Hi, good evening. My name is Amy Humphries and I'm a medical student working up with the Departments of Anatomy and Medical Imaging and Obstetrics and Gynecology. And it's an absolute pleasure for me to present my work on the effect of physician on maternal hemodynamics, which is basically a fancy way of saying how blood flows around the body in late pregnancy. And I'd just like to start off by thanking my supervisors, Professor Peter Stone and Dr. Arlie Merjolele, for being fantastic supervisors. So I'm looking at this in relation to late stillbirth, which is defined as intrauterine death after 28 weeks gestation, which as you can imagine, for expecting parents only months away from welcoming their little baby girl or little baby boy into the world, this is a hugely devastating outcome. And it still occurs in around two to five per thousand births, even in high income countries, making it a significant obstetrics problem. Now the Auckland stillbirth study in 2011 was the first of its kind to show that maternal sleep position had a significant role in increasing the risk of late stillbirth. And this was later backed up by the Sydney stillbirth study in 2015, and a large study coming out of the UK this year. And what all of these studies have shown is that women who sleep in a supine position, that is lying on their back in late pregnancy, have a significantly increased risk for late stillbirth. And this is thought to come into play as part of a triple risk model, where you may have a mother at increased risk of stillbirth already, a fetus in an already compromised situation, and throw into the mix an acute fetal stressor, in this case maternal sleep position, and this may act as the tipping point resulting in stillbirth. And one of the proposed mechanisms behind this association is thought to be that when a woman in her third trimester lies on her back, the graved uterus acutely obstructs her inferior vena cava, which is the large vein returning blood back to the heart. This acute obstruction is thought to be compensated for by an adequate collateral venous system, providing an alternative route for blood to return back to the heart. And this therefore enables them to maintain their blood pressure at a normal level. However, we speculate that women with inadequate collateral venous drainage, potentially due to anatomical variations in this system, may have a reduced ability to compensate for this, and therefore may drop their blood pressure in the supine position. And this is seen clinically as supine hypotensive syndrome, which is where a woman feels faint or dizzy or may even lose consciousness when lying on her back, and occurs in around 8-10% of women in their third trimester. And we speculate whether women in this category may be at a further increased risk of late stillbirth due to this acting as that fetal stressor. Now these are a couple of MRI images taken in an axial plane, so if you imagine it's been cut right through the middle, of a woman in her third trimester. We have the graved uterus here with the fetus in sight, as you can see the abdomen here with the legs. And we've got the inferior vena cava and the aorta sitting just on top of the vertebral column here. Now in the left lateral position the RBC is completely patent. However when the woman turns supine, it becomes quite dramatically compressed. And in this scenario it's thought that a system of veins called the azogus system provides a collateral pathway from the pelvis back to the thorax. And I know this picture looks a little scary, but this is the inferior vena cava coming here, and it splits into the common iliac veins further down in the pelvis. This gives off the ascending lumbar vein, which travels up beside the vertebral column to join with the subcostal vein at the level of the diaphragm. This forms the hemiazogus vein on the left hand side and the azogus vein on the right hand side. And this hemiazogus along with its accessory hemiazogus eventually drained back into this main azogus vein, which drains back to the supere vena cava and therefore the heart, creating a nice collateral pathway from the pelvis back to the thorax. Now the following image I'm going to show is of a cadaver or a person who's donated their body to science, in which I've dissected out the system. So just to orientate you, the head is up this direction, the legs are down this direction, and we're looking at the vertebral column from a slightly left hand view. To make it easier the RBC has been reflected off to the right here and splits into the common iliac veins in the pelvis. The ascending lumbar vein travels up beside the vertebral column to join with the subcostal vein at the level of the diaphragm. Because we're looking at the left hand side, this forms the hemiazogus vein, which drains back into that main azogus vein, which then will drain back to the heart. So as you can appreciate, a nice alternative pathway from the pelvis back to the thorax. However, this system of veins has never been studied before in pregnancy. So the aim of our study was to investigate the effect of the supine and left lateral positions on maternal blood flow in late pregnancy using MRI. We obtained ethics approval to recruit healthy pregnant women and we used a 3T MRI scanner to scan them in the supine and left lateral positions. We took axial phase contrast images at the level of the aortic root and images of the azogus vein at a similar level just before it joined to that superior vena cava. We also took images of the abdominal aorta and the IVC just above the level of the renal veins and just above the aortic bifurcation. And we analyzed these images using a software called SINGOVIA, which allowed us to calculate net forward volume through a specified region of interest, in this case the ascending aorta as it comes off the ventricle. And we combined this with heart rate to calculate cardiac output, which is a measure of how much blood is pumped around the body per minute and blood flow through the azogus aorta and IVC. So we recruited 12 pregnant women without supine hypertensive syndrome and these women had a gestational age between 34 and 38 weeks, so in that third trimester. All of these women had a normal pre-pregnancy BMI with an average of 23.3 and went on to have normal pregnancy outcomes. So what we found was that blood flow reduced significantly in the supine position through the IVC by 43.5% at the level of the renal veins and 86.5% at the level of the IVC origin. So in keeping with that IVC compression that we've talked about. However, we also found that cardiac output reduced by 15.5% in the supine position and I'm going to talk about the significance of these results in just a moment. We found that blood flow through the azogus vein increased by 164.5%, and maternal heart rate increased by 11.7%. However, the most surprising results came when we measured the blood flow through the aorta, which reduced by 17% at the level of the renal veins and 36.6% at the level of the aortic bifurcation. Now to put all of these numbers into a bit of context, what we're seeing is that in the supine position, there is a reduction venous flow due to that IVC compression that we've talked about and that this is of the magnitude of 86.5%. This will reduce the blood flow back to the heart, therefore reducing cardiac output, which we've showed to decrease by 15.5%. Now cardiac output is directly related to the pressure within the arterial system, which will therefore also decrease. This will stimulate the maternal sympathetic nervous system to increase maternal heart rate in order to try and compensate for that drop in cardiac output, which we've showed to increase by 11.7%. Now the level of IVC obstruction and below, there will be an increase in venous pressure due to blood pooling in the extremities and unable to return back to the heart. This will force blood into the collateral venous circulation, which we've showed to increase by 164.5%, and that will serve to try and increase venous return back to the heart. However, this increase in venous pressure and a decrease in mean arterial pressure is likely to reduce driving pressure across the lower capillary beds and therefore explain the reduction in arterial blood flow that we're seeing. And this is of the magnitude of 36.6%, which is not insignificant, especially when you consider that the uterine artery, which supplies blood flow to the placenta, comes off below this point. So unless there are significant vascular resistance changes occurring across the placenta, there is likely to be a significant reduction in blood flow. This will reduce oxygen delivery to the fetus and therefore act as a significant fetal stressor. And this is important to remember that this is occurring in women who can lie on their back without experiencing any symptoms whatsoever. And if you think back to that triple risk model, while a healthy fetus may be able to tolerate these changes, an unhealthy one, this could be the tipping point. So our study is currently limited to normal pregnant women, but we have significant questions about how these results will change with women who do experience supine hypertensive syndrome. And we question whether this is potentially due to anatomical variations in that collateral venous system that I've talked about. So we're currently in the process of recruiting and scanning women with this syndrome. We also question whether these results will be different between lying on the left and the right-hand side due to normal anatomical differences between the two, with the RBC being more on the right-hand side. So again, we're currently in the process of doing this study as well. So in conclusion, the supine position causes important maternal hemodynamic changes during late pregnancy. And the azúcar system of veins has been shown for the first time to be utilised as a collateral venous pathway in order to try and compensate for this. However, despite this, we're still seeing significant reductions in maternal arterial blood flow, which has the potential to reduce placental blood flow and act as a fetal stressor. And this work, in combination with a lot of work that's being done by the Maternal Sleeping Pregnancy Research Group, is leading on to a future public health campaign to recommend women to not sleep on their back during late pregnancy. And I'd just like to quickly thank all the participants of the study for their invaluable contributions, the Maternal Sleeping Pregnancy Research Group that I've already mentioned, and the staff and technicians at the Centre for Advanced MRI and Keoghs for funding the project. Thank you very much.


I got a little away from me in the third quarter. What were you seeing there that was that was at fault.  We we thought our our our guys got a little tired from the load they were carrying and, you know, they were able to use their depth and talent to kind of find a little separation. But I was proud of the way the guys competed and approached the game. On that point, what is your big takeaway? You mentioned being proud of the way they played. What's the what do you pull away from this game in totality, especially when you consider the last 24 hours? Yeah, I thought that, you know, we need to get a little more physical. And at times we showed we were we we got in there and crack people on rebounds double on the floor for loose balls. Some of the things that we're going to have to do here to get better. But I thought we also cleaned up a little bit of our defensive schemes at times and, you know, we grew a little bit. So, you know, it was a tough loss. We were a little under man. But I thought there was a lot to be proud of from our guys.


Okay All right, good morning everyone Morning good to see you A week has gone by quite fast Isn't it? Feels like I finished my class yesterday Right, okay, let's do a quick recap of chapter three it was all about government and structures What do you remember from last class? Okay, let's just pass on the mics. Okay, can someone be in the middle and just pass the mic on So the audience online also benefits from your answers First they started the church. Yeah After the church there is an emergency for deacons for there to help Okay And right so there's an emergence of deacons, okay, what's the Greek word for deacons? Yeah, are you saying or asking? You know Diaconos, what do you think? Diaconos, okay. Yes All right So we saw we see the emergence of deacons. So what is the meaning of that word diaconos? To help assist serve. Okay, so that's the emergence of deacons. We see that happening in which chapter of the axe Chapter six, okay Right, then what else do we see happening? What else did we learn in the last class? Deacons can also we're also encouraged In this in the spiritual ministry as well, okay, not just the administrative part, but also the spiritual ministry what sorry After we after that we see the elders also being added. Okay, the emergence of elders, but so Deacons going and building new churches, right and planting churches Going out in mission trips. Okay, but what were the Some of the criterias that that were required of the deacons They have to be filled with the spirit of God there should have faith Yeah in page 17 in your PDF or page 25 in your textbook, so it says on its report. That means their reputation Yeah, like in other words on and off the stage has has to be consistent with who they are I'm full of the Holy Spirit full of wisdom took responsibility for daily distribution of the food Okay, that means they were responsible accountable What not okay, so they were encouraged in spiritual ministry as well not just administrative part. Okay, I knew churches were raised Because of them and we see the emergence of elders Later on in next chapter 14 onwards So I give a very basic definition of what an elder is, right? There can be a new Christian, but and but elder at age, right an old advanced in age, so hence The word elder or the title elder Okay, and then later on we see that churches in different places moved from multiple leaders But eventually being a head by one leader, right? That hence the word we get the presbyter or presbyter, you know, we get it simply means presbyteros It simply means bishop or to shepherd or to pastor, okay? So that means a church can have multiple leaders. That means they can have many deacon board members They can even have elders Who give counsel and advice and whatnot, but eventually the decision would lay on the bishop Right one leader who would oversee so those were all and we saw different systems that Yeah, the clerical system and all this different clergy system How a church can function basically right the different network of churches they function very differently your church back home will function very differently Etc. Etc. Okay, so that's what we looked at chapter three is the structures and the systems, okay? Francis all right So let's move on to chapter four What is the stages of growth and development? Okay stages of growth and development, which Okay in your hard copy page 41 page 28 in your PDF So in this chapter to give a very quick overview We look at one of the different stages that Church needs to function or to progress in order to grow and we look at a couple of case studies as well Okay, but very quickly amongst us Please use the mic if you have to response again, it's for the benefit of everybody online and also the e-learning students So when you think of the word growth Right growth. Yeah growth. What comes to your mind? What is Mike Mike Mike Mike to be developed in certain things to be developed Okay Okay, Nina says growing to maturity growing to maturity. Okay going to maturity. Okay Changing like how before Like we can say Everything is changing like how before before and now it's like it's different. So there's a change with growth. Okay Stages of a judgement says stages of development in a person stages of development So develop that means there's some sort of a progress develop, okay, when I was in school They used to teach that India is a developing country. That means it's a present continuous and I'm not saying anything after that Okay, okay, so that's what it's a progress progressing like present continuous developing or it's not developed So it's so that means there's a sense of progress, right? It gives you a sense of progress So Justin says stages of development. Okay, that means the stages of growth or progress. Okay, what else? Before I have done a study in India. Now I'm thinking Okay So You're learning it. Let's say, okay, that's that comes under a different skill set So you're learning a different skill for example, right? So, yeah, okay Again, I'm not sure if this happens nowadays, but then during my time in summer holidays Two months of summer vacation you had to go and learn a new skill like you go for typewriting classes shorthand classes Used to happen in my days. Okay Along with playing and whatnot. So yeah, developing a new skill set shows growth, isn't it? So in this day and age you have to kind of grow every day or every, you know Your skill set has to keep improving. Otherwise, you'll be in trouble. AI is going to take all your jobs Yeah, okay, what else guys Rather sorry see rather Growth growth, yeah, I don't throw everything in Sorry Prince Increasing, okay, roughly nothing. Okay, progressing. Okay Yeah, so I think I Mean I do this you haven't say Nina you sure okay Right, so it's such a simple word, isn't it and with so many different definitions with all You know accurate examples or explanation of what that simple word growth is isn't it but In the Christian circle It's very easy for us to overlook certain words Very very easy in the context of the church, for example, let's say even growth for that matter We use that word so much if we need to grow we need to grow this ministry We need to grow so but when you take time to put a definition or give a definition of what your understanding of that is Of that word is slowly the perspective changes Isn't it okay, so this is what growth means to him So this is what growth means to her. Okay, so what can we do to work otherwise? Okay, let's grow the church Where how why? You know But and so our God is a God of growth He starts small you started small and you know from human beings even isn't it And something about him he likes to start ball and then and then yes, I'm you know There is a lot of answers for us in life itself. So Yeah, at least I teach my music students.  My son looks at me and he says like Dara, I want to become big I won't become big just like you but he doesn't understand the responsibilities and All that that comes with it because something about growing fast or playing anything fast. It looks really cool but It's so important to go through that stage. Isn't it like Are you with me right so going through that process or that? The progression of growth is so important than just skipping So that's why the chapter is called the stages of growth Is that you take one by one step at a time if you skip anything like jump from one stage to another stage? There's a problem Right So that's what this chapter is all about but before we could do that. I want us Anand has shared a file with you on whatsapp. I think so but Where is I want to just let me just share something Oh, there it is. Okay, I just wanted to because we are going to go through the book of acts and you know A huge majority of the time. I wanted us to give a timeline Like and I'm doing this because it It helps me in understanding the Bible, okay for me, I need to understand Okay, what happened when you know that and so and once I understand what happened when things like that I'll never forget it That's how I learned So I'm trying to share the way I learn and understand the Bible with us. So you can all see the screen, isn't it? You know, okay Francis the screen is over there What is period I have to look at what screen you're talking about I am in the early church All right All right. So this is the timeline of the book of acts Let's just go through that the blue thing it says the purpose of the study is to illustrate how the young church advanced Amidst seasons of struggle and growth Seasons of struggle and growth during the first century. Okay, this is the first century church We all know that we'll set our scope on the period between Jesus's ascension and John the Apostles death Acts provides an outline for the first 30 years will lean on the early church and Roman historians Fill in the next 40. Okay. Let's move on So act chapter one Starts off at 30 AD. So what do you see the column to your left? We have different season So the first season will it's titled as a season of gathering Okay, act chapter one is that the year 30 AD Jesus's death and resurrection ascension. Okay acts chapter two happens around the same period where we have the What is it? Pentecost Apple room and counter the day of the Pentecost Pentecost is what? It's a feast of the Pentecost as they call it one of the festivals Okay, and the Pentecost is in Greek is the 50th That's what it's the 50th. That's what it is. So the 50th day of the feast Okay, is And I mean we can go deep into all those details about the feast and what not the feast of the tabernacles the feast of the Pentecost We can study separately or you must have you would have already learned about it in the New Testament survey or the Old Testament survey But yeah So we're still they're actually up to 120 people are baptized 3000 people are added on the first day and then God adds Members to the church every day. Okay, and the map just have a quick glance at the map. I love looking at maps So you see Jerusalem and then you look at Mesopotamia Cappadocia Pontus Asia Phrygia Libya Egypt Judea Arabia, so now, you know which direction What is Rome is the farthest Maps are important is the ancient maps. Yeah So during this time the Tiberias is the emperor of Rome in your third column a Roman Empire Okay, so let's move on one year later 31 80 act we go to act chapter 3 Peter heals a crippled man in the temple draws a crowd Peter and John arrested by Sanhedrin released the warning the number of men who believed grew up to 5,000 All right, you guys are with me, right? Okay. I hope you're not getting bored because of all these Okay. Yeah, so back then when the early churches formed that 3000 and 5000 believers are added to the church. Yeah, so is was it like a Sunday meeting or every day they used to come and break the bread and Fellowship they had fellowship very regularly so see one of the things what we need to remember is that What we think of these people Who believed in Jesus later? We see that or they were known as the people of the way Right people of the way. They were not known as Christians until much later. I will get into that But we need to remember that the people who were saved were still Jews That means they still practice going to the temple Or they would meet in smaller places because of smaller houses small groups And there was all big and that happened very regularly, but and also I think their big day was the Saturday, yeah, you know, it's like before the day before the Sabbath was kind of big for them. So Yeah, it was pretty much same. So I think Sunday came in much later as their So Friday and Saturday they took their Sabbath very seriously because they will not do anything on the Sabbath day, you know Yes, so I mean they got they sat and spoke about one day that before Sabbath Yeah, and they just decided one day after that they used to meet weekly ones like that Yeah, that's how this everything came out, right? Yeah, and They they believe very they believed a lot in the power of community I think it was I'm not sure that they even knew of what community was, but they enjoyed that, you know, coming together See this idea of Discipleship Discipling and all this small synagogues and all comes from the place of Galilee Right this Methods of discipleship or this idea of discipleship was pioneered from Galilee And that's why Jesus is kind of headquarters away from Jerusalem was a cappernum, which is one of the towns in Galilee But he would go there because he saw and he knew that this thing of discipleship was very famous there like a rabbi taking Under, you know disciples I mean, there's a lot of lot we can talk about just that but when we will speak about it when we speak about discipleship later Okay All right in 80 32 and 33 and we are in Acts chapter 4 now Barnabas Joseph who's his original name, you know the meaning of Barnabas That name Barnabas was given to him by his friends. It means son of encouragement Yeah, so can you imagine your friends giving you a nickname?  Like what's that Francis? Yeah, I mean most of the time it's not great It's it's either funny or something to insult you with kind of a thing right, isn't it but But imagine Barnabas which is his nickname his original name is the name that was given to him by his parents as Joseph means He was an individual that was so full of encouragement that he would always encourage Anybody who come across his way and says like hey, dude, you are always encouraging So let me just let us just call you by you know by that date title and so that's hence Barnabas Ananias and Sapphira light of the Holy Spirit into the day Jerusalem church meets regularly in Solomon's colonnade apostles perform many miracles More and more believed. Okay. So the church is growing now. Okay, and we are in Acts chapter 4 third year. Okay, that's 33 AD. So and then now 33 and 34 number of disciples was Increasing so in that title, I'm sorry in the document. What am I saying? Let's go back to the act chapter 1 and 2. Okay the first year it says baptized, isn't it now baptized baptism is Simply means bring them into Bring them in Okay, or immersing baptism of the Holy Spirit of water baptism is what being immersed in the water and other the root meaning of that is to bring Them in okay, so that is also So as they're bringing in what is happening, it's they're growing Isn't it 3,000 people are being added. They've been baptized, isn't it and then God adds daily It says there. So you see all the red Name words is all pointing towards one word called growth Okay 31 it says they believe it grew so growth also points to the expansion and number Right, that's obvious, isn't it and and In act chapter 4 and always says they were added to their number and here in act chapter 6 the number of disciples was Increasing there's a growth happening. Okay The disciples was increasing because someone was being discipled and someone was discipling they were not sitting idle Okay, the number of disciples in Jerusalem increased a large number of Jewish priests believed Okay, so One very important thing is the number of disciples in Jerusalem increased now I remember Jesus telling as soon as you receive the Holy Spirit go out, but until you receive weight in Jerusalem So something tells me these guys Didn't go out yet and That now this is what almost four years later For us it is two three chapters Okay But now so okay, let's move on to the next season the season of scattering Okay So the first season is called a season of gathering that is from acts chapter 1 to acts chapter 6 We can look at it that way. Okay season of gathering and the second season is a season of scattering Oh, good Lord. Okay time is running out. Okay From acts chapter 6 and acts chapter 2 acts chapter 8 suddenly they were supposed to go out But then persecution comes Main man hero and villain at the same time is coming in Saul arrives. Okay, it's an arrival major fool Okay, Saul arrives in Jerusalem Killer music in the background.  He was thrown to death so unleashes persecution All except the Apostles scatter so the Apostles the 12 original Apostles remained in Jerusalem So then it says they all accept the Apostles scatter Okay, so forced to scatter by persecution the church Scatters seeds of the gospel everywhere they go. So what should have happened? Organically after the baptism of the Holy Spirit in chapter 2 what should have happened organically That means once they received the power from on high They were supposed to go into Judea Samaria and to the ends of the world should have happened organically But then now it's happening because of the persecution Are you with me? But God uses, you know, anything that comes our way to his glory. So So because of the persecution people are going Apostles deacons elders Whatever they're planting churches. Gospel is being spread Philip of Acts chapter 6 not the disciple evangelizes in Samaria Peter and John go to Samaria to check out the converts So they Peter and John they hear about the new believers in Samaria They go and baptize them in the Holy Spirit. So you read the chapter. It's great. Okay, so now we are in Acts chapter 9 So I converted he encounters on the road to Damascus Couple of years ago, I think 2020 we had a youth conference. We called on the road to Damascus So Thanks It's like a 30 seconds later. It's like, oh, yeah D masca's the D masking Yeah, so I converted on the road to Damascus. Sorry Damascus So it's filled with the Holy Spirit. That's act chapter 9. So goes to Arabia for three years So if you again go back to the map, you know where Arabia is so, you know, which direction Sol went in. Okay, all of that is crucial guys Like for us to know which direction you went, you know, event north or south or east or west All of that is you'll never know when will when that information will come in handy. Okay Those online, I hope you all are with me as well, Nina Prabhu, Shiv Kumar, Josh and Anthony. Okay All right, let's move on. So now So act chapter 9 is eight years later, right? That's 38 to the left. You see that's 38 AD. So we started at 30 AD Right. Okay. So we're still in act chapter 9 in 39 AD All breaches Sol gets into action right now. So 40 AD. We are in act chapter 10 Peter's vision and Just gonna go a little bit faster now. Okay. All right So let's move on to the next season the period of organized mission From act chapter 12 So I've shared this PDF with you those online. I will share this PDF with you guys, but let's just come down all the way I'm gonna just calm down To the last season season 6 the season of John and the last Apostle Wait, hold on a second one second So there are 28 chapters in the book of acts Right 28 chapters in the book of acts and now we are here. It's in AD 62. So Approximately 32 years of Ministry and life is covered in the 28 chapters. Okay, and then and then a little bit more It's great when you have like, you know something like a reference point like this Do you know what happened when and for how after how many years? I mean, this is this is applicable for Any book in the Bible that you want to study because for us We only have chapters and we don't really think in terms of okay This happened one month later or two months later. We don't really know that but So it's very crucial any book you want to take any chapter You want to take the gap between chapter one and chapter two. It's kind of important, isn't it? It starts it starts from the very first chapter and the very first verse in the beginning God created the heavens and the earth and Then the earth was you know without form and void and then verse three suddenly something else is there And even in verse two. So what happened between verse one and verse two? God only knows that okay, so I don't want to add anything to God's book. So let's leave it at that Okay, are you guys with me? Yes. So it's very crucial For us to just understand the timeline the maps who was the ruler everything I just add one side note and we move on to the notes Why is it important to know who the ruler is again in the Old Testament if you go? depending on who the king was and the region he set for example Say five thousand cubits Could mean different in under different king's era rain because he said when you convert it later for example Let's just take a present day for us to understand better. Let's just take one dollar one US dollar at the moment It's about 83 rupees or something 78 okay, thanks. Nikhil. So Nikhil is the king now So just like that a king will come and tell it was 83 now It's 78 just by him saying with the authority of that power of his word it. That's what it would be and So like it's very important us to understand Okay, during Noah's time if it is one qubit What was the one qubit and his time because it can change in another period? Are you with me? Okay, so It's the same thing and there's a lot of things. Let's just move on. Okay Okay, so now let's do a quick We've gone through the book of acts we kind of understand the timeline a little bit Let's do a case study of the early charges Okay, this is where I want us to use the mic as well because we'll go point by point and Towards the end of it. I'd like you to share what is there a couple of points that kind of stood out to you? As we do this case study. Okay, so we'll take the mic and Each of us will go through at least three points. We'll read three points and pass the mic on Is that okay? Yeah, we start with Prince Because the mic is there next to you. You're only reading what you're giving looks Yes, please start Started by believers who are scattered out of Jerusalem due to persecution Established through supernatural Demonstration which one are you reading? The Jerusalem church Thanks to our Prince Is the the Jerusalem church Born during the Feast of Pentecost Started in a powerful way grew very quickly through science and wonders focus was on small groups meeting In houses and also met together in the temple. Okay, awesome. Thank you Everything in the church was initially handled by the Apostles even though there were thousands in the local church Deacons were appointed later to handle food administration. These deacons also was strong in the spirit and were involved in the ministry Multiplication came about because of persecution Initially the Apostles remained in Jerusalem Although other believers and the deacons dispersed some of the expansion was directly orchestrated by the Holy Spirit after some years the Jerusalem church heard elders were part of the leadership Perfectly ministry teams were sent from the Jerusalem such a minister to other locations seemed to couple with Rapid growth initially use a small group Meetings effectively during the rapid growth Mended a good balance between might mighty manifestation and strong teaching to establish the diverse Establish a strong sense of community and sharing of things result internal conflicts well Apostles from and in Jerusalem to keep the primary base strong Apostle and elders resolved doctrinal issues well Okay Seemed a little slow to raise up second and third lines of leadership perhaps to focused on key leadership Apostles did not seem to get too involved with new churches directly Awesome. Okay. Yeah, thank you. So we So Apostles did not the last point was Apostles did not seem to get too involved with new churches directly. Okay All right, some of the key points that stands out stood out to you What is the mic please pass on the mic? Let's be quick to pass the mic on please One of the thing is There is a rapid growth initially it's because of this prophetic ministries and all and The second point Apostles and elders resolve this doctrinal issues actually Apostles and elders resolve Okay, last third point The last third point. Okay. So prophetic ministry teams were sent from Jerusalem. Is that what you're saying? Okay There's a to minister at the locations. Okay. So what about it kind of stood out? Why does that point stand out? So it's it's a continuation of the second point of the seem to cope well with rapid growth initially I think after this prophetic ministry and all Maybe there is a growth in this church Like due to this prophetic ministry like healings may be It not just that no, there's also science and wonders everything so prophetic ministry was not just evangelism that happened but Everything being One of the points that's a recurring points we see that is God added to the church every day is Is a point that says there was evangelism happening So it's water and in that there was also prophetic ministry So it seemed like almost everyone was moving in the prophetic back then because of they were filled with the Holy Spirit There is a lot of like in this Jews and well, there is a lot of doctrinal differences and after these apostles came there is actually so many got resolved I've heard in another class also After this of course is there is a I mean the result is resolved. Yeah, yeah, so one of the other key points. I think That we need to pay attention is It says resolved internal conflicts Right, so it doesn't just say it result they resolved internal conflicts. It says they resolved internal conflicts well It's the key word there as well. Okay, so that means they resolved it with wisdom and understanding and with maturity So they will as they were, you know, they were as they were growing in number They were also growing spiritual in spiritual maturity. So they had the wisdom to resolve conflicts, right? Resolving internal conflicts guys. Let me tell you Yeah, it's not an easy thing Okay, you can resolve it But maybe not well, you know Okay, anything any of the points that kind of store for anyone in case study Speak speak speak or yeah Yeah, sorry, go ahead. Yeah, this point Where it says seem to cope well with rapid growth initially use small group meetings effectively doing rapid growth I mean they continue to Still meet up still and I mean it shows that they They came together pray together Continued in that, you know to strengthen and grow even though they were Increasing or they were growing but still like internally Spiritually they strengthen each other and yeah Yeah, the small groups it just seemed very powerful and they believed in that a lot and I think I mentioned this in the previous sessions that When they were in the exile with Babylon in exile for 70 years because they did not have a common place to meet for worship And because the temple was destroyed, they did not know what to do But they wanted but they had to keep this fellowship kind of thing going this worship going and so they would in during the period of Exile they started this meeting in small people that's what the historians and scholars say and and most of the evidence kind of point to that fact and so the Synagogues and all these small groups Hundreds and hundreds of years later is the final form of it. Okay, so yeah anything else Okay, Jachan says sorry lovely she says points towards maintained a good balance between mighty manifestations and strong teaching to establish believers I mean Yeah Nation came about Because of persecution. Yeah, so that is very interesting. Yeah, I don't know how it really happened because Yeah, because people are opposing it so much It may be generated a curiosity in the people as well And also they're seeing a lot of science and wonders and miracles being happening day in and day out Through this group of like 3000 and 5000 years gathering and stuff. Yeah So I think this might be related Practically when we said this area. I mean this era what's happening. Yeah, even the persecution is there, but there is a chance of growth Yeah, absolutely. I think Sorry Yeah, so It's not just in this period historically, but then you go through the church history Does this take for example the Bible? Right the Bible There are so many people emperors leaders who wanted to destroy the Bible like one of the Roman Leaders Diocletian or something you wanted to Burn every Bible and on that ashes build a pillar or something That's what it's another form of persecution. It's it's an own way, right? But then here we are Today right with different versions and languages one of it's the only book that's translated the most the most selling Etc. Etc. Right is the Bible. So I think any time Something about persecution is about when you press you get the oil out of it, isn't it? So there's more pressing more the oil comes out. Isn't it so yeah Yeah, anything else and Nina, okay, just pass the mic to Nina, please Establish a strong sense of community and sharing of things like there'll be even though the people are different from different places, but still they have that Community love for each other. Yeah, maintain. Yeah, absolutely. Yeah Okay, so This community in the Jewish culture was big I please forgive me for sounding very redundant to keep going back saying okay community was important community was important but But it was really big like they're in amongst them like their community was huge like they believed in in the sense of community being one Being within themselves all of that, right? And so because of that there were two things that was that would happen one is they would not like the other communities Samaritans the Jews did not like them necessarily It's because of the other community of people a group of people We are this we believe in who we are we know who we were shipping we know who our fathers worshipped we believe in that You with me, but what happened within that is they would be helpful to each other. Isn't it? Yeah, and one of the things I studied What discipleship and the culture of the period is You know the parables that Jesus used right so during the period there were a huge number of parables like at least a 3000 stories odd and so what? Jesus did is he would take the one of the parables that existed back in the time and then he would change one key Point in the parable, so let's take in the parable of the what says a prodigal son Is in the in its original story The father does not go and receive his son Why because his greatest sin of the prodigal son the greatest sin according to the original text it says is That not that he took his father's thing, but the fact that he left his people his leg He left his community and went so that was considered to be so anyone who left their community Was considered to be a big sin and they were not accepted back And so when the or when the son comes back In the original story he says the father would be weeping But he would not go to receive a son and everybody around him would say you did the right thing to the father But didn't would take that key element and would change it and irritate every other Jewish people right and so and And that's the beauty of it is they took community seriously It was very big and it's no accident We see that you know in the case study that community was important the small groups was all important and what not Okay, so all right time we'll stop here and we'll continue in the next session from where we left off, okay Great, we're still in page one. Okay All right, we'll stop and we'll come back after the break. Thanks guys


This is the House Health Care Committee. It's Wednesday, May 5th. It's just about 3.30 in the afternoon, and we are convening following the floor. And this afternoon, we are going to be reviewing language again that is in the budget, but language that was on our agenda for the morning and had to be deferred until now. It's language that addresses setting up a healthcare task force. I think I'll leave it at that, but I've asked Jen Carby to walk us through the language and so that we have it in front of us and then we will be in a position to be thinking about it further over the next between now and when the Appropriations Committee asks for our input on languages in the budget. So with that, I'm going to turn it over to Jen and will you give it a more proper introduction? Sure. Good afternoon, Jennifer Carby, Legislative Council. I will put up the language. We're looking again at the Senate passed budget, so H439, and I'll show you what page we are on if you want to follow along. So it's the same document we looked at this morning. We're now on page 114 and it's section E126.2, Task Force on Affordable Accessible Healthcare. This creates first the Task Force on Affordable Accessible Healthcare to explore opportunities to make healthcare more affordable for Vermont residents and employers. The Task Force would be composed of six members, three current members of the House, not all from the same political party appointed by the speaker and three current members of the Senate, not all from the same political party appointed by the Committee on Committees. It gives the Task Force certain powers and duties. It directs them to explore opportunities to make healthcare, including prescription drugs more affordable for Vermont residents and employers, including identifying potential opportunities to leverage federal flexibility and financing and to expand existing public healthcare programs. Directs the Task Force to consider the following, keeping in mind the Principles for Healthcare Reform enacted in and this should be 2011, and astute reader or watcher pointed out to me this morning, should be 2011, acts and results number 48. That's the big Act 48 that people know. So keeping in mind the Principles for Healthcare Reform enacted in Act 48 and codified at 18 BSA, section 93, 71. And I think we've looked at those somewhat in here before as well. So Task Force is supposed to consider the long-term trends in out-of-pocket costs in Vermont in individual and small group health insurance plans and in large group health insurance plans. How Vermont's current healthcare system is impacting Vermont residents and businesses and their access to affordable healthcare. The extent to which Vermont's uninsured rate may have increased during the COVID-19 pandemic and the specific causes of any such increase. Opportunities to decrease healthcare disparities, especially those highlighted by the COVID-19 pandemic and those attributable to a lack of access to affordable healthcare services. The findings and recommendations from previous studies and analyses relating to the affordability of healthcare coverage in Vermont and opportunities made available by the Biden administration to expand access to affordable healthcare through existing public healthcare programs or through the creation of new or expanded public option programs, including the potential for expanding Medicare to cover individuals between 50 and 64 years of age and for expanding Vermont's Dr. Dinosaur Program to cover individuals up to 26 years of age to align with the young adult coverage under the Affordable Care Act. And that talks about public engagement in order to gain a fuller understanding of the impact of healthcare affordability issues on Vermont residents. The task force shall solicit input from a wide range of stakeholders, including healthcare providers, healthcare administrators, Vermonters who lack health insurance or who have inadequate health coverage, employers, labor unions, members of the new American and black indigenous and persons of color, BIPOC communities, Vermonters with low income and older Vermonters. Beginning on or before September 15th, 2021 hold public hearings to hear from Vermont residents from around the state. Public hearings may be held in person or by remote means and a summary of the findings from these field hearings should be included as an appendix to the task force report. Then it says to the extent that applicable funds are appropriated in an earlier section of the budget. So $175,000 is appropriated in section B1106 of the Senate proposal on the budget. The task force through the office of legislative operations would hire a consultant to provide technical and research assistance, deliver actuarial analyses as needed and support the work of the task force. In addition, the task force would have the administrative, technical and legal assistance of the office of legislative operations, the office of legislative council and the joint fiscal office. Then there's the report by January 15th, 2022. The task force would present to the general assembly its findings and recommendations regarding the most cost-effective ways to expand access to affordable healthcare for Vermonters without health insurance and those facing high healthcare costs and the various options available to implement those recommendations. The first meeting of the task force must occur by August 15th of this year. The task force will select house and Senate co-chairs from among its members of the first meeting and the co-chairs would alternate acting as chair and task force meetings. A majority of the task force membership will constitute a quorum and the task force shall cease to exist on the date its report is due. Compensation and reimbursement for attendance at meetings during adjournment of the general assembly, the members of the task force are entitled to per diem compensation and reimbursement of expenses under two VSA section 23 for not more than eight meetings. And those payments will be made from moneys appropriated to the general assembly. And that is it. Okay. Thank you. Sure. Why don't we take the language off the screen at this point? I think it's, we can access it as needed. So this is, so again, just to state again, this is a proposal from the Senate in the budget with an appropriation attached of $175,000 to primarily provide for the engagement of a consultant as needed and some of the, and the some of the per diem expenses and attendant expenses in holding meetings and hearings as laid out here. Representative Dahlia? Yeah, just on a technical background piece is one option among the options to say, well, we endorse creating this task force but we don't think a consultant is needed. So we don't endorse the money in terms of what we tell appropriations or is it an all or nothing kind of? Well, I mean, I would just say for my take on it right now is it's not all or nothing, but it's also the case that appropriations might say to us, we think the task force is a great idea, but in fact, we are not going to appropriate $175,000. Understood, understood. It was more for newer members on process. Yeah. Yeah, it could go either direction, because in fact, again, I'm trying to put all these proposals in context of a conference committee. This is $175,000 and a policy proposal, neither of which are in the house budget. And so it is not uncommon or it is actually quite common that if in fact, one body wishes to include something of a substantive nature from a policy point of view and or a financial point of view that there's some concomitant balancing at times that the other body needs to adjust to advice in order to reach the same agreed upon bottom line, et cetera. So yes, that is completely possible. It's not a package deal. From my point of view, that's the Senate might feel differently about it, but that's not my point of view, right? It's also the case from my point of view that the specific language of the proposal in that it's being presented to the house from a Senate proposal is also subject to modification, perhaps by suggestion of our committee or by the appropriations committee. And I think it's important, I'm just gonna say this and this is the broad piece. This is in the budget. The appropriations committee, as you need to understand has the final word on what's in the budget. They do and increasingly, they're turning to the policy committees for input and guidance, but they do reserve the right in the larger picture of what they're dealing with to modify provisions and or make decisions. But I would think they will turn to our committee for recommendations. And I think it's important to understand too that they then have to, just as when they created their budget, they have to prioritize among all of the different pieces of input, but then beyond that, they have to prioritize what they're willing to give up and get in a negotiation process with. So they may agree with something we asked for, but it may fall somewhere on their list of what they're gonna push back on if we're not, I mean, if we agree with it. No, I think that that's what I was trying to communicate as well. Representative Black. So I'm opening up to committee questions at this point, clearly. So our committee questions, comments and then, and again, we will, this will not be our only opportunity to talk about this. So I guess I'm confused about the process. Isn't this essentially S120? This is, well, let's talk about that. So a creation for S120 that we haven't gotten. This is a portion of what, a portion or a version of what was once in 120, which was a Senate bill from the House Health, Senate Health and Welfare Committee, which they chose to move. And there was a few days there when people were asking, you know, well, when are we getting 120 or what's happening with 120 and 120 didn't make crossover. And they chose at the last minute to take certain sections of 120 and embed them in the budget. We have never received 120. It has never left the Senate. Yes. But that's a way of... And we will never see it. Well, we won't be taking it up this year, I think is pretty... I think that's pretty certain. I think that's pretty certain. But that is a way that House and Senate, you know, go back and forth is things can show up in the budget when they haven't shown up anywhere else. And I'll say it again, and I'll say it in light of what your question, the Senate has somewhat of a different process and culture internally where they tend more than the House to put policy pieces in the budget.  They are in the position where they, in this instance, there was a bill, S120, which clearly had not made crossover, barely was making it out of the committee and much less through the Senate and would have ended up in our rules committee. It ended up in their rules committee. They were gonna have to get it out of their rules committee, take it through the Senate floor. By the time it got to us, it would have gone to our rules committee and et cetera. They made the strategic decision, let's put some language in the budget. Let's bypass the committee, let's bypass the traditional sending a bill process. And just to point out, I'm sorry. Well, I wanna just say, that's why I'm couching all of this as this is not a given. None of what you're talking about is a given because in fact, this all bypasses the process and it's typically the house process of putting policy language in bills and having the committees go back and forth to sort out the bills. We've done a lot of that, but the Senate chose in the later hours to embed a number of policy provisions in the budget. The house appropriations committee will need to take a look at what their approach is to policy being put in by the Senate. I was just gonna add that sometimes you will see that happen with a bill that for instance, did pass the Senate and is in our committee and they're worried about whether we're gonna take it up. And so they also put it in their budget. Yeah, sometimes they put it multiple places. Or also on another bill, right? That's being sent, a house bill that's being sent back. There's all sorts of ways. Different, this is the end of the session, yeah. So, but it doesn't, but nevertheless sometimes, sometimes people send you things from the other body that you actually wanna warm up to and you're like, oh, this came a different way than we would have anticipated. And now we have to work through all the processes of what that means. Well, I think a good example of something that was coming to us late in the game that we recognize the urgency and we actually told folks, go and try to get this out from the Senate. And that's the, I forget the numbers, 10, 30. Yeah, I can't keep track of the numbers. Yeah, exactly. And that turned out to be put in the budget. I didn't, they asked, if I wanted to put in the budget, I said, I cannot ask you to put something in the budget because my appropriations people are going to say what? So does that help, Alyssa or Representative Black just kinda, yeah, so that, yes, that does reflect, but this is not all of what was in 120 and it's a different, so it's what we have. So what's more than in front of us? Perhaps proving how diabolical I am to me, it makes perfect sense and it sounds genius, so. Yeah, there's different ways to look at this and it happens from both sides at different points in time and I could regale you with stories. And as to why someone stands on the floor and reports a bill that has to do with amusement parks and the amendments have everything to do with natural resources and healthcare. And you have to try to explain that things got amended. There's nothing, and there's nothing anymore about amusement parks in it. That could also be. Sometimes. It could also be. Okay, so we're getting a little off track, but yes, in terms of process, that's where we are. So Representative Burroughs and then Representative Peterson. Thank you, Chair Lippert. I have a comment about the language and that is that I find it very unfortunate that members of the, or a member or any member of the disability community is not included in people who would be consulted. Thank you. Okay. Take that comment under consideration. Representative Peterson. Yes, thank you. It looks like a good opportunity to reduce costs. To me, that should be at the heart of what we're doing here or one of the things that we're doing. My concern is that it looks like, and maybe I'm wrong, and maybe I've read it wrong, it's all legislators. It is all legislators. It's absolutely. And not some of the experts we have with us all the time to me are the people that work with this daily and should be proud of the process to see how we can make things more cost effective. Just a thought. Yeah, no, let's be clear. This is, as proposed, is a six-member panel task force. Happens to be labeled a task force. Three members of the House, three members of the Senate, not all of the same party. We have set up a number of other task forces or study committees, et cetera, but this is not akin to that. This is a task force that will take public input and we'll hear from and we'll elicit input about topics from other staff and experts and has the ability to also hire a consultant to assist with that if necessary, or as they deem necessary. Yeah, now the very structure of the task force is also completely open to consideration as well. Because the Senate proposed it this way, it's not set in stone. Right, like Elizabeth's comment, we could say we wanna add people who shall be consulted. I mean, that's not a given. Yeah, okay. Representative Goldman? Well, it seems that this process is sort of echoing what I hear you say a lot, Chair Lippert, about how budget is policy. So this seems like a really good example of that. That's my first thought. My second thought is, well, maybe we'll save money, but maybe we'll also help people. So I think the helping people part is a little more primary for me. And my third thought is on page 115 in section one, it references individual small group plans and large group plans. Does that mean we don't have any access to Medicaid that this group won't be able to access anything having to do with that? I don't know that it says they wouldn't have any, I mean, that this is looking at out-of-pocket costs and there are almost no out-of-pocket costs in Medicaid aside from prescription drugs. So I'm not sure it's as relevant for that. Group, I mean, but I don't think it, I don't think it precludes. Yeah, I'm wondering about access because, you know, if you change sort of what the accessibility might be or some standards, because it does say expand Medicaid to people over 26, you know, to echo the ACA. So I just wasn't sure, I didn't want to exclude at least having that be part of the conversation or I wasn't sure if that made sense or not. I think that fits to my mind and some of the other potential things that they're supposed to look at. So particularly the opportunities made available by the federal government to expand access through existing public healthcare programs or through creation of newer expanded public options. So that might include looking at that aspect.  I know we can't touch Medicare, but I was just thinking about this other part. Well, what it does, I think one of the things it does focus on and something which I for one, I'm very interested in and I think numbers of people are is what opportunities are there with a different administration in Washington thinking differently about healthcare than what we've had for the past four years.  I mean, my tone may be, make it clear, but the Affordable Care Act, which was a premier achievement of the Obama administration was in fact, actively being taken, trying to be taken apart by the subsequent Trump administration, both in terms of repealing it and then going through the courts to invalidate it. What we were positioned to deal with healthcare here in Vermont during that period of time was how do we protect what we've done in Vermont from the possibility? I mean, it's a whole different world from the possibility that if the affordable care had been repealed, I mean, I don't wanna go off on a tangent, too far off on tangent here, but what I'm wanting to point out is that one of the things that I think is potentially actively, apart from whether this task force does it or we approach it a different way, let me put it that way. Something I'm very interested in is what are the opportunities that are newly created by the new Biden administration that may allow Vermont to take further steps to ensure access to healthcare and affordable healthcare to as many Vermonters as possible within the parameters of what the Biden administration's and new initiatives or what new initiatives we could propose to the Biden administration. And that's a very different playing field than where we've been for up until 2021. Rep.  Yes, up for a comment. This is a sort of maybe picky on element, but it struck me when we were reading through the language, one of the best prior reports when we talk about, they're supposed to read and review the recommendations of all the prior reports. One of the best ones I ever read in terms of really articulating issues and public input, Vermont actually created a process of a series of small focus groups all over the state that really got into depth about people's goals and ideas and so forth. And that was all put into a report. However, that was sometime in the late 90s because I was reading it as a new member to catch up on issues. We might want to put a time on that saying, thou shalt look at reports post whatever year. I don't think there's anything that requires us to go back to the 1700s and read any reports that were available back. I don't know, it's wide open there. Right. Well, language is wide open to what they have to do. Yes, right. So I would like to suggest this that, so it's good to have this in front of us right now. I would like to ask members to be thinking about as you hear this, digest it. What does it, is it something given, if you were given your druthers, is this something which you would want to help move forward or modify or help move forward or help move forward and modify or not interested in moving forward? And so that's the kind of committee discussion that we're going to need to engage in over the next period of time as we come back to this as well as others. But this in particular, and we've heard advocacy around this today. I mean, this was the language that, I'd hoped we would have it on the table before we heard our witnesses today because I had some sense that that would be part of what was being talked about. So we're going to need a committee to think about whether is the structure what we would want? Is the, are the charges the right charges to this task force? Is it the right timeframe, et cetera? And I would ask you to be thinking about that. And then we will based on, because we just had the conference committee set up today, literally on the floor as we, before we left the floor conference committee was set up and they are going to need to give us and other committee chairs and policy committees parameters about how to approach the budget issues that are relevant to our committee. We've tried to take a jumpstart, get a jumpstart on that. That's what we've been doing over the past few days because, because I also point out, I don't mean to beat a dead horse here. We have the good fortune that most of our legislative work between the house of the Senate has been pretty well resolved. I mean, we have, we still have H 210 to resolve tomorrow and that's on our agenda, but most everything else has been resolved. So we're not, we're not engaged at this point in conference committees, whereas some other policy committees have some very significant policy differences with their parallel policy committee in the Senate and may be engaged in their own conference committees. We are to a degree freed from most of that. And we, but then again, we have more, I don't know if we have more because I don't know what's happening with those, but we have a number of issues in the budget from a policy point of view and very few from a financial point of view. It's frankly, it's a bit of an unusual situation from my point. Another thing I wanted to mention on the same lines about what to think about is from seeing a lot of legislative task force in the past, is it framed in a way that it will have something that committees will read and want to engage in and want to follow up in next year? Sometimes we ask for those things and we don't then do it. And in addition, is there too much to reasonably have on the plate of a summer study committee as there's sometimes called? Do we, are there things that we think should be prioritized over others because maybe there's too much? I'm not trying to prejudge, I haven't drilled down in depth, I've read through it, but, or as Bill already mentioned, things that we might want to add or suggest instead of and so forth. Rebson Goldman, Rebson Cina. I was wondering actually along the lines that Ann was saying, I was kind of anticipating that the report that comes out of this task force would then come to us. I mean, that would seem likely, right? Yes, and I was gonna add to what Ann was saying. It's like, what would you like something, what would you like to come to this committee? Basically, that's another way to frame the question. What would a product be? If this were to be used as a vehicle for creating a product to take us into the next stage of healthcare, what would you charge this group or a similar group that you would structure? What would you, how would you structure it and how would you charge them to bring back a product that would position this committee to best take next steps? That's really what I'm thinking about, frankly. That's really phrases it well, but that's kind of what I was thinking. So do we need to include recommendations and timeline to the task force, recommendations for potential legislation or maybe you don't do that with this? Yeah, I don't know. But, so my other question is, do you think, does anyone think that this language addresses the underinsured as clearly as it needs to? I'm not sure. I'm not sure. I'm not sure it does. And that's one of my, that it's not, doesn't seem specific to me, but maybe it's sort of implied and I just wanted to make sure that we had that on the table too. Yeah, I think, well, let's, again, we're gonna, this is not our only occasion for putting those kinds of thoughts on the table. And I'm gonna ask us like to come back to this with suggestions, questions and thoughts once having looked at it further today. Representative China. So I've been reading it over and over, just kind of thinking about what is missing and I've landed on two things. One was just spoken about. So I'll just second what Leslie said. I think there needs to be specific language related to under insurance because I read it and it's vague. It talks about, and I could read it again. It's talking about out-of-pocket costs, but it's not really getting into it, or naming it maybe. So I don't know if there's a way to strengthen that if we would recommend that that language be strengthened. So it's clear that we want them to look at how people are not accessing healthcare because of under insurance. And I don't have the answer. I read it a few times, but it doesn't seem strong enough. The second thing is that the legislature made a commitment to Vermont. In, you know, I can't remember the act now. Is it was at 48, Act 48 that we always talked about? 48? Yeah, so the universal Vermont's attempt at creating a universal healthcare system, we kind of stalled in the middle of that, but a lot of that language is still in our statutes and many people still would like for us to keep pushing towards a universal publicly financed system. And I don't see why we wouldn't mention that here in some way. It's not that explicit. So if there was a way to strengthen it, saying that the ultimate vision is a universal healthcare system and that everything we do should be taking steps towards that, even if it takes a hundred years. And it really shouldn't though, but I'm just saying. And then the other piece is around that was that it specifically mentions raising the age of Dr. Dinosaur and lowering the age of Medicare. I think it should also specifically mention universal primary care, because that's another one of the ideas that's been thrown out there over the years. And a bill passed out of this committee after clearing the Senate, but it died in appropriations two years ago, was it? Or three years ago? Four years ago. It was that long ago. So I mean, it's- I think a three or four, yeah. It would have been anyway, yeah. Yeah, so it's an idea that- It wasn't last biennium, it wasn't last- No, I thought it was the second year of my first biennium, but it could have been the first year. But either way, the reality is that a bill did pass the Senate related to universal primary care. It came back to this committee. This committee actually suggested that it move closer to the original bill it came from. Or the version that- To the closer to the version that left the Senate health and welfare, because it got changed in Senate finance, I believe. Whatever the case may be though about the details, the point I'm trying to make is that that was a viable idea in the past. I think it should still be something that we consider as one of the many possible ways to make health care more affordable. We know that investments in primary care reduce overall health care cost. That when we spend money on prevention and give people access to health care early, it saves money on the expensive things that happen later. So I really think we need to consider adding language that talks about universal primary care or increasing spending on primary care as a way to improve health and reduce the cost of the health care system. So that's what I thought of as I was reading this. So thanks for listening. Yeah. So we're gonna, I'm trying to think we're gonna, I haven't been taking notes right here myself, but we're recorded as we know. And we're going to need to take some of this, if and as the decision is made to try to structure this and refine it in a way that is more aligned with what this committee's structure and goals would be, structure for it and its goals would be, we're gonna wanna, we're gonna, I mean, we know of all the time in the world, but we're gonna need to bring some of these ideas to the table with some language and work with Jen to redraft possible suggestions. And then that will happen, that will need to happen over the near term. So thank you, Brian. I mean, Brian, thank you. I forgot something. Okay, go ahead. Just when you thought it was safe to go back in the water. So I don't, I keep rereading it to make sure I'm not missing something before I speak, because I hate when I say something and then someone's like, on line four, it says it, but I don't see the accountable care organization mentioned in here, does anyone, and how can we talk about affordability without talking about this institution we've created that's supposed to reduce the cost of healthcare? That's just a question I have. It's actually. Yeah, can I just refresh? We didn't create the accountable care organization that the feds did, CMS did. We have the all-pay model. Well, we have the all-pay model that we created that makes use of an ACO to be aligned with it, but we didn't have anything to do with creating the ACO, the ACO model. I guess I meant we as a society. Well, okay, we, the broader, not we as this committee, I wasn't there when that happened. The feds for Medicare, right? Yeah. The feds for Medicare created it, yeah. But I think you're accurate in saying that there's not a lot of reference to that here. That might be strategically a good thing or maybe not a good thing. That's depending on your point of view. Yeah. Alyssa? Black? That's fine. So, I mean, I've been listening to everyone. I actually watched a lot of this testimony. In the Senate? In the Senate, because I was really interested in it. I think, and I won't go into, I mean, I don't know what their thinking was necessarily, but I think this was sort of an attempt to kind of get away from, you know, I mean, in this committee, and not that they're not all wonderful people, but, you know, we hear from the same people over and over and over again on every single topic. And I think this was an attempt to, instead of looking at our healthcare system from the views of who we listen to all the time in committees, that it was just addressing, okay, what is the affordability like for actual real Vermonters out there and what is impacting their affordability? So I think it does address a lot of the, you know, like the ACO. I mean, if you're answering these questions and you're listening to people, you're also, you're answering the question, how is the ACO affecting their cost shares or how is it not affecting them? And is it doing what it should be doing? So I mean, I think it was really, frankly, it sounds like it's a listening tour. Part of it is, definitely. Which I think is important for legislators. I mean, that's why it's not for other people. It's for legislators to get out there and find out sort of really what's going on from the everyday Vermonter perspective. I think that's a key part of it. I see two key parts. The one is that it's that. And it's also trying to say, which I think everyday Vermonters are not going to have, I see is kind of like two, at least two different pieces to it. One is just what you're saying. It's a listening tour. It's actually, it's like doing what we did just in the last few hours, hearing from people about what their world is like around healthcare. And it makes it very powerful and makes it very real. But those, but people are not going to come to the table who are struggling with specific challenges and say, and I think this is what could happen with the Biden administration. I mean, because that's not their world, but it's not, they shouldn't be expected to do that. But we should be expected to search out other people who can help us with those questions. And that's where you bring the two together in my mind. And I also think it was really hyper focused on the affordability piece, which gets into the, into uninsured or underinsured. And when they're talking about accessibility, I think it was really more about how affordability affects accessibility. So there's also a lot more information in the findings. I mean, there were findings that went with this and what the Senate Health and Welfare Committee passed that was not, were not included in what went into the budget. So there is, you know, there's more talk about uninsured and things, or underinsured and things like that in the findings.  I have it in my way, that's funny. You mean in 120? People could be pointed toward those findings, but 120 also, I mean, it was had a broader scope. It was not just this task force. Right, but the findings went with the task force. Okay, I'm not, you would know that I did, yeah. Well, they were in a similar, I mean, the findings were not particularly changed from the bill as introduced, which was just findings and task force and then the additional provisions. Maybe you could help point people toward that. Sure, I will send you the link. Okay. President Peterson, and I'm going to suggest that we wrap this up in just a few minutes because we will come back to this, but I wanted to get this on the table. I have, and as perhaps some of you do as well, but I have other meetings scheduled in the next 20 minutes, so I'd like to. I won't take that long, Chair. Okay. If you've got time though, I want to tell you a little story that has a point, a couple of little stories, and it has a point. I worked for years for the Bell System Company as an engineer, and there was a number of us in the office in Rutland. And for years, we would design cable jobs and this, that and the other. And forever we would say, gee, why don't we provide TV over the telephone cable? We have the technology, we know we can. And the answer was always, well, you know, why not? But, and for years we would say that. Base level employees just, hey, why aren't we doing this stuff? Well, along comes a VTEL who does that. Now other companies are doing it. Now cable TV takes your business away. Same thing with fiber optic. If the company had listened to the engineers, there wouldn't be a H360. There'd be fiber cable off to everybody because we recommended it years ago. And my point is, I'll bet there's employees within the healthcare system here in Vermont that can make really, really, really good suggestions about how to save money, how to gain more access, how to bypass systems, how to coordinate systems, how to get rid of systems, eliminate redundancy. And I just fear if we're just gonna put us legislators in charge of the commission, we'll never get down to those people. I really think we need to get to some interested state employees. They say, gee, I know how to. Yeah, if we did, why don't we take this and maybe we don't need that section of employees. Maybe we can get by, there could be a million ways we could save money. Yeah, quite a lot. So I'll just suggest that the question is, how do you get to that information? How do you access that? And I'm not, I'm just saying, I'm not sure that you do that by having people on the task force. I think you do that by engaging people to come forward with their ideas in a way that they feel empowered or able to share those ideas. Yeah, if we'll do it, yeah, if we'll do it. Yeah, yeah. Okay, I'm gonna, one last comment from Representative Woodman and then we'll wrap for the day. I was just gonna say, maybe we have to go back to the very beginning of this healthcare journey to really look at what was originally proposed to maybe get to the answers that Representative Peterson was alluding to. So, can we go back to the very beginning, start all over, look at our roots, something like that. Well, at a minimum, everybody should go back and read the principles and- Go back to the 1700s, Anne, yes, I know. Okay, well, let's stop there for today. And we will come back to this. And I'm going to try to get guidance from the Appropriations Committee as to how, what timeframe and how to move forward on the various things that are in the budget. Tomorrow morning, we will join the House Human Services Committee. I would encourage people to do that. And if not everyone, but this is not, you don't have to, if you have other commitments that, as Anne said, or Representative John, you said, we also anticipate there were some other work that some folks needed to do. And then we're gonna come back to the committee at 10.30 and think about, we're gonna need to think about how to proceed with H210. And anyway, we're gonna take, we just have to keep moving forward step at a time.


about this topic, so I will present it instead of him. And there are basic problems that exist in detonation initiation. So still, after many years, many decades of research, there is many models, ideas of what happened on microscopic level, or mesoscopic 2, which leads to initiation or ignition of the high explosive, condensed explosive. So in this talk, we will focus on the porous explosive and we'll try to make as a final step to do mesoscopic simulation. But as a first step, we want to just do some preliminary thermistic simulation to find the equation of state, reaction rates, and all chemistry on an atomic level, molecular level. So the major idea behind the ignition, which may describe the ignition in the all kind of practical high explosive material, or energetic material, which are not ideal crystal, which always have some imperfection in form of the grains, voids, and so on. So that the ignition happens through the initiated or started from the formation of the so-called hot spot. So hot spot usually associated with some small pore, or small void between grains, this size of maybe micrometer, or even 100 nanometers. And this pore may lead to formation of the high temperature spot after compression and collapse of this pore. This idea has a long history and still because the complexity of direct simulation, mesoscopic simulation of such samples, there is many uncertainty about what the mechanism behind of this heating. Of course, the collapse is a just general thing, but some void can produce additional heating and transfer to detonation way. But some pores may be very small pores. It may just simply collapse and do not cause any effect. So here I show that our first hydrodynamic simulation, not a thymistic simulation, but this hydrodynamic simulation using smooth particle hydrodynamics code was performed on the basis of a thymistic simulation. So all chemistry here, all reaction rate equation of state was obtained from the first step of the simulation and molecular dynamic simulation of some model energetic material we call AB. You may think it suggests N O atoms. I will tell you about it later. So the term hotspot actually means a class of the objects which may lead to the initiation or ignition of detonation. It suggests simply if you go to a restaurant and ask, I want to fish. Maybe no one understood you well. So because a fish itself has a very different sort of fish. And we have to think in the same way for meaning of hotspot. If you talk hotspot, we definitely ask first in what condition this hotspot was formed. And the evolution, the life of this hotspot, will it survive or will it die soon, will depend on the environment condition or the type or class of this hotspot. So the simplest I'll discuss it about classification later. And itself classification, as I said, is important. And yeah, there are some examples. So poor collapse will lead to formation of one type of the hotspot. But laser heating will provide another type of hotspot. So in laser heating, we have some high temperature, maybe in hotspot produced by poor collapse, low temperature, but high pressure. Quite different condition. And the life of this hotspot will be quite different. And the critical condition it will die or expand infinitely will also depend on such class or type of hotspot. So you see, I'll say a few words about this simulation. The porous material just consists of the spherical pore here. They are not shown here. It's just a shadow of wall three-dimensional sample. So pore size will be realistic about 50 microns and some length 10 millimeters. Of course, such dimension sizes are not achievable in molecular dynamics, a timeistic approach. But here, as I said already, all chemistry taken from the molecular dynamics simulation. You see that the wave, initial wave, propagates without actually heating here. The temperature remains cold. However, after colors, a few, several pores you may see here. So the reaction initiated somewhere here, far from the piston, by the way. And detonation just in the forward direction is initiated here. And backward detonation wave also initiated from this area. Well, the ensemble of hotspot was quite strong to produce this transition to detonation regime. So the outline of talk. So first, classification of hotspot. I already said that it's really required to understand the various ignition scenario. So actually, classification still, we don't have a good classification in literature. The idea of classification, of course, kind of in air. But usually, experimentally, we do some kind of conclusion. We cook this kind of hotspot in such condition. Maybe we cook another hotspot in another condition. But theoretical classification still is like that. So then I will show some MD simulation of two classes, I think the most important classes of hotspot is produced by fast laser heating. And then there's a kind of hot hotspot. And then another hotspot produced by the collapse of the pore. So produced by external pressure or short compression. And finally, just conclusion and further work. So to transition to from atomistic level to hydrodynamic level of simulation. OK, the simplest and I think very natural classification of hotspot can be based on the characteristic times of the major process driving or guiding this process of formation of hotspot. First is the reaction time. It's quite of general kind of the definition. I will tell you about definition of characteristic time later. Of course, it's not simple quantity because it must include major chemical reactions initiated in the explosion. But we may derive it or even obtain an experimental condition. So heating time, of course, it's clear that the hotspot produced by laser or electric spark may be controlled by the heating. Slow heating or fast heating will give us different results. And acoustic time or sound wave time. Typically, it is associated with the radius of hotspot and the sound speed in the material clearly. So it determines how fast the reaction wave unload with hotspot or how fast compression or shock wave propagate inside. Anyway, so the combination of these three characteristic time may give us about six class or six type of hotspot. But however, I will just focus on two type of hotspot, that the heating time much lower, much less than the acoustic time. Of course, if heating time much longer than acoustic time, then actually we cannot really produce a good hotspot because unloading wave will release a pressure and maybe just some class of hotspot will never survive. OK, anyway, so time of heating much less. Reaction time and acoustic. This is one of sorts, one of kind of hotspot. So it produce fast heating, decomposition, and hydrodynamic flow. So and here just one example, sorry, is one kind of hotspot. Is the reaction time much less than acoustic time? Then much less. So the reaction, it's probably opposite. Reaction time, if reaction time is here, should replace growth here and extension here, is acoustic time much shorter than reaction time? Then much shorter. OK, then it will lead to extinction. So we have a hotspot produced by a laser heating, but due to unloading, fast unloading temperature, reaction have no time to produce a temperature. So it should be replaced to grow here and extension here. And the opposite case is the reaction is very short. So unloading wave cannot reach the center of the hotspot. Then reaction will complete, release a lot of energy, and hotspots survive and start to expand. OK. So here, as I said, two major types of the hotspot. So the fast heating, fast heating in this area, so the boundary contact between reagent material, so initial material here and hotspot here. So fast heating results in the high pressure there and high temperature here. So density remains the constant, just isohoric heating because of too fast. So another hotspot here. So slow heating in mechanical equilibrium. So we have a, but because mechanical will be low density here, and the pressure is just constant. But we have a high temperature, very high temperature. So heating in mechanical equilibrium. Yeah. OK. So let's first try to simulate, I will show the simulation of the cylindrical hotspot produced by fast heating. It means heating is much shorter than the acoustic time, unloading time of the hotspot. And yeah, first I will discuss about what potential, what the forces acting between atoms. About two decades ago, the very simple classical interatomic potential for the reactive material, which includes valency, chemical bonds between atoms was developed by Brenner and Covofer. So this year. So this potential is quite actually simple and consists of two parts. For chemical bond, we have a very deep wheel, very energetic 2EV, presented by Morse potential, short range potential. And for large distance between molecules actually, we have one there was force, using a linear just potential. Actually quite simple. There is another important thing is a bond order. I show next slide. But I would like to say that this potential, AB called some kind of AB potential, or reactive, reactive, empiric bond order potential, plays exactly the same role as a Lener-Jones potential, which probably everyone knows very well. So Lener-Jones potential is good for just theoretical study of equation of state, operations, many things just to understand anatomic level what happened inside the material. But Lener-Jones potential has no way to select, this atom will connect to this atom, like make a bond. And the bond should saturate at valency, at given valency. And in order to include the valency in classical MT, we, Brenner-Slistkofer introduced bond order. So if one atom close to another atom, then this assume valency one. Valency is saturated, and all third, fourth atoms cannot contact and make chemical bond with a central atom. It's clear. So it's not simply, it's not a simple actually function, but it's a very effective from a computational point of view potential. It's just about two, three times has a low speed, calculation speed, than the Lener-Jones potential. OK. Here, OK. Wonder-Wall's term for a system energy of anatomism. Wonder-Wall's force is a long range of forces, repulsive forces, and the attractive force, which depends on bond order. If a bond order just one, then attractive force is large. It means we may make atom make chemical bond. If it's just zero, it suggests eliminate attractive force and only repulsive is active. OK. About the characteristic time of chemical reaction, you know that the real energetic material explosive a lot, I mean thousands, or maybe 100,000 reactions. Of course, there are very some virtual reaction, but it's not no way to include in a realistic simulation program, include all of them. And the problem even deeper, we may write many equations, so thousands equation, kinetic equation. However, we also, in order to close the system, we need also to provide equation of state of each species. So it's an equation of state of some radicals and other radicals. And now another intermediate some active molecules. So it's really not no any way to do this. And typically, people that just combine all of reaction as a initial, a reagent material products and reaction, intermediate reaction, like radicals. Here, it's simply very visible. A star, B star. So this interaction between B and A and B may result in formation molecule and production of the radical atoms. Radicals are important. They are very important in the initiation of the chain of reaction, production of the release of energy. Sorry for interrupting, but your talk is only 25 minutes. You've nearly taken 20 already. All right, thank you. I will think so. OK, so then the reaction in the hot spot will all combine it to the isochoric thermal decomposition time. In the isochoric heating condition, the time is measured when the product of the product are formed, as on this time will depend on the density, initial density, and initial temperature. So doing this way, we may extract the canonical equation to use in the hydrodynamic code. OK, so fast heating of cylinder. So initially it was heated here. Pressure jump, temperature jump here, and then expand star. What we may say just in brief that acoustic time of hot spot is quite about 10 picosecond. It's much smaller than heating time. It means the hot spot produced by a laser heating will expand long time. And the reaction may have time to test complete and release energy. And just from such simple thing, we may just derive that the critical radius of this hot will be order, not equal here, but order, that the sound speed on reaction time. It means that if the radius will be low, then this critical radius. Then unloading wave will come to the center faster than the reaction will happen.  OK, here the profile of the radial profile of velocity and density in unloading wave, reflection of convergent wave coming to the center. So at time 8 picosecond, wave reaches center, refaction wave. Conversion, refaction wave. It starts to reflect from the center. Refaction wave starts to reflect from the center, produce another new reflected refaction wave. Reflected refaction wave will lead to formation of inflow. You see the negative here, velocity. Produce that densification of central part. It may result in decrease of density here. And density, as I showed you before, high density provide a good chance for development of reaction, ignition of this point. So next. So critical radius here. In such condition, we found that critical radius of the hot spot is about 23 nanometers. So these small radius, 21, died. Hot spot dies here. Then it's expand, and this product is a product. Cycle is a product, and dashed line is a density. So because densification at this point happened at the center, you see the density jump. Due to reflection of refaction wave from the center, densification may, you see, change slope of this production of the final state of molecules. And then it starts to accelerate. So finally, we found that such condition may really happen in such hot spot. So let's keep it. And few words about hot spot after collapse. So shock compression of the material, shock compression, that low compression amplitude, will never produce any reaction. It's too small for this material. However, we have a pore. The collapse may result in the increase of pressure at the center, you see. And it depends on radius. Here, a radius was 16 nanometers, 12, 14, 16. So the critical radius is at the 14 nanometers. So if a pressure will exceed some critical limit, I guess about 10 GPA, somewhere here, 11 GPA. So the initiation pressure and temperature inside the center will be large enough to produce a reaction. Here's some just repeating that we need maybe 1% of radicals at the center produced by the collapse in order to give a chance of collapse to form a living hot spot. OK. And then in conclusion. So what we did, maybe we did some preliminary classification of the hot spot based on the characteristic time of the major process, guiding of evolution of hot spot. And the critical condition for hot spot generated by fast heating is acceleration of the exothermic reaction due to a reflection of the refaction wave coming to the center. Let's reflect, make additional densification in the center, which results, which triggers chemical reaction. And then hot spots survive and start to grow. And the collapse in power leads to high pressure. If the pressure is enough to produce a high concentration of radical atoms, then it supports, I mean, the hot spot start to grow. And the reaction accelerated just is the center of the pore. And at the future, and I already show some preliminary in the beginning of my talk, SPH simulation. So we want to make a mesoscopic simulation. It could be many pores and use a atomistic-based reaction rates, equation of state, in order to make a combined and consistent simulation on the atomistic level and the hydrodynamic level. Thank you very much.


Here comes the implant, I've freed it up. There it is. Okay, it says, we could see what it is. It's a 305 high profile implant.


So we're going to use these four squares now. We've opened it up and made it a bit bigger. Can you see them? So we've got an orange square here a yellow square there Orange square there yellow square there just go on that side of those two squares. That's it. Just go on that side down So combination in the middle trying to receive to play forward so greens are playing with greens blues are playing with blues So if the green started with it You'd play into mark good and stay there, but where would you go Kiran? Ah good stay there so opposite squares so Kiran couldn't be in line with mark You'd have to be in there combination in the middle got to be a combination Then wait there as it goes into will then you transfer it to the blues Jack Then the blues would play through So we play it through yeah go on play it through Hopefully quicker than that he played into Dan then Dan had played a hoop heelsy then we'd play through Ready play off the green heelsy off you go play Good now you're getting ready to move blues and play and play good you can get in their way greens just getting their way Now you're looking to play We'll have two in the middle again, but we'll add some defenders in so defenders can only defend in certain zones Which is still allows the attackers to movement to work off each other But still have more pressure than in the previous exercise Now greens are going to play first blues are going to do the combination first and play into a green But Jack's going to defend inside these two squares just come forward a bit more Jack So Jack can defend in this square or that square. Okay. You can't move anywhere else. You can go in either Dan can defend it in this square and this square here can't go anywhere else But the greens can swap and go anywhere they like, but they've got to try and be what? Diagonals and opposites so heelsy might go in there. Where would you go then good and Jack? You've got to try and pick him up in there Blues if you win it feed it to the blue on the outside. That's how you score Greens you score by transferring and going in to end Good Good heelsy. Can you find the end man? Yeah to one play on play on good Good take him out. Oh my he might go in there. He might go in there keep swapping keep changing it Keep changing it. Can you find a blue on the outside good? Well played bounce a green play feed him in swap over Yeah transfer it now you can play. Hey love that move. Well played blues. Well done What we're looking at is combination play so players receiving skills Moving as the ball travels being able to play forward whenever they can and see both targets