all take one? Yes, we do have it on our iPad. I want to introduce on Zoom is Meg Palete, who you all know as former Chief of Staff for Governor Ackerman, who is working with us on this project. And to the Chief of Staff for specific questions about what's going on, I'll call on Meg and may call on Meg to say a little bit about her experience in getting to know this subject issue because she has sort of fresh eyes. Here's my agenda for the day. Be straightforward. I want to stop sharing. Can you give me just a minute? I apologize. I have the wrong one pulled up. I recognize that person on Zoom. Welcome, Meg. Good to see you. Hi, everybody. Thank you for this hard work that you're doing. It's wonderful to be here on a screen. I wish I was there with you. Next time. All right. I'm going to have to do it this way. All right. I need to get back to... Is it something Charlie can help with? I think I'm there. Your screen. Apologies. It's maybe not as good as it could have been, but it's what I got. So let me just recognize the pictures, the people on slide two. I'm not alone. I have a whole team behind me. People who are working on... Who are part of my... Who are answering the phone, answering questions, and who are... And I also have to recognize, as I look at this picture, how outdated it is. We haven't been in person for a little while. A little shameless promotion. The HCA helpline is open. This is one of my advocates, Annalee. She is not in a cubicle in Burlington in the North and of Burlington. She is at home at the moment, but working just the same. We're available and people are reaching out to us today, like every day. Are there people at the office in Burlington? A few. Yeah. A few. So what do we know about medical data? Nationally, just last month, JAMA produced a new analysis that found that there was $140 billion unpaid medical bills that were at collection agencies. Here in Vermont, in 2019, the hospitals reported to the Green Mountain Care Board that there was $85 million of consumer bad debt that had been uncollected. The 2020 data, I do have the 2020 data. I didn't put it on here. It ticked down a touch, $81 million or something. 2020 data you got when you're looking at what's going on in healthcare and probably everything, we're going to have to put a big asterisk next to 2020. As a percent of net patient revenue, it didn't tick down, but the actual number did. You talked a little bit about the health insurance survey earlier today. In the 2018 survey, it found 40 percent of volunteers who had commercial plans were underinsured. The survey is indeed about, I believe it's about to be finalized and to go out into the field shortly. We engaged as did others in the actual questions being asked this year. I think that it's been improved. I think there will be some questions that we'll get at a lot of what you guys have talked about today, important stuff. We have always gotten calls about medical debt to helpline and they fall broadly into two categories, calls for which we can do something about. The examples are so technical, somebody got coded wrong, any number of problems that can happen along the way that leads to a medical bill. Many of them we can do something about. Many of them we can't, either because they are too old, past the period of time where we can intervene, or because everything was done according to the law, the rules.  The medical debt storytelling project is, sort of runs along, it was inspired largely by what we saw at the helpline and what we've been hearing out in the field. But it is, there's no overlap between the medical debt storytelling project and our helpline work. We kept them at arm's length. The role that we play as an advocate for somebody and trying to help them solve their problems is really different than the role we're playing in collecting stories and presenting them to you. And it makes sense to us to just keep them separate. This is a non-representative survey, really clear. Any data I give you about who called us and what percentage of them are this or that or the other thing is just a recognition of the people who self-identified and called us. And we did take a lot of information about age and insurance status and race and income, residents, and more. And so we will be able to tell you something about who we're talking about. Welcome, Senator. Thank you for saying that. You beat me to it. Welcome, Senator. We understand. It's a healthcare issue. Sorry, sorry. That's okay. I interrupt it. I looked at the number just now. I think we're up to 1930 or some people have participated. Yes, Senator? Does someone have to speak English to take the survey? No, we do invite people to. We gave a phone number. We gave various ways so that we could respond to. Did you get any survey responses in other languages? Meg, were you able to hear that question? I don't believe so. I did hear the question. We did not get other responses specifically in other languages, but we definitely got responses from non-English speakers. I'm not sure if you'll see some examples in what Mike's going to present to you, but very clearly when people identified from other races and countries you could tell their English in their own words was they were struggling with the words to answer the questions. So verbal interview where there was limited English proficiency. Exactly. In addition, we did a little bit of a targeted outreach to try and make sure we had as diverse as we could a group of people who at least knew about the survey. A surprising number of people I just want to start recognizing we were blown away. We knew we were going to hear some horror stories and we knew we were going to hear some passionate stories, but I had no idea and I thought we'd get a couple dozen that we could sort of tell you. Here's what people are saying out there. To have almost 2,000 people respond. And certainly some people filled out the survey and gave us very little information, but many, many people gave us, spent a lot of time and really told us in their own words what's going on. And that's sort of the most important part of this. It is that it's an opportunity to advance people's voices so that let me just say there's two main goals that motivated us here. And I'm not sure exactly what the order is as I sit here right now. One of them is certainly to make sure policy makers know about this and to try and affect changes instead, changes that will reduce medical debt. And the other one is people live in isolation about this issue, embarrassed, feeling horrible about the dynamic. And we really wanted to do what we could to reduce the stigma. I think people feel a sense of individual blame about something that I would assert is a structural problem. It's not people's fault that they got sick. That's what we're talking about here. People got sick or had an accident, didn't have a Cadillac plan, afford a Cadillac plan, and therefore have medical debt. And I really want to send this clearer message. And we have some work to do. I'm going to ask your advice a little bit about how to do some of this. Really getting the work out, saying to people, hey, you're not alone and this is not your fault. This is really a structural problem. That does raise a question about how you emphasize the survey in the first place. And then so the next step will be letting people know some of the concerns that you have about reducing stigma and blame reduction. How did you get the survey out? So we did and make jump in where we did press releases everywhere we could. We approached every group we could think of that could get it out to their members. We did a paid ad on Front Forged Forum almost statewide. And we reached out to all of you legislators as well. And many of you shared it on social media and email newsletters and on Front Forged Forum yourself directly to your constituents. A relatively high number of people said that we could share their stories. That also surprised me. I expected a lot of people to say, I'll tell you, but I don't really want you to tell the details of my life. And 87 percent, we have a tremendous amount of work to do to get through this, coming ahead of my slides, to get through this and to develop the themes and to be able to make a summary and a report about it. It's just a slide to say it's still open, still open through the end of the month so people can participate still. The end of August. Yes. Thank you for the end of August. And this is I started to say this already. We have a great deal of work to do. I mean, for instance, the the race field, we decided in most sense to let it be a text field, not give people boxes they had back off. And so we now have the work of going through and defining that in a way that makes sense. That's interesting because my question was going to be, I mean, this is obviously very compelling. It's all qualitative. It's it's really hard to say we were we had a goal of getting 10 percent BIPOC participation in a survey because you have no idea and then making sure that you're properly categorizing people so you know if there's a disparity. Well, yes, you're right. There's two things I want to say. One of them is that we understood that even if we had X percent of the people who fed off the survey were BIPOC, that we wouldn't be able to set to extrapolate from there about the experience of BIPOC people in Vermont versus white people in Vermont. So that's one part of the answer. You still might set a goal to say we want to make sure this voice is we're understanding the unique stories from these voices. Yeah, I think all you're right. I think what we'll be able to do is report to you how much participation we had. And yeah, Meg, do you have anything to add on that point? I would I would just say you're correct. We knew from the get go that we weren't we weren't trying to get a representative story. We were trying to get stories to show show the picture. We did reach out to and this was shared by both of the NAACP chapters as well as migrant justice to their members in rural Vermont all touching some of the BIPOC groups in Vermont. But there's so much more and I think the language issue is huge and we just knew we didn't we we didn't have the resources in this project to do a survey that would take all of that into account, which would really have to be going out and reaching all people and asking them about their experience to put this into a category. But I can tell you for sure that in that race race ethnicity field, there's a wide variety of how people have self identified themselves from different countries to different regions to colors. So there's definitely stuff in there and we will be able to pull out at least what percentage we heard from using this tool, which was really primarily an online tool. So we offered people print, we offered people verbal, but most of the ways we were advertising it was through some form of online engagement. So we know we missed huge swaths of people. Yeah. And then I'll also remind you that the Household Health Insurance Survey is a representative survey. It's a high quality survey and it does have, I believe, though I haven't seen the final draft, I believe it will have medical debt question in it. And that may give a little bit more of an ability to understand how, you know, how does medical debt, how people across different groups in Vermont experience medical debt? Well, when you do an initial qualitative analysis, then it does help you identify places that are unclear or where the gaps are. So that could direct you in the future. But it could also direct you, as you said, to other surveys that are going on and where those gaps might be filled in. We've only gone through 400 surveys so far, a little bit in preparation for today's meeting. Again, we have close to 2,000 to do and we generally see them in these categories that I've listed here, access to health care, affordability, impact on daily life, surprise and corrections. And I want to also recognize my bias here. I and others are interested in the impacts of medical debt on people's ability to heat their homes or put gas in the car. That's really important. I'm most interested here in the impacts of medical debt on people's ability to care they need. So that's sort of the main question that I was really curious about. Again, I'll use that number $85 million in medical debt in 2019. What does that mean? I'm sorry, $85 million that hospitals recorded in 2019. Hospitals are about 40% of the health care system. And I don't think it would be correct to just multiply out to the other parts of the health care system, but medical debt is, but anyway, trying to get it to boil us down into real human stories. But when you do that, it also helps us to identify affordability because if people can't afford to heat their homes or feed their families, there's the cutoff. Yeah. I think, Senator, we talk a lot in health care reform about the right care at the right time. And I think the question, I think I know what happens to people when they owe their hospital or their provider, $5,000 or $10,000 or a high percentage of their income when they need to go to the doctor. I think I know what happens to people, but I really wanted to hear it in people's own words. Wrapped up in that a lot of these stories are about people foregoing care because someone else in their family needs it more. So it's not in the same vein for you. It is. And it's an interesting, thank you for saying that. It wasn't exactly on my mind when we asked the question that it wasn't just, of course, your own experience. It is people within your economic unit. If your husband is experienced, has a lot of medical data that impacts you or your kids. We wanted to demonstrate, we wanted to put some real words in front of you and wanted to demonstrate the state-wideness of this. And so we just won one quote from each county. And I'm just going to go ahead and make a decision. I'm going to read. Addison County. My wife has epilepsy and she prays every night she doesn't have a seizure because my insurance would not cover any of the costs. I was from a male 18 to 26 insured from Bennington. The premium for my health insurance is manageable, but the deductible is not. I'm in chronic pain but have to pay out-of-pocket for the care I need. Female, 41 to 64 insures. Caledonia. For years I went to the doctors, went to doctors, dentists, etc. For major emergencies only because lack of affordable insurance also would skip on necessary prescriptions for the same reasons. Female, uninsured. Are you saying a percentage of females is compared with males or is it pretty equal? You don't know yet. I don't think we know that yet. It's an interesting question. Chinden. I'm postponing medical treatments because I'm in the deductible period and cannot afford to use my private health insurance. Essex. My income is social security so I can barely afford Medicare Part B. Supplemental insurance and Part D, which now cost me $320 a month. Monthly medications are approximately $1,000 my cost and I was in the proverbial donut hole in May. Franklin. Husband owed $50 to primary care physician that he couldn't pay would not go see him about his GI issues because he felt bad and worried they wouldn't see him with a past due balance. Grandisle. I have suffered pain in my feet so that I am forced to be less active causing my health to suffer further. Simply cannot afford these high medical bills even with the insurance deduction. Lamoille. I have several serious conditions but try not to go to the doctor because it's too expensive to see all the specialists I need. My husband had two emergencies last year that were more urgent so I try to go without care. Orange. Today, every decision is looked at with an eye to the financial consequences not to quality of life or even length of life. Orleans. Living paycheck to paycheck. I didn't have an extra month worth of rent and utilities to pay for the medical bill. I avoided going to a primary care physician. Rutland. I put off going to the doctors for as long as I can hoping things improve on their own. I was supposed to go to a surgeon to discuss diverticulitis but have put it off for at least six months knowing I do not have any extra funds for the appointment or surgery. Washington. I can't acquire more medical debt and put off basic debt tests until affordable and sure of coverage. And Wyndham. My son's type one diabetes care is so expensive myself and my other son can't afford to go to the doctor. And Windsor. I constantly put off care. I have insurance but never know what my obligations will be. Once you enter, enter the medical system.  I guess I I guess I want to just pause for a second. Recognize. I just want to pause for a second but it's sinking for all of us.  And I hear the I'll say secondary trauma that my advocates experience as they attempt to help people. So there was as I've paged through the responses. I can't tell you that there's anything I've heard that individually was all that shocking or surprising or I hadn't heard before. But there is something immense about the sheer volume here. We touched a nerve. And so Meg I maybe I'll ask you to say a sense or two about Meg has done more than anybody of actually reading what's come in. So I would welcome a sense or two from you, Meg about your experience with it. Yeah, well, I think thank you for letting me speak for a second and hello to everybody in the room. I think you all know that I've also been involved in the world of medical healthcare medical coverage and these issues for a long time. But I was in no way prepared for what I took on in an offering to gather and go through this information. And I think I'll just say three things have really, really struck me from this one. It is so hard to read the volume of what we've received it from as Mike said, we've only I've only gone through 400 surveys before so far. It seems like about 30% of them are telling a story from what I'm looking at. So that's a lot of information where people are telling their personal trials and challenges. The second is I was shocked by how many people are forgoing other necessities because of it like I would say every single survey people we had a choice where people could check things that they've had to forgo to pay for their medical debt and the list was you know relatively long from things like electricity, heat, childcare, transportation. I think there are about 12 things on the list. I would say every single survey has one or two of those checked and some have six to eight of them checked. And the third thing was how accepting people seem to be of this debt and that they're very willing to pay it. There's things that people say like you know I know I had to pay my bill even if it made it harder for my kids to have something to eat. Like that something in our society and something about the fact that people know they got treated and they're grateful for the care they're getting makes them very they want to do what's right they don't want to walk out on it but they're strapped in that they just don't have the resources. So it's going to take a while to go through all the other ones and find the pieces but I'm anticipating that at the end you know you would see quotes like we just saw you know hundreds of them maybe five, six, seven hundred quotes like what we just saw just to give you an idea of the volume that we're seeing and how concise and articulate people are sharing their story and problem. So as you're looking through all of the information that you have are you able to get some specificity around socioeconomic status for any of the folks income levels that kind of information that would tell us a little bit more about the relationship between the insurance premium or the hospital charge and then what people are actually capable of supporting. So we did collect income self-reported income information so we will be able to break it down in that way and we did collect insurance status so we'll be able to break it down in that way as well. Terrific. Yeah I would just say once the survey closes and we put it in a database because right now we're literally I'm literally just going through surveys so I can't sort on all the different criteria but as Mike said we we collected a lot so we will be able to look we also had an open-ended field on the amount of debt that people have and it ranges from you know people who put something like 127 dollars and 32 cents in to people that put more than 50,000 so that field we need to go through and add up but we will be able to get a self-reported total of what people are saying and then again because we sorted on county we had county reporting we could take it down to the county level and break out you know debt per county or income levels per county we can break it by gender gender including that was self-identified so people could be trans female trans male non-binary as well as male and female so there's a lot of ways that once it's in the database we'll be able to extract and pull clear pictures of what that looks like out but right now I'm I'm just looking through them the 400 I've gone through and grabbing the the quotes out thank you can I say that one of the things that I'm struck by as well and I keep sitting here thinking I think I understand but these are folks who don't have access to Medicaid so because if you were on Medicaid theoretically right wouldn't have this medical debt but you could be at that point of socioeconomic status where you might have been on Medicaid at one point and no longer on Medicaid or you might be eligible to Medicaid at another point but that there's a whole because we have a five percentage of our models who actually access their health care through Medicaid or not Medicaid that's a whole world of people who could be very well in the same situation or worse or as bad if it weren't for what we provide through Medicaid or Medicaid and Medicaid expansion and they didn't think about Vermont that's well over a hundred thousand dollars right who are not in this survey because this is not to say that's okay it's a good job but just to think how much greater yeah the potential is for people to be suffering from medical debt that yeah I think the the thought that comes up for me in response it is um this question of um sort of what drives behaviors here and um you know when you know we asked the question a little bit broader um about sort of medical debt in your sphere you know you know like if you grew up in a family where your family was fighting medical debt you know your parents were struggling with medical debt their entire lives how does that you know does as impact your your thinking we want people to get care right that's the goal here you know we we we frame it in terms of preventative care to uh to you know getting to your primary care doc so that you better outcomes and don't cost the system more um um but so sort of how does the legacy of medical debt people's families impact them and I think that's the one that's the one caveat I would come up you know I think people who are on Medicaid some of that people are not exactly rational thinkers I'm going to go to the example of how many people switch to a Vermont health connect plan that has much higher subsidies you know we have we have a hard time getting people to do things that are in their own economic interest sometimes um so I I think um it's a backdrop in a lot of people's minds that is a wind that pushes in exactly the opposite direction of what we're all trying to do in health care reform um on the insurance question are you just asking an insurer an insurer we ask what type of insurance yeah and as remind us it's all self-reported I I think uh uh sometimes policymakers have a hard time distinguishing between Medicaid and Medicare I think people do as well yeah a lot of people talk about chronic pain and kind of uh chronic issues and I recall from talking to the chief medical examiner in west Virginia when I was there looking at the your over-the-step rate he said you know so much of what we've tried to do is treat pain but what really people are trying to treat is suffering and if they can't get any replacement they can't fix their teeth they can't get care that is for a chronic issue they would likely turn to opioids to manage the suffering instead of pain and it just strikes me how much suffering we see here that is like I can go to the doctor and you know get surgery a lot of it is going to be a chronic treatment I don't know what to do I can't manage that I don't know the way to sort of get more detail about those stories and what people do to cope and how expensive that ends up being for us yeah thanks for that I I would just add add to what you just said dental um many of the stories of chronic pain are dental stories and many of the access to care changes are dental stories um um but you also did something about getting a more um a richer I didn't use the word but more detailed story um and uh it's something that we have entertained whether we we could um go a little bit deeper with a smaller set of people um to get a more full story and um we're still figuring that out exactly I I I also want to recognize at some point Jeremy Lippert asked me across the table two years ago or something how does the healthcare advocate decide what the healthcare advocate focuses on and I have an answer that was something like oh you know we you know we we have the information that comes in through the helpline that's primary and you know I've got a great team and we sit on every board and commission that you guys dream up where I have dreamed up in past years and um and um and we read a lot and we look at what other states are doing um but there's something this is a new way for us to interact with Vermonters um this doesn't demonstrate a little bit you know you know nobody ever calls the healthcare advocates office and says I went to the doctor and I got treated and my insurance company worked exactly according to plan it you know we know we're never going to hear stories and the stories are clearly out there um but um this is an experiment one I hope to do much more of of um picking areas of healthcare where um not just waiting for people to call us but we but we need to reach out and hear more directly and and I actually I have to say it's been on my mind and I really need to figure out who to partner with um to really hear uh uh uh firsthand stories of race disparities right how people are treated um by back people are treated when they get care it's it's really interesting because so many medical clinics and hospitals now are doing patient satisfaction services and I would think that insurance companies might be doing that as well I don't know if there's any way to access that information some of us good and some of us bad yeah well um to the race uh is there race data in those surveys um is a question that's always been on on my mind and one that I uh have asked and never got a really good answer about um so what is the timing on this so obviously I I think this doesn't form our work it would be helpful to see some of the analysis that you folks are doing and and what comes of it but so the survey closes at the end of this month of august and and you know we will work to pull together uh summaries and you know presentations about it takeaways um for you for the legislative session will it be in time to come back with a uh report to us um what would you have that analysis done say by november or december uh I will I will have something to you whenever you ask for it um my depth of analysis will be uh will be more I I will I um just to give you a little insight into sort of my life I've just climbed out of the hole that is uh maybe I should say the ring that is insurance rate review and my team has been to our eyeballs in that we're not even done a decision has been made but there's still motions floating around and so that's still happening and as I referenced this week and next week is hospital budgets and um that's a um a tremendous effort for my team and also of tremendous importance when we're talking about the cost of our system um I wonder if I could spend just a minute responding to a few things that have been said this morning um a few thoughts that are on my mind that I wanted to um I wanted to be uh um chairman Lippert um mentioned a few things that other states have done and I wanted to add I want to agree with him on those and add um I think Colorado has done some very interesting I was not trying to list all the interesting things that there's lots of things Oregon, Colorado, and I think I'm not sure where the representative was exactly going here but the Medicare Savings Program eligibility is exactly is a place where the state has some options. Maine has done some something interesting that I think we should at least cost out um I want to be clear these are enabling around the edge of things these these are this is in the in the realm of things that I think are well Colorado might be a bigger step but things that I think are reasonable certainly reasonable to entertain um I would phrase the New Mexico story a little bit differently I think it's a New Mexico style way of raising money and applying that money um to improve access um they did something a little bit broader than just wave mental health copays for fully insured people um that I think is worth looking at I want to remind us all we have something like $500 million of ARPA monies that have not yet been allocated or identified where they're going to be spent and and I know there's a tremendous amount everywhere and I sure hope that at least some of that goes directly to consumer access to care and would have proposals to put on the table about that um I want to recognize I'm not sure I've ever heard it said at a legislative hearing I understand why there's a tremendous amount of effort that's put into attention that's put into people who sit in emergency department for mental health conditions um there is another I'm not sure if it's equal or smaller there's another tremendous issue playing out in our hospitals today and that's people in hospitals who are subacute maybe even in custodial level needing of care who are waiting skilled nursing facility placement for which there are none for somebody who has a behavioral uh who's been violent or somebody who um has a drug addiction issue it's you just can't place them and those people sit in hospital rooms um spending spending a lot of money and and I think it's sort of similar to the mental health one it's a structural problem you know do we need places that are designed to take the pressure off of hospitals uvm told us the other day that there were something like 30 or 40 people on that day that's right in in beds and and the workforce issue plays a huge role across all of them and then because long-term care was mentioned yeah a washington style long-term care funding um washington state style is something that um is maybe a little bit outside of the health frame of this committee but um I can't help but mention it because I think it's really cool when I see states doing stepping up and doing some really innovative things and then I'm and I can't help but mention there are also bills on the committee on the healthcare committee's all that um you know particularly focus on um on how much hospitals uh uncompensated care uh really belong in the bad debt category and really and how much of it really should reasonably be put in the free care category I'm not talking about increasing the amount of money that hospitals don't collect from people um I would like to reduce that um but um we see plenty of evidence across the hospital system where there's um where people who are economically eligible are low enough income to qualify for their care policies but who are roped out of those systems um using things like duration durational residency requirements or hospital level residency requirements um or or other ones that frankly we worry have a race equity concern I apologize for being like maybe some of this was said I think this is a good start but what I don't really get is is um what the picture is of the people that are in this category is it just is it mostly working for would you mind speaking into the mic with your mask on? I'm trying to figure out what this population looks like because as you throw out solutions to that that um what I'm shooting at for a group of people what those solutions might be would be different in each of this is this working for um um are these people that have some insurance and it's high deductible and and that breakdown and that would yeah would help me through figuring out what I'm talking about um and and will there as you go further in this survey will this be broken down further so I get a better picture of what the categories of people are in this yeah yeah yes um we certainly will be able to give some more insight about the people who filled out the survey how many you know what percentage of them or what percentage of the debt um was for people who are uninsured versus insured with a high deductible um I'm not sure that and and and will I find out how many are working and not working because my sense is your this is all pretty much adult population that is and it sounds like working poorly yeah and by income so I think I'm not exactly sure so I think you can extrapolate from that working poor um but we did not ask a question about employment we did ask about income and we and we did it in in in income range we don't we have pockets that people place themselves in okay but that picture would be helpful to me and um you know i'll anecdotally say I've had um three employers come up to me in the last week that are um one owns a small bakery and um they feel lost to be able and they want to help employees but they don't our information is kind of all over the place and there's nobody for them to really sit down with and have a talk with to for them to help I I I want to I want to echo exactly the last thing you said is is a really uh really important point and one that troubles me um I'm a consumer advocate my office is a consumer advocates office we're not a small business people's advocate and we get calls from people are saying I'm trying to sort this out and we help sometimes I help them to take it out of the realm of the advocates um but but um the role is a bit different and it troubles me greatly that um the people that are available to give advice to those people often are trying to sell them something not saying they're not getting giving great advice and getting great options um I'm just saying that there isn't a counterpart to me that gives small businesses um best advice they can about their employee benefit options should they're about the sales yeah well you know if you're trying to compare between that world and you're um running a bakery which was the people that I sent they and they've got eight employees and I I want to do something to help yeah I I call Nolan and gave me a bunch of links and I sent out the links but there's nobody really just to sit down and talk to them and it's a really tricky calculation um hey one other odd and end that I recognized is is to um clarify that the current open enrollment period goes through October 1st um the ARPA open enrollment period going to be very expensive I think it's very important for us to make that very clear here as much as we can that this is the open enrollment period for accessing the additional federal assistance which was going to which was scheduled to close on August 15 and for which for monitors can access enormous help if they're eligible with premium assistance with federal dollars yeah it's been extended to October 1st this is very important to make for us to get out into the public realm um again I I referenced some federal data that I'm asking and I'm hoping we're ready to talk planning have diva command in our next meeting talk about this I think it's just so much more important that uh well it would be nice to know what if any publicity is happening around that because I think we haven't seen enough of it and as uh so it it may be New York state has a we see I see I don't tell it in New York state yeah but so so let me clarify that the ARPA subsidies will be in place for the next year and so people who are signing up for next year's uh health insurance will be eligible for it um if you're direct to your your insurance carrier this this month today's the 19th not much time left I was going to make a thing if um three days ago by the 15th you had called to switch to direct care you would have been eligible for next month's ARPA subsidy um if you didn't you'll lose it you just lose it you lost which could what could be a thousand $1,200 a month for a family and so it's substantial subsidies that people that I am very afraid many many Vermonters are not taking advantage of and um and I'm going to be clear that is people who are direct to carrier um and I also want to be clear that the subsidies since we're talking about out-of-pocket costs the subsidies available to people who have had any unemployment last year even a week of unemployment is incredibly generous and it covers cost-sharing subsidies as well and so I I'm just guessing that we are going to be um we're going to be at the end of the at the end of this looking back and shaking our heads at how many people missed those federal dollars can I just clarify too um so if you are direct with the insurance carrier and you make a phone call to switch to direct vermont health care and switch connect you can switch your plan exactly as it is yes you're not having to make any other decisions other than saying I want to move what I currently have over here so I can get myself to be yeah I almost okay but close enough I mean there's the one little detail of overloading but but that detail the easy process for consumers to take yeah up the phone and say I wanted to over here yeah yeah so I I mean I just want to know because I got the I mean there was a terrific um one sheet or two sheet piece that legal aid sent out that included this with a whole list of don't miss out on all these important things which I converted into put it on our local front porch one but this piece was only one on a list of 10 and so I I do think it's important for a separate highlighting just of this yeah yeah in a couple weeks go an insurance rate review process we understood that 10 percent of direct rollies had moved and and look some people the subsidy goes really high I mean something goes as high as it can but with the point where it crosses the cost of the plan is high 600 percent of federal poverty level it's very high and I understand some people may look at it and say I would save $7.50 it's not worth my trouble but for other people we're literally talking about thousand you know over a thousand dollars a month and you know all the jumping up and down in excitement about the stimulus checks that went out we're talking about that much a month there's a single thing that we can do immediately it's to make sure that all of our monitors who are eligible access this right now especially but I believe that we were meeting after the deadline of August 15th but if the extension line is October 1st yeah I'm just saying that so it's been extended October 1st yeah and I think we should we should have something that goes out to all of our colleagues yeah to highlight this with something that's already prepared to use on social media front porch forms that are that they don't need to modify uh because I think I think that that would be something immediate that is in fact hugely impactful for for monitors and artists if you know one of the you know was two years ago I mean our committee really dug hard to try to find a way to help this exact group of people who were on that cliff yeah um who fell off the cliff and and couldn't come up with something um and here it is ended to us on a silver platter can you send us the information that you sent out to front porch form and then yeah um we can send it out to our colleagues in the house in the senate yeah and I and I because I do think that is something that we could do right away and it will save the bonners money and the short term right right yeah so thank you thank you for the time and thank you for um uh allowing me to chat a little bit and um and thank you for taking a little time to um honor the stories that I was able to bring forward today and um I'm looking forward to uh and I and I'm open to your suggestions each of you um right here um to uh ideas of how to share this kind of data you know these stories uh in a way that honors them and also um and and doesn't and doesn't overwhelm lawmakers or maybe it's supposed to overwhelm lawmakers but um um I'd be happy to talk more and um and thank you well thank you and I I think any analysis that you do have and that might inform the work that we're doing you know by November um would be extremely helpful have you come back in it's to you and Meg maybe consolidate some of the work that you know I think Meg is with us for just a short while and Meg Lee um and and then Meg is moving on to a new position Meg you want to announce your new position uh some of them saw that I'm going to be working with you on Alzheimer's related issues as their new policy director but I will be here to help Mike through the middle of September start to get this in place and and obviously support afterwards with questions since I was part of the initial um collectors and I would just say as you're as you're really thinking about what you're hoping for from this data what you think you need from this data we can provide some of the specific breakdowns that you asked for but the the highest value that I see from the data are these personal stories because all the other fields were self-reported so sometimes they would check like I don't have insurance and then it would say what's your insurance plan and they would say I'm on my employer plan so there were the the the other fields are gonna are because it's self-reporting it's not a it's not a sample size um that's been divvied out correctly the most valuable information is is from the stories and if there's things you want to hear like I believe it was Senator Rom I can't tell because your picture is small but um that asked about like one person putting off care one another because another person is getting care like if we know those things it just happened that there were two stories like that in the examples today because those were stories that had to come up but those are the kinds of things that we can be looking for as we're going through so we can provide some numbers on those specific details if you're if you want to see are you finding in a story a connection about for instance another one I see a lot is high deductible and the high cost of insurance how does that compound together to make a problem then we could flag those and we could start getting more um uh quantitative data around those issues but the the simple breakouts around insurance and employer even um even income levels because people are reporting for their whole family and one person in what they consider their family may be on an employer plan and enough they may not be married and another person may be on Medicaid so it's just it's cloudy the way the survey is so really think about what do you want to see from the from the stories so that we can be looking for that and flagging that um to then come up with the data of okay we saw this many stories around around this so that that's where it really to me is the richest thank you and congratulations I'm sure we'll be seeing you I'm looking forward to that that's one of the perks is getting to work with all of you again all right terrific a couple more comments so one you know when I read something like my wife pretty she doesn't have seizures because my shirts wouldn't cover it at the cost I mean I I see a path to do something about that I'd be wrong because I'm not at the healthcare committee but that seems horrible you know and I know you were saying you can only really get involved if things are illegal or you know they're kind of really outside of the realm of what should be people's experiences but I mean a list of things like that you know where there's a pretty specific policy change I think would be really helpful you know and then looking at things like someone said for years I couldn't do this it's also I think helpful for us to know what what has changed for people what does work you know what when I know that probably I'm hoping you talk a lot about when things finally work for someone they have better insurance tied to a different employer they you know they have better income but you know you said like we'll never know when someone things are working right for people but you know we also want to know when things are working for people when they might have gotten out of a bad situation because they made the right phone call I mean so much of what I hear from healthcare is I needed to know the right person to talk to to get or the magical change made in my life you know and that's the scary thing is that it's so uneven for people depending on who they talk to and you know where they look for help and I feel like they're really informative for us to know when someone had a positive deviance because they knew where to get help yeah it it it reminds me something that I wanted to say and and I was just saying about you and now just one more thing in response I think healthcare more than other policy areas beware the average you know you know the average cost of housing that's a range of the cost of housings you know obviously Jeff Bezos pays more for his monthly costs than you know the average person but you know other than that uh the you know housing has a certain range you know I don't know what the average healthcare spend in Vermont is something like $10,000 you know if you just divide the total cost by the number of people um you know to a lot of people $10,000 sounds like that's crazy I never go to the doctor um and then to a small set of people you know they're they're millions that's crazy I spend a lot more than that right exactly but the real point is that the the the details that go into people's lives that drive the cost um include include many many factors that um that you just can't average and so I I think whenever I hear people give averages healthcare I time out oh this doesn't exactly work this way as it really plays out on the grid um so um there's a a bazillion details behind each of these stories that it's um impossible for us to really evaluate on the face of it um seizure care should be covered I don't know whether that person is my deductible I don't know whether that person has an employer sponsored plan that's very limited I don't I just a lot I don't know so thank you I hope people receive some kind of response not a personalized response but something like this is what we heard this is what we're able to do with it you know these are solutions that we can advance right now I think people deserve some feedback when they share such a story um yes that's what we're about to do hopefully well um yes it is our we really do need to reach out to the people who participated and gave us their emails many of whom did okay we're good okay thank you thank you so I need to share working news report on workforce and healthcare access I just got a phone message from Central Vermont Center they have to postpone my mammogram scheduled for tomorrow because of the staffing coverage issue there you go so there we go it affects everyone Charlene is Jen Carby on Jen are you on zoom there she is here well I thought that we will we should move into a review of the act 48 principles and then we'll have a discussion about future meetings sure do you want me to share my screen and put up kind of that presentation that either either copies made of either document is fine we have the um short version and we have the power point so I think the power point one may be easier to look at as together um so let me just um Charlene can you let me share my screen thank you okay can you see my screen can you all see the document yes yes we can great um and just again I'm Jennifer Carby from legislative council um this was a presentation I put together a couple of years ago when the issue of the act 48 principles came up in the house healthcare committee and it just seemed like an easy way to look at them um so it starts off by quoting from act 48 uh and just to note that the principles are also codified in statute that's actually the what I the one pager handout that I gave you that also has the principles on it are the ones in 18 vsa section 93 71 which is the first section of the green mountain care board chapter and there have been some amendments um to the principles since they were initially enacted in 2011 um so these should include those updates so act 48 starts with um that says the general assembly adopts the following principles as a framework for reforming healthcare in vermont and the first one says that the state of vermont must ensure universal access to and coverage for high quality medically necessary health services for all vermonters systemic barriers such as cost must not prevent people from accessing necessary healthcare all vermonters must receive affordable and appropriate healthcare at the appropriate time in the appropriate setting so this sort of picks up on some of those issues that mike fisher just highlighted for you in his presentation I think so as far as as assessing where you are in achieving these let me know if you want to stop on any of them otherwise I will just go through them principle number two says that overall healthcare costs must be contained and growth in healthcare spending in vermont must balance the healthcare needs of the population with the ability to pay for such care the third principle says that the healthcare system must be transparent in design efficient in operation and accountable to the people it serves and the state must ensure public participation in the design implementation evaluation and accountability mechanisms of the healthcare system principle number four primary care must be preserved and enhanced so that vermonters have care available to them preferably within their own communities the healthcare system must ensure that vermonters have access to appropriate mental health care that meets the Institute of Medicine's triple aims of quality access and affordability and that is equivalent to other components of healthcare as part of an integrated sorry integrated holistic system of care and just to note that the Institute of Medicine reference was actually not accurate that's been changed in legislation since then so the the hard copy the one pager that i gave you has slightly different language there other aspects of vermont's healthcare infrastructure including the educational and research missions of the state's academic medical center and other post-secondary educational institutions the nonprofit missions of the community hospitals and the critical access designation of rural hospitals must be supported in such a way that all vermonters including those in rural areas have access to necessary health services and that these health services are sustainable the fifth principle is that every vermonters should be able to choose his or her healthcare providers number six vermonters should be aware of the costs of the healthcare services there yes there's a question go ahead i mean i just could just be me but i don't find it that helpful to just read these without like stopping to say are we there are we measuring that like what are we doing right now let's go through the and then we'll come back to that's a longer conversation but you know yeah much much longer but for example we do have provisions that allow people to pick their provider but we will we'll come back to to that question unless somebody has a specific statement to make go ahead Jen okay so number six is vermonters should be aware of the costs of the health services they receive and costs should be transparent and easy to understand so just as a just as an aside to answer senator hint stale's question the transparency issue past legislation last session on increasing hospital cost transparency and there's that that is still being being worked on also insurance company transparency to demonstrate the costs of services and then the payment for services so we don't measure if vermonters the cost of transparency we don't measure what vermonters think we i mean we don't know if it's easy to understand well the only way we can know if it's easy at break is to look at it and and determine do we have a comparative analysis of all the hospitals for uh colonoscopy for example so then you start to get into more specific details and in some cases we meet their criteria and other cases we do not meet the criteria but so it gets to be more complicated but there's no formal process right there's that anyone who goes back to this okay and has a measure okay there's no my government accountability right i have a general question but i'm not going to the end okay because i think it's important because m 48 gets brought up in many many contexts and for many purposes and i think it's important for us to understand and maybe Jen can help us with this later what how okay this sits in statute and what is the point of it in terms of i just didn't know i was missing something you well have go ahead Jen yep principle number seven is that individuals have a personal responsibility to maintain their own health and to use health resources wisely and all individuals should have a financial stake in the health services they receive principle number eight the health care system must recognize the primacy of the relationship between patients and their health care practitioners respecting the professional judgment of health care practitioners and the informed decisions of patients number whoops sorry number nine vermont's health delivery system must seek continuous improvement of health care quality and safety and of the health of the population and promote healthy lifestyles the system therefore must be evaluated regularly for improvements in access quality and cost containment number ten vermont's health care system must include mechanisms for containing all system costs and eliminating unnecessary expenditures including by reducing administrative costs and by reducing costs that do not contribute to efficient high quality health services or improve health outcomes efforts to reduce overall health care costs should identify sources of excess cost growth number 11 the financing of health care in vermont must be sufficient fair predictable transparent sustainable and shared equitably number 12 the system must consider the effects of payment reform on individuals and on health care professionals and suppliers it must enable health care professionals to provide on a solvent basis effective and efficient health services that are in the public interest number 12 is that vermont's health care system must operate as a partnership between consumers employers health care professionals hospitals and the state and federal government and finally number 14 is that state government must ensure that the health care system satisfies the principles expressed in this section and then i think at the time we've been looking at some statutory references the act 48 principles so to the extent that this kind of goes to what representative lipid wanted to get into where these come up the vermont care board is directed to execute its duties consistent with the act 48 principles the board also has to review and approve the statewide health information technology plan to ensure that the necessary infrastructure is in place to enable the state to achieve the act 48 principles and the board's annual report has to identify how the board's work comports with the act 48 principles there's also some language about the act 48 principles in the green mountain care board payment reform pilots language expressing legislative intent to achieve those principles and qualifications for nominees to the green mountain care board the nominating committee must assess the candidates using specific criteria including their commitment to those act 48 principles comes up in the health resource allocation plan that in developing that document the h-rap the green mountain care board must consider the act 48 principles it also comes up in the all-payer model that in order to implement an all-payer model the green mountain care board and the agency of administration must ensure that the model maintains consistency with the act 48 principles and then there was obviously an additional reference to it in the green mountain care implementation statute for the single payer system so i can take that down if that would be helpful but state but so as you're talking about the the role of state government in overseeing the having accountability for ensuring that we meet the principles so most of that responsibility lies with the green mountain care board i think certainly some of it lies with the green mountain care board and their enabling language but the the specifics in that last principle are really state government it's not limited to the green mountain care board who must ensure that the system satisfies those principles so i think as you've moved for example the director of health care reform into the agency of administration there's a role for them to play as well and others and then through any of our waivers analysis if we're looking at quality metrics so that which we're not going to be talking about too much in here but that falls into vcures or other we don't have another metric that is the state metric at this point i guess i'm not clear on on well i'm just thinking assessment of quality we also have the department of health that looks at our health outcomes so in terms of individuals accepting responsibility and so the department of health looks at the the youth risk behavior survey for example or the incidents of different types of cancers or cardiovascular disease which would be an indicator of overall health and personal theoretically could be traced to personal responsibility but we don't have a direct there's not a direct line to that it just simply that that's the role of the department of health and identifying some of that information and data and there's nothing in here about diversity either right here i think it's been a few years since this was all put together when i look at it we talk about the relationship between professionals and and patients we talk about the system we do some reference in here to infrastructure and underlying all of this is the people doing the work and we're desperate now for primary care doctors we're desperate for nurses we're desperate for mental health professionals and there's no place in this that clearly to me just states that and we're doing across the board scholarships loan repayments all sorts of stuff but somehow in it we're in a crisis of medical professionals and that's not it it's danced around but not said you're right i mean it does talk about the relationship of professionals and patients but it doesn't talk about the state responsibility for ensuring any kind of well the atrap does somewhat of that yeah we dance around it but yeah you're right in terms of just having a having a adequate and professional health care workforce yeah not there there is some of it and go ahead but that's not to say we aren't doing some of that loan repayment scholarships but doesn't we dance around it we're doing a lot yes we're doing a lot it's not the result of any principle that has that been put in place yeah jan what did you want to add well there is some of that embedded in number four which talks about other aspects of Vermont's health care infrastructure including the educational and research missions of the academic medical center and other post-secondary educational institutions and other things must be supported in such a way that all Vermonters have access to necessary health care services i think it's looking at it specifically in the kind of the access side but recognizing the role of the post-secondary institutions so in countries yeah yeah i brought that up because when i was looking at every people number one in my head i said systematic areas such as cost and health care workforce but not you know yeah that's where it belongs and that's right don't kind of found i'd like to pick up on that because that's part of what i was wanting to say earlier because i think because i wasn't on health care when act 48 passed some some of sport i was not i would just i would just say and so and there's a difference between when you're in the room in the committee that's you know really wrestling with this and uh and i have oh and and and subsequently in many now number of years um working directly on health care act 48 gets brought up sometimes it gets brought up frankly in uh as a goal as a goal sometimes it gets brought up as a cuddle uh it's like we're not vermont's not living up to act 48 and other ways other times it's brought up in other ways i i have interpreted these principles act 48 as aspirational and that's the phrase that that's the word i put on that they're uh and i think no that's i think that's kind of what you're describing they're they're principles to guide us as we move toward where we want to be but uh i think that uh so that some i just put them there i i think the principles are aspirational we're not just for us to not that we shouldn't measure and think about how we're trying to get there but they're not they're not to be measured in the same way i i do have another question maybe this is the right time and place but it's something i've been wanting to read for some time and that is act 48 also it gets quoted as saying that vermont should provide as a public good but we financed health care coverage for all vermont residents and that's quote that's quotes that other people provide and and i think it's also important for us when we talk about act 48 what is it it's something that well we want to move up to act 48 and that's it's a different part of act 48 it's not the principles of act 48 and gen i don't know if you can help make us help us distinguish between you know what parts of act 48 are statutory expectations and which are vermont so just this one comment that act 48 does say that health care is a public good that is a statement in act 48 i don't i don't know exactly where it is in the so that's actually what i'm looking at right now so the phrase public good is used three times in act 48 itself the first is in section one which is the intent section and it starts with saying it is the intent of the general assembly to create green mountain care which was the name of the so-called single payer program to contain costs and to provide as a public good comprehensive affordable high quality publicly financed health care coverage for all vermonters and it goes on so that's the first place where it's the intent to create green mountain care to contain costs and to provide as a public good this comprehensive health care the second is in the purpose statement at the beginning of the sub chapter in title 33 chapter 18 sub chapter two on green mountain care the purpose of green mountain care is to provide as a public good comprehensive affordable high quality publicly financed health care coverage and the third place it comes up is in the qualification for it's a little bit different context qualification for nominees for the green mountain care board and that's regard for the public good sort of more generally so the public good is really seems to be health care as a public good here seems to be in the context of creating green mountain care to provide that as a public good i mean i'm not arguing that a principle is different than a goal but principle nine says the system is evaluated regularly for comprehensive access quality and cost containment principle two seems to be our charge i mean principle two says health care cost must be containing growth and health for spending and vermont must balance the health care needs of the population with the ability to pay for such care whether it's a principle or not if we agree with that we have to have a way of measuring it otherwise it's irrelevant so i'm just like this feels like a kind of mental exercise otherwise unless we are trying to understand how we want to live up to that principle in our in our next four meetings and what information we well so well we would have to do look and as you said we'd have to look at all the information that we have all the all the laws that we've passed to support each of the that would support each of the principles i think um what we might want to do and we'll have to think about this we we might want to consider what do we need further to demonstrate that we are achieving the goals and meeting the spirit of the principles that that's a separate it's a separate question if we start if we start going through this and suggesting that um we establish uh metrics for each one of the principles that that'll become everything that we are doing here we'll be able to finish it by december well right that that statement must be evaluated i think you're right there are a lot of pieces where we are we do have metrics we are evaluating that's what we need to kind of refresh our memories identify yeah um from all those existing reports that but it could be a recommendation that that happened more thoroughly yes going forward otherwise um that's what we'll we'll be here well it's like so but if yeah and if you look at number nine number nine um already in some ways is has there are goals for number nine that are developed through the department of health for the reduction of substance use disorder the reduction of smoking and the reduction of cardiovascular disease associated with yeah they have goals for mental health behavioral health so um well yeah so we don't i'm not sure i'm not sure that we can go through and identify all of the goals what we might suggest that there are goals associated with each of the principles and that those should be maybe further developed yeah yes and maybe in a more formalized way because when i think about all of these things i think yes i've worked on a lot of legislation that supported each of those goals but maybe not systematically that's yeah kind of yeah a lot of scattered things that a lot of stuff going on that pulled together more clearly yeah which ones are in support of which yes goals and yeah what's missing any other questions for Jen on the principles or comments but review this again i think yeah nice try i thought we just did all of our work we sort of have what we'll do at our next meeting right two three and five and we have some witnesses identified but i think primarily we want to if at all possible meet with our consult so the question is we have a total of five meetings this is number one um and then we have september october november december so we've got we have four months plan four meetings we have four meetings in four months and and then we have an opportunity to complete our work so so december would be the time where we would have to review our draft recommendations and make the final because we won't meet again before january 15th take doing that calculus we would have our draft recommendations in november which means that september and october would become the heavy lift for us and part of november so september um what's the best way to do this do you want would you like charlene to send a doodle pull up sitting here yeah that's what i was gonna sound available i think i think a doodle pull would be and so what today's the 19th of august yes it is charlene yes do you want to be sent one for the next week or four four four four yes december and you want to participate or yeah i was thinking the dates that are not l car thursday's might work and i i don't know the dates that are not just this oversight the dates that are not that are not green care protection on the committee the dates that are not green back here what is it joint fiscal committee so i think see what's left yes i think we should be looking for the second half of september because we have a lot of things to do between now and a lot of corporate public consult i think i could tell you september and thirtieth and october first are not okay for you yeah well those are the green back here award nominating okay did you hear what no one was suggesting that we each send days that don't work to charlene and see if there are a date of hers that you know she could do it yeah i know i think ideally we looked at after september 15th oh yeah yeah i know a lot of the start from ten to three i have a question about the interview process you know i feel like it's really common especially a big charge that they aren't good at all the things i'm particularly worried about understanding disparities and trends about where resources might go to tackle disparities and i know that there's a lot of new you know groups led more by five pack folks and other people who are really emerging in that space of health equity and i wonder if it's if it's if you're going to be considering that they might need to subcontract part of their work or really not treat that particularly like an afterthought and not have any expertise in that but build it is


Hey everyone, welcome back to figure fantasy. So today we'll be talking about your frost team compositions and most likely where they are going to excel in the content of the game. Okay, so let's start off with your front line, which is most likely going to be Krosos because most of your frost units do belong in Tenma. So I'm gonna create this team based on a Tenma theme. So Krosos is your main defender, definitely. Your next defender, just gonna keep this kind of free to play friendly. Your next defender is going to be Sapphire. But if you do have Megan, of course, you can definitely use her. I just put her on the alternate just in case people don't have Megan yet at a high level. Sapphire will definitely do for your team.  Your two main defenders. As for your healer guys, you will be depending so much on Zephyr for your frost team.  So it's at level two. So you have to unlock this to unlock her frost because this is the only frost ability that she has. So increase the amount of health restored by 10% and energy to 20%. Also frosts two random enemies for five seconds.  But if you encounter a lot, let's say for example, nine or eight enemies, this, this will be just a small factor. But definitely Zephyr is your, is your healer for this team. Then for your main baddies for frost, your main baddie here is going to be Vasruin. So Vasruin gonna take you through her skills. She needs somebody, she needs somebody to, to apply frost so that she can deal lots of damage. So in her ultimate, so attacks all enemies, deals great amount of damage to them, boosts damage by 10%, attacks enemies that are frosted, deals extra frost damage. So and also for level three, this is also needed though it boosts now up to 15% and grants 30% chance to freeze the enemies hit for two seconds. So I'm just gonna go back to, to what frost is. So the lower the frost resist, the higher the amount of frost damage taken. So what's more defense will be ignored when taking frost damage. So those are basically the benefits of dealing frost damage. So again, she will be your main damage dealer for this team. Your other frost baddie is going to be, is going to belong to Galatea, which is Usuke. So let's take a look at his, his kit. So for him, frost, this is actually just frost, applying frost. The other one is frost damage. So Vasruin completely deals a lot of frost damage while him, he basically just applies frost. So for frost, causes the target to lose health every second. This ignores defense as well. When frosted, targets attack speed will be reduced by 15%. Some figures attacks against the enemies that are frosted deal extra frost damage to them. So again, a lot of factors come in when you, when you do frost on them, lowers defense, lowers attack speed and they receive more damage with, with frosted deals extra frost damage to them. Okay. So for him again, going back to Usuke, so boost damage, this is going to be his passive boost damage by 10% has 100% chance to freeze enemies that are frosted. So freezing keeps them, I think, immobile or unable to do things for a couple of seconds and boost damage by 15% extends the frozen state to three seconds. So that is it for his passive for his ultimate. This one is going to be dealing damage. So attacks all enemies has 75% chance to frost them for eight seconds. So it's only 75% to apply frost and this will be adjusted by Usuke's, Usuke's accuracy bonus. So you have to improve his accuracy to increase that 75%. So level two boost damage by 10 grants it 100% chance to frost the enemies kit. Okay. So at this point, it's 100% already and level three is boost damage by 10 and reduce each's enemies energy by 15. So for, for almost all of the combos, Usuke and Vazirwin will be your top two in bringing for your frost lineups and another one. So that usually rounds out your first five. You have Usuke, you have Vazirwin, you have there as well. You have Sapphire, you have Cruces and you have Zephyr. So that's roughly around three frost dealing characters or figures in that lineup. But again, for the alternate, it's going to be Sani. So I, by the way, I was able to get Sani's new skin for Christmas and she actually fits Christmas because she deals frost. So, but she brings reduce, at level two, she brings reduce all enemies frost resist by 25% until the battle ends. So definitely, if you have space in your roster, please do bring her because of this one. And number attacks and frost all enemies for 12 seconds. So this is going to be good as well. But again, her handicap is basically whether ultimate because you will need to reach level three for you to maximize her. That is why I'm leaving her out of the lineup that I'm doing in a while. But definitely, she's going to be a good addition to your team because of mainly because of this one, the frost resist decreased by 25%. So this one for her ultimate, she is actually good already. She can heal, but again, you need to maximize her output by this one, the 20% and boost defense of teammates and healed by 35% for five seconds. So again, to maximize your value out of her, she needs to heal. Sometimes you can actually swap her out or pair her with Zephyr to add more vulnerability. But for this team, I'm leaving her out because I've noticed that she can't really heal that much without level three. Okay. So ideally for your frost team, you're going to be bringing them in your final battle. For frost teams right now, unless if they have lots of damage built within them, they're not really built for 5-1-5. I'm going to do this. I'm at level 12 right now. Okay, guys. So this is my team for Azazel. So again, just want to recap this team. I have two healers. Then you have one support for shield. Then you have two defenders up front, namely Megan and Cruces. Then you have Zhao Yun as your vanguard. At the back, you have two DPS. You have Zerola. You have Vasruin. And you have Asuki as well for your specialist trying to deal frost and damage as well. So that is my team. I was able to try this lineup with Eryxia before I replaced her with AoE, but definitely the shared health sometimes kills off your more squishy heroes or figures. That is why she's not here. I replaced her with AoE. So this team is more stable in terms of handling waves of damage and surviving. And hopefully I could survive this. And they could survive and move on to stage 5. Hopefully we could clear this one moving forward. So we are at stage 3 and still we're good. So be careful guys because sometimes the RNG plays a lot of jokes on you and sometimes some runs are successful, some runs are not. So definitely try to do a rerun if you can't finish a stage. Sometimes it goes in your favor for this one. I did a lot of trial and error just to reach stage 5 for this one. So they're barely, you know, barely survived all of my figures. So we're now at stage 5. So this is the last stage. Hopefully we could clear this one and survive the RNG. I'm not afraid of Azazel. I'm more afraid of the RNG that it would screw up everything that I have prepared for this team. So far, very good. Shields are up, HP is up, and we just have to weather this last couple of units that are in front of me. So far, so good. So far, so good. So I think that's the last, the back. So I think, oops, I'm not gonna say that this is good already. But hopefully we're nearing the end of this and we can clear this one even if I lost some. I think this is doable already. Okay, so that is it guys for Azazel. So stage cleared. Perfect clear. Five waves. So that's it. That's it for your Frost team. So hopefully I've given you enough, you know, convincing on where to use your Frost team. So thank you guys for staying this far. So please do subscribe if you're still here and do consider because this helps my channel a lot. Also guys, don't forget to click that bell icon. Thank you guys. Stay safe. Take care. This is The Warden and I'm out of here.


Hello everybody, welcome back to another Adobe Animate, formerly Adobe Flash tutorial. In this one, I'm going to show you how to create your own custom paintbrush. I'm going to create a very simple paintbrush, but for all you artist types out there that love to create brushes and stuff like that, illustrators, this is the technique to do it. So let's get started. I've got a basic document here opened up with nothing on it, just a blank layer.  Why not? All right, good enough. Now the next step is I'm going to go over here to the left side onto my toolbar and I'm going to use the fluid brush tool. But do note you can use the other brushes. I have the classic brush tool and the paintbrush tool as well. If you don't see any of those brushes, just go to these three dots down here, edit toolbar and make sure to select them to add them. So you would just left click on them right there and they will add to the toolbar. OK, good. All right, let's go.  No big deal. Let's just go ahead and create a brush.  So there we go. I've got an arrow. I've got basically a line down and then I'm going to create a arrowhead on it. So instead of using red, I'm going to create the arrowhead. I'm going to go over here to my fill color and I'm going to select some sort of purple for the arrowhead. And again, this is not very good. It's just me showing you the technique. So there we go. We've drawn a line and then I'm just going to draw something like this.  This is just me monkeying it on my on my Mac here. OK, good. So we've got this. And now what I want to do is I want to make this into an art brush so I can paint arrows like this as I see fit. So what I'm going to do now is I'm going to have the selection tool selected. I'm going to go ahead and I'm going to select everything here, making sure I've got all of this into my selection. And then I'm going to right click on it. And now you're going to see an option down here that says create paint brush. All right, you're with me. What you're going to see here is you're going to see a couple of different types of brush. There are art brushes and pattern brushes. We're going to make this an art brush. And here's where we're going to make some differences. It's going to see here that it says scale proportionately, stretch, stretch to fit stroke length and stretch between guides. What we want to do is stretch between guides. I'm going to left click on this one. It still looks kind of funny. And what you want to do next is you actually want to go ahead and adjust from this left to right, click on that. We're going to go from top to bottom, which is the way we drew this. And now you're going to see that the arrow right here is pointing this way. The next step is I want the brush head or I want the arrowhead part in me to remain proportional. So I just moved this guy. Now, this isn't required for all brushstrokes. There's a chance that you just want dashed lines or funny colors and you don't need to do this. But if you're drawing something like a shape like this that has like a base here, like a stem and then an arrowhead, for example, I'm going to restrict the guide so that this part is proportional. So you'll see what I mean in a second here. And now I'm just going to left click on add. And now when I go to my brushes and I'm going to go to my paintbrush tool, you're going to see over here that I've selected this. And this now is a stroke style. So we have created this brush out of nothing. And now I'm going to go ahead and change my stroke size to one hundred just to show you what I'm talking to one on one, whatever. And I'm just going to draw down and let go and presto. We've got the arrow that we drew here. We've got it here sort of proportional. Now, if I was to make this say 200 and I drew it here. Very similar to what we have here. This this middle one that we drew was about 300. But what we've done is we've created our own basic brush here in seconds, guys. That's how you do it. This is how you reuse brushes inside Adobe Animate. Makes your life easier, makes things faster. I have a ton more tutorials coming up. Stay tuned. Be back soon.


What's up everyone, welcome back for more XO Cirrus content. In today's video, we're going to discuss core reverse chance increase for Brooke, improvements to her design, where you can use her and if she's worth summoning for. But before that, if you want to see more XO Cirrus content, please be sure to hit the subscribe button in the right side of the screen. Here is the core reverse chance increase for the strong ship Brooke recruit and I'm pretty much excited that she's going to get a rework because I've had her FC for quite a long time and I think I had her FC fusion already so I think I got two copies of her and it's already fused with FC Brooke. I'm excited to see how they reworked her skills because from the start when I tried to use her, her kit was pretty much underwhelming in terms of damage and in terms of utility. Overall, the current Brooke FC is not really recommended in the current PvE and PvP meta. So let's take a look at what changes they gave her. So this update will be dropping after the September 7 maintenance. So again for her skills, here we go with her passive. So we have a new one which is Angry Lab. If the caster has a removable buff, recovery, positive effect applied, this is similar to Flap Flap. So attacks together with an ally when the ally attacks, so once every third. So I think this is interesting because when Brooke has a buff, has a positive buff, she can attack whenever an ally attacks. So I'm assuming this is tied to her basic attack. So again, if she attacks, considering Brooke is an attack character, she gains mana every time she uses her basic attack. So this generates mana for her well as long as she has buffed. So this is kind of an interesting kit that they have put into her. I think she can be used probably in a couple of scenarios already in the game. So let's go first to her S1. So her S1 before was a one mana, deals 240% damage to an enemy. It was changed to, now it's two mana, but her damage has decreased. But the special is turn resets if a target lies. This is very good in terms of finishing off enemies and moving on to the next target without wasting your turn. So I think this is good even if it was bumped up to two mana. And her S2, if you can see, the initial scale was her baba rush. Her initial scale was three mana cost, so deals 420% damage to an enemy. So it's three burst. The new one already requires four mana, but her damage is already at 750% damage to one enemy. A very big buff compared to 420. So I think this is similar already to some of the top tier burst characters for single damage that we have. I think Rodney has this one. So it's at par with Rodney's S2 already. So if you can take a look at the overall improvements that they've had in their kit, I think this is pretty much very, very, very improved compared to the last one. I think you can use her now in the Holy Dragon Grounds. You can use her Barrier of Will and also use her Dragon Hunter Blessing. So this will all be more effective with her angry lamp. You can build your Holy Dragon Ground team with her using a buffer for your attack or probably any positive buff that you could give her. So Holy Dragon Ground is one of the areas where I recommend that you use her once her new kit drops. The next one is she's going to be used more during the challenges for fire day. Anyway you have to build your team.  And also, my last recommendation is you can also use her now with her new kit in the PVB tag. So you can use her in your second or third team, which just makes sure that you build her around a team that gets buffs, so that you could make sure that angry lamp triggers. So again, as a Black Fate Core, she is going to have a probability of 0.7% to summon. So also you'll have 19 core milages for her Black Fate Core. But for those who acquired her FC before, the changes will be applied after the update. So like me, I'm already excited to test out her after the update. And also for her FC weapon, I also have her FC weapon actually. So I don't have to get her FC weapon. Her FC weapon is also 0.7% and 19 core milages as well. So and that concludes this video guys. Please tell me if you like this video and if this has been useful, let me know what you think in the comments below. You always stay safe and I'll see you in the next video. Warden out.


QTEM stands for Quantitative Techniques in Economics and Management. So what QTEM in essence offers is an additional year, beyond your one-year master. Within this year, students do both study period abroad, as well as internship, possibly at one of these companies that are in the network. Among the universities there are Monash and Melbourne, Australia. We have Waseda University in Tokyo. At the other end of the globe, we have HSC Montreal in Canada, but we also have universities closer to home, such as Louise in Rome and Solvay Business School in Brussels. Among the academic partners, we have companies such as McKinsey, Bain, Deloitte, Abbey Inbeth, prestigious companies that offer internships and all kinds of other possibilities for students joining this network. For most business-oriented programs, there is an access to the QTEM network. So basically all programs belong to the Tilburg School of Economics and Management. There are a couple of benefits. First of all, there of course is a knowledge benefit. A one-year master is very short, and what QTEM offers is an opportunity to go more into depth into certain topics. So it's an opportunity to gain more specialized and advanced knowledge. The other benefit is a network benefit. You will of course meet other students, go to other universities, go to different places, but also there's a network of corporate partners that will become available to you. Of course these companies are not only looking for interns, but also looking for their next employee. The final benefit of this network is the international experience that you will gain, because each QTEM student will spend time in at least three countries in order to get the QTEM certificate. The application procedure starts in the fall, so students apply for the QTEM network during their master year. The most important requirement is a GMAT test and a GMAT score of at least 650. So we're looking for intelligent students that are ambitious, that are serious about their career, that would like to gain more international and professional experience as they go to the job market. Students that are interested, they can go to the QTEM website, QTEM.org, which has all information available about this additional year.


Up until a few weeks ago, I didn't know much about Barbara Gordon. I knew that she was the daughter of the iconic commissioner Jim Gordon. I always thought about how she became the one thing her father despises, and how she turned from Batgirl into Oracle. So after brushing up on my babs, I wanted to share my findings. I wanted to explore the first woman to don the bat symbol, who would turn into so much more. So I asked, who is Barbara Gordon? After picking up Batgirl year one, it became immediately clear to me who the young Batgirl was. Barbara Gordon or Babs had a personality that was immediately alluring, from the moment she appeared on the page or on the screen. She had a genius intellect, she was cunning, and she was very spirited. Barbara wanted to do everything that anyone said she couldn't do. Barbara had a chip on her shoulder. And when she donned the bat costume, the one thing that jumped out to me was how she offered a different perspective to being a Bat, especially when she began. As she would state in one of the panels, there wasn't a patent on wearing the bat symbol, or on wearing a mask. Especially since she wasn't aligned with the Bat family, at least not yet. And her morality also differs from the others, as she shows that she's not afraid to use lethal force. Barbara Gordon, daughter of Jim Gordon, wanted to be a detective. She possessed a genius mind, the proper training, but was halted by her father. At the time, soon to be commissioner of the Gotham City Police Department. Jim Gordon would, under no circumstances, allow his daughter to become a detective on the field. She was too small, she was his daughter, his world. Too fragile. She wasn't ready for the life as a detective. A theme that would come up incessantly, which is the underestimation of the feisty Barbara. So with this underestimation, Babs would don a cape and cow, and she would add a little flavor to it, to first become exactly what her father hated. Jim Gordon, under any circumstance he is placed in, his identity in each iteration is devoted to being by the book. Even after the Joker utterly humiliates Jim Gordon, even showing him explicit pictures of his daughter and shooting and paralyzing her, he still wants the Joker taken in by the book. The commissioner is a man so rigidly tethered by his sense of justice, which is ironic considering how closely he works with the Batman, who is willing to do nearly everything not by the book, except kill. Commissioner Gordon explicitly hates vigilantes, or anyone who wears a mask, an idea that his daughter mocks as she parades through Gotham City as Batgirl, slowly integrating herself into the city's crime field, as well as joining the Batman, and especially getting close to Dick Grayson. Through her short solo stint and a few interactions with Batman, she proves herself worthy of being part of the Batman. She tells Batman about how she sees the future of Gotham City. It's need for the three of them, and she also proves her loyalty. After a few years of being Batgirl, the Joker enters the story, with the killing joke. The Clown Prince of Crime plans on using Barbara to get at her father, and to get at Batman. So on one night, Babs hears the doorbell. Without any thought to looking through the peephole or anything, she opens the door and is greeted by the Joker. The Joker holding a gun, shoots Barbara in the waist, and the bullet travels to her spine, paralyzing her from the waist down. As we see in Oracle Year 1, the entire incident brings Barbara so much shame and disappointment in herself and in others. She is Batgirl, or she was Batgirl, and the daughter of the Commissioner. Because of her status as Jim's daughter, how could she let her guard down? Possibly making a commentary on the choice by Alan Moore, writer of the killing joke. Barbara showed signs of PTSD and she was depressed. Her identity was stripped from her, along with her happiness. Barbara searched for her purpose. Oracle Year 1 ventures through 20 pages of the mind of Barbara Gordon. After being ridiculed, Babs goes in search to find a way to defend herself. When she finds her master, a man by the name of Richard Dragon, he tells her that she needs to find who she wants to be in this world. He almost looks at it as a second chance at life. Barbara was a dancer, a gymnast, Batgirl, but now she is Barbara. In her dreams, the Oracle of Delphi tells her that she has not lost anything of importance. Everything she needs is still with her, also giving her the origin for her name. And in one specific moment in the Suicide Squad comic, in her earliest days of being Oracle, she comes across a villain named The Thinker, or Cliff Carmichael. And Carmichael threatens her entire being.  Barbara releases her frustration out at a firing range, one that triggers memories of the Joker. Barbara begins to question every fiber of her being. She questions her morality, she questions Batman's, and she questions her father's. Whether it is right to use a gun, whether it is right to kill for protection or for revenge, Oracle didn't know what she planned to do with that gun, and if she had it in her to kill him.  While holding the gun, Amanda Waller asks her a weighted question. Who are you trying to kill? Was Barbara trying to kill the Joker whom she saw a flash of? Was she trying to kill all of those who were responsible for her paralysis? As the panel shows the Joker, Batman, her own father, and herself.  Her current or her past self? As Batgirl was a part of the people she saw, was she trying to move away from that part of her life? Barbara has so much inner turmoil and anger and soul searching to do, and for good reason. It wasn't her fault at all, but Babs made the conscious decision to choose change, to move away from self pity and to move on. Which began her transformation first from victim to survivor, then from Batgirl to Oracle. When she was Batgirl, she was another bird in the Bat family, like Dick Grayson, like Stephanie Brown, like Cassandra Kane. But as Oracle, Barbara becomes so much more valuable to the team and to those around her. And she even becomes incredibly important to the Justice League, easily superseding her old self. And in the Birds of Prey run, we get to see the Oracle live and indirect. We see Oracle flex her vast intellect, her photographic memory, and her self-made supercomputer. She shows her leadership, her cunning, and at times her fighting skills. Oracle was truly a force, and the Birds of Prey, the Justice League, and even the Batman, would all benefit from her. It must have been so tough for Barbara whose life was hinged on freedom. She was a dancer, a gymnast, but what Barbara would learn was that her disability was not a crutch on her life. Her motive, when she was younger, was to defy the expectations. She was too small, too fragile. And as Oracle, she just defied the expectations one more time. She hadn't lost anything important. Barbara trained what she already had, a genius mind and arguably became more valuable than she ever was as Batgirl. Barbara was tired of being a victim and ready to help, in any way that she could. And she would become incredibly valuable. She also showed that she was worthy of love, as she still held the Grayson's heart, like the first time he saw her, back in her Batgirl days. So who is Barbara Gordon? She is someone who will defy expectations. She is the model of strength, someone who would build herself back to becoming even stronger than she was before. And she is good representation for those with disabilities. To dig Grayson and Black Canary, she is incredibly loyal and will do anything to protect them. Barbara Gordon is a survivor. Barbara Gordon is strong, both as Batgirl and as Oracle.