The link that's posted on that PowerPoint slide right there, and with that, we'll move to Gina. Thank you. Thank you so much, Jeffrey. Great introduction. I suggest to remind the people of the public, this may be the last subcommittee call that we have, but now it is in your hands, so we really want to hear from you. So please use this public comment link, and we will be hosting two town halls in November. It will be in person, but also virtually online, so if you can't attend, you can attend from the comfort of your own home. So please join us, and we will have further information that we post on the Vermont Cannabis Control Board to have your part in creating a social equity plan program to put into place to ensure that this is something that you want. You know, help us co-design this together, which brings us into our diversity, equity and inclusion program. As a reminder, you know, we had created this separate from social equity, because social equity had to do about harm, and diversity, equity and inclusion is about historically underrepresented in society. We had included women, people with disabilities, LGBTQ, immigrants or current members of an immigrant family, a refugee, a person based discrimination based on race, color or religion. Yeah, because there's no humans. I'm just being on the screen. One of the things that we did not talk about last week, which is low social economic income people. Now we tried to speak about this when we were speaking about social equity, and we refer to it as opportunity sums. However, that part was not accepted as a recommendation from the cannabis control board as they were fearful of people moving into those areas in order to gain the benefits of the social equity program. So I think it is more than acceptable to include them in the diversity, equity and inclusion. Julie, we're just going to talk about this. I know that there may be other plans that the Vermont cannabis control board does in order to include people with funding issues to get into the industry, but I thought it would be great to include them into the programs that we have readily available. Actually, your thoughts on those social economic people in diversity, equity and inclusion program. And I think that would be a really great addition to the program for sure. Thank you, Nader. I would support that. Yes. Thanks, and Julia. Yes, I'm fine with that. Thank you. So now our start of this is how do we determine what is low social economical for the state of Vermont? What is the maximum income some family households can have or an individual could have who wants to take part in this program. Now, there are different ways that we can look at this. We can look at it from the public defenders services standpoint in Vermont. We use 125% of federal poverty line, which right now that would be anywhere from 16,100 to 55,825 depending on the persons in the family. And you can see that chart on the side.  Or we can look at it from some best practices that we're seeing, which is 80% of the state medium income. And in 2019 for Vermont, an individual at 80% would be 27,661 dollars and 60 cents. And for our household, it would be 49,578 and 40 cents. Ashley, what are your thoughts on sort of maybe going with the first one of 125% of federal poverty level, or, you know, going on to something a little more to encompass more people or somewhere in the middle between the two? I mean, ideally we find kind of a middle ground here. What's tricky is that we live in a state where, you know, affluence in certain areas high. So a household income isn't always necessary. So sometimes I find that when I see these cutoffs for a household income, others are potentially earning, but just not on the books. That makes any sense. So I mean, 49,000 majority of the folks that I know, you know, make a lot less than that. So, you know, I'd like to see that as far as a gauge, because I think we would get a lot of quote unquote, like, average people in Vermont participating, putting it under like a lower socioeconomic status, like it sounds bizarre, because that is a lot of people make less than that, that I am familiar with that. I just want to make sure that we're not going to have this program abused or this particular element abused. So if we could figure out a way of creating some safeguards in there, that would be ideal for me. Thank you, Ashley. And those are really important factors here to consider. You know, we don't want it to everybody, but we also want to do how now 49,5008 that would be for a household. It didn't exactly say how many were in that household for an individual with 27,661. It sounds like you're thinking maybe more of the 125% of the poverty level, which would be for an individual about 16,100. And then depending on how many persons in the family, but taking into consideration everyone's income, it would increase. Yeah, I think that's smart. Okay, great. Thank you. Nader, your thoughts on this? You know, my first thought, as I'm seeing these two options in front of me, I'm tending. Well, actually, no, my one question of clarification. In the first option, that's 16,000 to 55,000, we're saying that anyone who makes between that range is eligible for this program. Is that correct? No, so it would depend on the persons in the family. So this is the chart on the side. So if we're going 125% of the fed poverty level, someone who was independent and individual themselves can make up to 16,100. And if they were to, then they could make, you know, about 19,000. And then so it would just increase to there. On the chart, it just reflects what the rate is. But Vermont uses 125% of the fed poverty level when determining public defender services and some others. And this is in Vermont. So we were using that as sort of a tool that if for legal issues, they were willing to use 125% and just sort of taking that model and moving it over to cannabis. Okay. And for the second option, how did we land on 80% where does that come from? The state minimum income is what NACB has determined to be the best practice based on our state evaluations of social equity programs. Okay. And got it. Yeah, my inclination is does lean towards the second option. If that's the one that covers more people. I think I just need to spend a few more minutes absorbing the numbers and trying to figure it out and fully understand it. Thank you. Julio, your thoughts. I share the same view, which is that I think the, for me, the question about how large the household size is. For the the census base, the median income, I guess is really the question because, you know, two member household with $49,000 versus an eight member household with $49,000 are quite different. So the appeal for me for the public defender standard is that this is something the state of Vermont already does and it relates to the criminal justice people. These are services that are provided that I think in terms of the state expenditure outlay are probably and maybe getting ahead of our sense of a probably greater expenditures per person that are made in this program. So it seemed to me to be a pretty fair measure, but I would rather earn the side of having more people as is not said. Thank you. And you know, we can really kind of determine, you know, what that sort of household numbers are if you'd like with the 80% of the same income. But I would love to hear Susana's thoughts on this before we start trying to dissect this little bit.  So I see it as probably doing more good than harm to be more inclusive. And I'm not, I'm not certain that I even have a preference between the two. I think they each have their benefits and disadvantages. Like Julio said, one of them we already do it in another context here in the state. So there's a certain familiarity that we have with that. Yeah. Thank you Susana. So taking into account that if we did a household income, if there were two people and saying making the 27,000, they would individually, if they weren't living together be able to qualify if we take this 80%. So if we double that, you know, we're at over 55,000. So, you know, having if you're living together with someone at, you know, 49,500 is still what we lower than what we would have allowed for an individual. That being said, would people want that household to be three persons in a family and not two and make something lower for two, because there is something said to be about supply, you know, working together and using all your resources versus someone who's trying to fund everything for themselves. Julio, I'm going to refer to you because you did make a mention about sort of that household size. What are your thoughts? Or should we just go with the state model? I don't know. And I may not be able to do the math in an impromptu way. I mean, I'm not sure it follows that, you know, if you have two people at 49,000, you would divide that two ways because you can have a household where it's one parent making $49,000 and one child who's making zero and the child's not eligible. And the parents would be making a lot closer to the, I would think, making more than 80% of the state meeting income for a person. Right, they'd be making 20,000 more than the next individual working parent. So, you know, I'm not sure if I'm able to do the math here. I mean, we might, and we might want to play with the numbers so that if you wanted to extend as far as the range that's provided for the census information to just change the percentage of the federal poverty level so that it encompasses the outer bounds on the lower end and the upper end of the median income. So it might end up being 135% of the federal poverty level because we do have those federal poverty guidelines which you've helpfully put here, which are used for a lot of things in terms of state services. And then, you know, the kind of the variable that we might adjust would be just that percentage. So that might be an approach that would be helpful would be to kind of run the range at 135% and see the numbers so quick. So 135 is what you're interested in? Yeah, I mean, if you did, you know, I don't really have. I have a calculator. Yeah, I don't have my hands free at the moment. It would be 17,388. I can't prepare Julio. So that would be 17,388. And the highest level would be 60,291. And that's a family of eight, which is a lot. Yes. Our people are more happy with those sort of figures and then obviously it would be different. So let's say family of two, which you were concerned about would be 23,517. Yeah, I mean, someone who is making 17,388, you know, if they're working full time, that's like eight bucks an hour. So I don't feel like we're being too generous on that end. And on the higher, I don't really know how to break out the challenge. And we all can realize it's a crude measure, right? Because somebody could be making 80%, but they have one of the people in their household is a parent who has medical needs. They can have exorbitant childcare costs that their net income is different than their gross income. So I think we all, there's going to be some, you know, crude measure here. But yeah, I would. I think it's a good middle ground, Julio, 135. It's sort of in between these sort of numbers. If you're comfortable with 135. Yeah, I'd like to do better than the public defender standard. I think that's a good standard because I mean, it's a helpful standard because again, the cost of that the state is already has already committed to for a public defender, which is the state paying the cost of a lawyer for legal representation, which could go on for years is a pretty substantial expenditure. And if they're covering it at this rate, it tells me we're not being too restrictive. And then I guess the question is what do you want to do that? So I'm comfortable with 135. I'd be open to hearing other views and especially public views about, you know, going a little higher than that because, you know, there are lots of expenses associated with Vermont, including high heating costs and the cost of housing. But I think that's a little bit built into the poverty guidelines that they're that is the guidelines for living in Vermont. So, but yeah, 135 I feel comfortable with right now. Thank you, Julio. Ashley, how do you feel about that 135% of Fed poverty level? I mean, I think that that is fine. I was like, I don't know that I have a preference of one over the other. What is our goal in the sense of like, okay, we establish what the economic height is of what someone can make an household or individual. And then it's the anticipation that they are then going to self fund in the cannabis space. So like, or then they're going to be able to have access to funds either through our cannabis program that we're establishing or cannabis fund or other business development. Like, I think that's a disconnect that, you know, I don't know, you know, what the cap really should be for a household income when I don't really know what the intention of that business person is in the industry of how they're going to fund their business. Yes, so I think our next slide, we're going to talk about, you know, what this group benefits will be. I feel because we want to ensure an inclusive industry is definitely having, you know, if I cannot say if this person will not have their own cannabis company, they're entitled to do so. But to also just allow for some workshops and certificates and some training available free of charge for them to be able to say, you know what, maybe cannabis may be a better fit for me and give them other job opportunities and make sure they're part of the cannabis industry and not excluded because they don't have that education in that area. I mean, you know, I think including more people is best. Making this industry a place where everyone feels that they can get in at any level, it is ideal. So, yeah, I mean, I don't have an opinion one over the other. I just want as many people in as we can. How do you feel about 135? Yeah, I mean, I think that's fine. A little higher? Yeah. Or do you want to go higher than 135? 135% of the Fed poverty level? I'm open to other other opinions at this point. Great. Thanks. Nana, your thoughts? I'm fine with 135 and I'm not opposed to going higher. If we think that could be more helpful and also really like the points that were brought up earlier about bringing in people on any level, not just somebody who's going to open up their own business. I appreciated that point. So yeah, I'm fine with 135. Thank you. And Zuzana, your thoughts? I like the 135 and, you know, the more time that I spent thinking about it, the more I have been thinking about, you know, that phenomenon we have in Vermont of like, I've got a trust fund, so I have zero income.  The more that we try to thwart, quote unquote, abuse in these programs, the more we end up being heavy handed with respect to people who actually do need it. So again, I think I still would rather err on the side of more inclusion than not. But I'm thinking about that. And I'm also cautious. There was another point I was going to make and I forgot it. Well, and then I'm fine with 135. And oh, that was what I was going to say. Debt burden is a big one. And I don't know how I'm going to count for that, especially with younger folks who may have larger educational debt. You can have, you can be a high earner and still break even. And again, I know that sounds like a first world thing to say, but it's just something to keep in mind as a member of a generation that's probably never ever going to get out of debt. We're probably going to be the ones to pop that bubble in this country. It's definitely a reality, I think, for people who want to get involved in the market. But I appreciate these points as well and the tweets that are being proposed here. I would support those. Thank you, Susanna. I'm really good points made by Susanna about debts and, you know, about trust bonds, you know, we can't create a perfect world, but we can try to get to a little more balanced one. And, you know, if people are listening on to this recording right now, please take that into account when you're seeing people that maybe we don't have into the program, but maybe you have your own programs that you start. When you create a cannabis industry or someone who's looking to get into it, you know, we may not have been able to help them, but we hope that you extend on same courtesies that we have made for all of these people. But that being said, I think a lot of people are sort of okay with the 135% of the Fed poverty level, which would be 17,388 for an individual up to 60,291 for a family of eight and all of the incomes in between. And we will create a chart to reflect that right by this 100% chart going forward. So I would like to vote as always. I'm sure you guys getting used to this now on including low social or economic as an individual group that diversity, equity and inclusion will help. And the max income would be 135% of the federal poverty level. Ashley, how do you vote? Yes. Thank you. Nada? Yes. Thank you. And Julio? Yes. Wonderful. So for the bracket, three guesses and adding low social economic as a group at the max income of 135% of Fed poverty level. So since we have all of the groups that we want to help with this program, what benefits should they receive? And I think that we have spoken about many, many times about educational programs, you know, including the certificates and on any of the workshops that the social equity group is entitled to you. This is extremely important to make sure that we're giving people the education they need in order to be included in the cannabis industry. Priority processing, which is in the statute, especially for women. And I believe maybe people with disabilities as well and just extending that over to any of the groups that we fill really needs the encouragement of getting into it. Now, some of the questions is, do we start to waive any of the fees that are associated? Some fee waivers that we might want to consider is that if we want someone to be really able to look into the cannabis industry or even starting up their own company is perhaps the intention to apply fee. And this would enable them to say to potential investors. I have. I'm interested. I've qualified for Vermont cannabis adult use program and then start to be able to look at real estate. With confidence that they will be able to get a license. Another fee that we might want to waive is the application fee. For this program, there will be as of your thoughts on anything for licensing. But since I'm focusing on intention to apply an application fees due to the fact that we are trying to promote an inclusive industry and trying to have people want to go into this industry. But they did not receive the harm that the social equity candidates have. So Julio, your thoughts. Yeah, I mean, I think the fee waiver, given the cost for entering into into the economy for at least for many of the licenses. I think are more significant, you know, the lowering of the state imposed barriers for the, you know, the application intent fees, I think is appropriate. I'm I'm also thinking about just what the state recovers in terms of the tax revenues that results, you know, that compared to these fees. I don't think it's particularly burdensome to the state educational program probably. I mean, I think it's quite helpful. And I think after the initial cost associated with developing that program, it becomes much less expensive to administer. And in terms of priority processing, I mean, it's hard for us to estimate how many applications are going to be in a given period. But when you already have processing for is already kind of a different level of participant, which are the social equity program, you know, to have this group also received prior priority over the, you know, the non disadvantaged segments of the population. I think I think is appropriate without being unfair. So I think I'm comfortable with them. Thank you, Julio. And one thing that I would like to state with the fees that if we waive the intent to apply fee that was that provisional license. It's like a two step application process now that the application fee will be reduced by the amount of the intent to apply. So in reality, the if we do the intent to apply is $500 and the application fee is a thousand, but that's subtracted by the intent to apply. So if we do both really the only cost savings benefits would be that $1000 unless a person doesn't apply afterwards. This was just to ensure within the cannabis industry that we don't have so many people applying without really doing their due diligence and overwhelming the industry about giving out so many licenses and then companies not being able to really produce. And so this intent to imply so they can really explore and see if this is beneficial for them actually your thoughts. I think you hit the nail on the head, you know, with your points. That was exactly what I was going to say in a lot of ways. And I think there should be a level of seriousness that's taken when somebody enters into this industry at whatever level. I think there needs to be, you know, all of those things consider to be waiving fees is huge. But and then where's the barrier going to be and then where's the barrier going to be, you know, we're reducing as many as we can. But I just want to be sure that this isn't just overwhelming the system and either the CCB or whoever's going to be reviewing all these applications isn't just like inundated. And then we have all these people who qualify for these programs and then are the programs getting set up simultaneously and then those programs that can be overwhelmed by all these people have been approved. So I'm kind of like worried about sort of the downhill trickle down effect of making it too easy to get in with or, you know, not enough sort of trepidation about the seriousness of what it takes to get in and be in and stay in the industry. So I just kind of want to piggyback on your your points. They're really good. Thank you. Ashley, would you like to just do a waiver of the intent to apply and not the application fee then? So they have the ability to really explore and then say, if you're really interested, you have to pay the additional 500 that comes with the application fee. So I think that we're reducing the application fee by half of them. I think that's appropriate and hopefully, you know, there will be some grants created where someone who is really serious could apply for those in addition to getting these education and programs and workshops that that sort of a package deal and not just a like, OK, here's some money or here we're reducing this cost but then we're not providing any other additional help. Like there needs to be an all encompassing ability here to get somebody a launching pad to get in. So exploring, waiving that intent to apply, I think is important. I don't know that waiving the application fee entirely makes the most sense. And like I said, that really just comes down to seeing how serious someone is. And I think as we're trying to iron out these grant programs, like there will be money to apply to cover those fees and then some. Thank you. Great point, Ashley. Nadar, what are your thoughts about the benefits and specifically with just waiving the intent to apply instead of that and not having anything for the application fee? Yeah. So I have a couple of different thoughts that have been brought up just recently. The so my I also share the concern of inundating the system with applications and with people who may not take it seriously. And once you start getting all these applications, it'll turn priority processing into just regular old bureaucratic processing, which takes a lot longer. And then there's also the fact that even though this isn't for profit, there's still going to have to be a mechanism to pay the people who are reviewing these many applications. And also taking into consideration the fact that we are opening this up to a lot of people. So, you know, I'd be I'd be fine with maybe proposing 50 to 75% reduction or discount in the fee to apply. The other thought that I have is if somebody wants to apply to just the educational program, but as they're interested in just working on a farm or working in a shop and they just kind of want to test the waters before they actually apply for a license. I think that applying to the educational program that should be free and, you know, it could produce more well rounded and educated employees for these businesses. So those are my thoughts. Thank you. And just for everybody to know that the application fee for DEI or social equity programs are free. And that would be funded through the and the cannabis fund that is available to develop and program fund that we have. So with that intention to apply, now that I just want to make sure do you want that at 50% off? Or were you referring to the application thing? You mentioned that the application fee that the $500 goes towards the application fee later on. Yeah. And so I actually was thinking of getting rid of the application fee and saying if you're committed to really starting this program, then you have to show us and, you know, paying the application fee, which I think, you know, is a really good idea. So we're thinking of only keeping intent to apply so that they will be able to really explore their options. You know, can I get people to back me what do the prices look like for real estate and other factors that I need to run the business and, you know, be able to put a proposal together. Yeah. Do you want to waive it or just create a percent discount? So I think waiving it and then including the other fee would be fine. Thank you, Madar. Susanna, your thoughts? I'm comfortable with waiving it as well. I understand the concept of the offset from the intent fee versus the application fee. And, you know, I also get the point about legitimacy and seriousness. And yet most of me says let people make choices, you know, people like they can take risks on their own without us having to signal the gravity of the risk through high fees. Thank you. And Julio, are you okay with waiving the application, getting rid of the application fee waiver and just only having the intent to apply fee? No, I would waive both. Okay. I have maybe just a different angle on this, angle on this and so people will be patient with me. You know, the application fee to become and you don't have to go to law school in Vermont to become a member of the bar and practice law. You can study for it and then take the exam. The application fee to be admitted in Vermont to the Vermont bar without having gone to law school is $800. And that's the fee that's not targeted toward people of a particular income level. That's just the fee for everyone. So the application fee that the state would be imposing for this group, which is targeted toward people who are a lot closer to the poverty line than the average person perhaps who's looking to practice law in Vermont. And that troubles me. It troubles me a little bit to have the means of conveying seriousness about making investments in terms of borrowing money. That the mechanism for the state to convey that seriousness to people is to take money out of people who are already closer to poverty than most Romaners is to take $1,000 out of their pockets for purposes of messaging. It just strikes me as maybe having an unintended, I don't know, I don't know the right word for it. But I just think that there's going to be an educational program that I think will include. And hopefully people apply it for any kind of educational benefits that hopefully the state will develop infographics or some kind of materials to give ideas like what is the average cost or what you can expect to have a cost to start a delivery service so that people can make those decisions based on their reading materials and hearing people, you know, offer them cautions rather than imposing an economic barrier to say, well, you know, regardless of how you do it or what you think about it, we're not going to let you in or even seek an application unless you give us $1,000. That just doesn't sit well with me, at least the way that I'm looking at it now. I mean, the estimates of the economy that's going to be developed by this new market suggest to me that the state of Vermont is going to have plenty of money that they can do to process the paperwork for people who are applying for the program. And I think as after the flurry where people are rushing out to try to claim their place in the market, I think people will understand that there's a lot more cost involved than the application fee. So yeah, I mean, because this economy does include delivery service and that for a lot of people may be the way into this economy, I'm not worried about using the fee barrier as a way of keeping the unrealistic applicants out. And it also makes me worried that people who do, who nonetheless borrow from their family or whatever to submit the $1,000, if they're being unrealistic, they'll end up not only with, not only have spent time and energy on a failed project, but they're not going to get their $1,000 back from the state of Vermont. So it just doesn't sit that well with me. So I'm inclined to wait both for this group. Thank you, Julio. And I know that you made several points about the taxes that they would receive if this person who applies does end up getting a license from that company. Ashley, I saw your hand raised. Yeah, I want to be conscious of the time before public comment, if there is going to be any today. So I'm going to try to fit this into a minute here, but I just want to paint a quick picture. So for the hemp industry, there was a huge boom, huge bust. The cost to grow was $25. Everyone went nuts and grew way too much without understanding or just not realizing what the risk was because they thought they could just sell all of it. Hardly anybody could sell any of it because there's a very small amount of people who are successful in that part of the industry, therefore even less people were successful on the brand side of the industry. And so saying let people just assume that risk, we've seen what has gone on in this state for hemp and it wasn't good. And a lot of people are still sitting on product. A lot of people lost tons of money, lost tons of time, effort, energy, confidence in the industry, confidence in Vermont to create safeguards for people so they didn't go all in. I think it's just human nature that if there's an opportunity that has a potential for this kind of income and growth, people are going to go crazy. Even if we waive these fees or we see that only charging $25, that people went crazy and that now here we are. So waving the fees I don't think is a great idea because I don't think it lets people understand that there is a risk. There's probably more risk in this next phase of the cannabis industry than there was in hemp. Stakes are much higher and I feel like I'm not in the interest of deterring people, but the people need to know what the heck they're getting themselves into. And I understand there's a very long period and series and process that goes on to actually being successful. It doesn't just happen because you're here and you're in it. It's hard. Every day is hard and it's only going to get harder. And so I don't know that just letting people go in blindly, waving all the fees is going to prevent people from in the end possibly becoming quite disappointed. That is all. Thank you, Ashley. And it's a good point that was made about the hemp program in Vermont when they had $25 licenses. They had so many people who got into the industry and then once other fees were included and it became higher, it was different. I'm going to, I do want to also just before we allow for public comment to say that there are other licensing fees that we haven't talked about. So this is just that application fee. It is not the licensing fee that they would need to pay to fully be in the industry. Do we have any public comments today? Hi, everybody. Hi, Ben. I'm no longer alone. Ashley has also joined today. I just wanted to thank you all. I know this is the last of the subcommittee meetings. Most likely you all have done an incredible amount of work in this amount of time. The NACB, Jeffrey, your leadership in this has been incredible. Julie, same to you. I'm sorry to miss Monday's meeting but glad to catch up on the DEI program. I have to say I do support what Ashley is saying about the application fee simply because I know that there's a lot of people who they'll be making a decision. Do I educate myself or do I just go for it? I think that giving people a moment to pause and not necessarily invest the money but to pursue these educational options that are being made available is going to be a huge benefit to them. And just since DEI isn't necessarily looking to correct disproportionate harm and impact, I think that it would be okay to keep that fee barrier in place. That's it for me. Thank you all so much. I look forward to spending more time with you. Thank you so much for your public comments throughout these eight weeks. It has been honestly an honor and a pleasure to be a part of the process so thank you. Is there anybody else in the room who may like to speak? Okay, well thank you so much for that public comment. And as we just heard from Ben, you know, he is very supportive of Ashley's opinion about what happened with the hem and, you know, an agreement with not waiving the application fee. Not are your thoughts. My thoughts remain the same as before. I don't want to weigh all of the fees. I would be open to reducing the amount. Maybe by 50%. If that can, that might bring us all to a consensus, but I don't think it should be 100% free. Okay, no, I agree. And so we have, if the Ramon Cannabis Control Board applies a credit for the intention to apply, which is up to them. I can't guarantee that they will or won't. If someone has the intent to apply waived, then they may be getting a reduction for the application fee. Julio, your thoughts. We have people who would really like to speak just the intent to apply so people can explore what it actually, the cost of being in the industry and see if people can get, you know, maybe investors. How do you feel? I'm where I was before. I'm in Vermont in order to get a licensed operator food establishment, like to open a small place to feed people. I think the current licensing speed is $100. I don't think we have a problem in Vermont where people who want to make money and aren't educated about entering into the food service business are rushing into it blindly because it's only 100 bucks to open a restaurant. I'm just not persuaded by the use of a fee, an application fee, which would be waived, but you still have to pay a fee to get a license, which is a different fee and there's annual licensing. I just don't see an application fee as being a necessary or meaningful barrier. I agree that people shouldn't enter the industry blindly. That's why I said we should educate them about what the costs are. And I think that to the extent the state is involved in making sure that people enter the market with realistic expectations so that there's not going to be aggregate, you know, there's not going to be insolvency for a lot of people who weren't really prepared. I think the mechanism for doing that is through education and not through taking money out of people's pockets, especially a part of the population that we identify as being a lot closer to the poverty line as other people. It just, the fact that, I mean, there's just, to me, that I just think that that's wrong, you know, I use one law example, let me use another, you know, to apply to my law school or to Susanna's law school, it's less than 100 bucks to go to apply to law school, just to apply. Less than 100 bucks for that, but people who apply to law school know that there are other costs like tuition and housing that present barriers, it's not the actual application. And so, you know, I just don't, I mean, I just think that, you know, it would be a lot troubling to me for access to the law system if law schools started saying, yeah, just to apply to our school, it's a thousand bucks. It's, you know, even if you are in a lower, you know, a lower achieving part of the economy or you have limitations on your income. So, I just, I'm very troubled by that. I don't think it's effective and I think there are other ways to do it. Thank you, Julia. Ashley, I saw your hand raised and then after you make your point, we're going to vote on this. I just wanted to make a note, like, I, law school is hard. I think it's general consensus that you know what you're getting yourself into, staying with the restaurant industry. Like, we know that the failure rate for restaurants is much higher than the success rate. I think that the general consensus about cannabis still is everyone's going to make a lot of money. And like, I live in the world. So, like, I understand the reality, but I don't think there's a lot in the world that doesn't suggest that people are going to make a lot of money and that there's just lots of opportunity in the cannabis space. So, that is why I think that there is a need for an application fee that is higher than what someone would do as a lawyer, a super established long standing industry or with a restaurant industry. We definitely know what that industry climate is like. We don't necessarily know what that's like in the cannabis space because so many people are making so much money and creating so much success. That I do think that there is an unrealistic view of what can go on in our industry. That's all. Thank you, Ashley. Julie, I see your handbraze. I know we're going to try to vote on this so we don't have a Monday meeting. I promise you we'll vote or try to. I just wanted to add the context. Since we're talking about sort of people being able to judge and understand what they're getting into and comparing the cannabis industry to what happened to him. Already our provisional license application and the licensing application that will be required for this, I think I haven't held the two up next to each other to compare to him requires a lot more information and knowledge about what your business plan is that I think the So I think just the application process alone will be educational for people, irregardless of whatever fee they have today. Thank you Julie and Susanna. Yeah, I feel very strongly that it seems as if we would like to keep this fee. Not because we necessarily think the state really need the money, but because we're trying to maintain an air of legitimacy here. And I think there are just other ways to do that. So I wonder if it's not a possibility just to say, instead of saying, I mean who you mentioned the possibility of like an education program, why not mandate that. Hey, if you're going to get a social license, then you're going to be required to take this course and I don't know you can even charge him for it pay $100 for this course. That's going to require you to, you know, do, I don't know, maybe it's like the five hour course. It's like, these are all of the, you know, things that could go wrong, or here are some examples of what happened with him or something like that. It's kind of like, you know, some softwares that don't let you advance without reading the terms and conditions. And if you just click that you read the terms and conditions in one second, it'll give you a pop up. It's like, we know you didn't read it because you couldn't have read it in the short amount of time, forcing somebody to acknowledge. Yes, I understand the gravity of the decision I'm trying to make and granted again, I still think it's paternalistic. But it's at least in a way that feels collaborative and positive and not just heavy handed, like we trust your judgment, but only if you can pay for us to trust your judgment. So I would just consider alternatives that arrive at the same goal, but through other needs. Thank you, Susanna. I believe Julie is saying that with the application, they really try to, you know, put a lot in there to really educate people. Do you know how your business will run with this and other questions secure them. So with that being said, I'm going to have this as a vote of what benefits should be included in the diversity, equity and inclusion program. The first one being educational programs, certificates and workshops, priority processing, and then based on the conversations we have had and the majority of the subcommittee voting members. Really, citing with just the way that intention to apply, that is the only free waiver we will be voting on. So, Ashley, yes or no. No. So, yes, yes, yes to not waive or yes to waiving the intent to apply fee. Yeah, so we're not voting. We've already taken off application. Okay, so just once again. Benefits would be the educational program priority processing and the waiver of intent to apply only. Okay, yes, yes or no. Yes. Thank you, Ashley. Not our yes or no. Thank you. And Julio, yes or no. For those things, yes. Thank you. So three yeses to the benefits of educational program priority processing and the waiver of intention to apply the only for the diversity, equity and inclusion program. Well, thank you so much.  I, you definitely have made me see perspectives that I didn't even start out with push me to the limits. Just, if I can take two minutes, we have gone through a lot these last eight weeks, you know, creating two separate programs for the state of Vermont, social equity, diversity, equity and inclusion. What who should be part of the social equity program definition of an impacted family. What a domestic partner is supporting documents that would be needed for candidates, eliminating discounted fees for social equity candidates and other fees. How should a social equity licensing business. How should that social equity candidate be represented in their business. You know, what happens if they transfer their business to someone else within five years. What are some social equity benefits that candidates will get exclusive licenses the cooperative delivery license. You know, what, what is the development fund. What are the expenses going to be used for how can we create additional funding for the social equity cannabis trust. And creating a social equity trust as well. Creating recommending recommendation of a cannabis social equity board and who will be on it, you know, lots of people from different diverse backgrounds and geographical locations and tons of social equity candidates being represented on there. What is the responsibility of the social equity board. You know, what do we need in the application for social equity. Who will approve social equity applications about giving money back to disproportionately impacted communities. Who are the disproportionately impacted communities. And as what we completed today was about, you know, who should be included in diversity, equity and inclusion program and what benefits they were received. So that was all done in eight weeks. So it was a mad dash to the finish line, but probably to everybody you have done such an incredible job. I like to thank Ashley, Julio, TJ, Nader, Susanna, Lindsay, Julie, I mean you have been brilliant and I would like to thank every member of the public who have come in for public comments. Thank you so much. We couldn't have done it without everybody's involvement here and your dedication and I know how much time and energy you're spent because it's more than just these hours that we speak in front of all the work that you do behind the scenes as well. So thank you. I truly feel blessed. Jeffrey, thank you so much. Danika who's not here who has also helped and trust me, we have Jeffrey and I and Danika have put tons of hours into this and many phone calls. We need to get this and have you research this Jeffrey so thank you for bearing with us through this process and really trying to have really wonderful recommendations for constituents in Vermont and we would like to thank the Vermont Congress control board because they have been lovely and answering all of our questions and answering the phone and I have asked them many many many things and there's been so much time and Vermont is definitely getting it right. I can say that they really want to create a cannabis program that is going to be beneficial to every single person in the state of Vermont. And to me that is a blessing to Vermont that no one else can have and I don't always get to see it. So they've already taken that first step. They want to get it right and they're okay with taking the time to do so and adjusting and getting not only the panel, the subcommittee's opinions but going out and getting public comments from the people that this industry is going to serve. So thank you so much and this won't be the last time you see me. So if you get email phone call I'm still here. Please if you have any questions we're going to be around and this is phase one committee members. I would love to see you at phase two where we go out and we meet the people you know social equity candidates. It is your time so now you're going to feel like it needs to be in the hot seat and we're going to get the comments from you. We're going to create two town halls during November. There will be an in person and an online ability for the public comments and the public comments that you make during that time. We want to hear your voice we want to hear your stories and we will write a report just as we have done for these subcommittee meetings with all of your recommendations that you have on the social equity. So come co-design this program with us please it's so very important and thank you everyone. I guess this is the last time that I asked who can I have a motion to adjourn? Motion. Thank you Ashley. Do you have a second? Second. Well I am going to miss these five weekly calls and you have my email so if you need me thank you thank you and I will be speaking to all of you I'm sure after this as well.


I'm your host Vikram Acharya. I'm the Chief Executive Officer of Cloudwell Health, an all-virtual telemedicine provider based in Hawaii. We have a great show for you today. I am very excited to introduce Mr. John Williams. John is the Chief Executive Officer of the Honahoe Medical Group here in Hawaii. John, how are you doing today? Hey Vikram, doing good. Thanks for having me. Thanks for being on. It's good to see you. Good to talk to you. To kick things off, John, tell me a little bit about your background.  You're the CEO of a medical group. Tell me a little bit about what got you into healthcare. Sure. I'll give you hopefully just the two-minute version. I think I've gotten it down to two minutes. So I originally trained as a clinical pharmacist, came out of UCSF. I can't even think the right number of years. I think 40, no, not 40, 35 years ago. So I got trained out of UC, practiced pharmacy. The majority of my career at Kaiser Permanente. And then about 15 years ago, I transitioned over, was the Chief Operating Officer for a Federal Qualified Health Center in California at San Francisco. And then eight years, 10 years previous to this, transitioned again, became the CEO for a legacy IPA medical group in San Francisco, Chinatown. And then most recently, my gig is here with Hanoi Home Medical Group. So you have made a transition from being a clinical pharmacist, really kind of involved in the day-to-day aspects of patient care to more of an administrative role, it sounds like. What made you want to make that type of transition? I mean, a little bit of a cliche to answer, Vikram. A lot of people say that to be able to impact more lives, have more influence on systems, understanding where healthcare was heading. But it was sort of, for me, was a natural progression.  And you end up signing just like you're complaining about stuff. And so instead of doing that, with each step in my career, I took a step up, so to speak, and then tried to improve what I thought I could improve. And it just almost naturally led me here. It was never a goal of mine to become a CEO or CEO in a healthcare space. It was just sort of a natural progression, Vikram. Interesting. Okay, that's great. Now, you're in charge of the Hanahoa Medical Group. What exactly is the Hanahoa Medical Group? Yeah, so in Hawaii, we are in Hawaii language, we're a medical group which stands as a risk bearing entity. And what that means is that we engage payers, whether they be direct payers, like Medicare or plans or health plans, to engage in risk bearing contracts where we partner with health plans to provide services to their beneficiaries, whether it's Medicare, commercial, or even Medicaid or MedQuest here in Hawaii. We are a physician-based organization. So there's physician governance, physician committees. We are physician-centric with the belief in terms of, you know, maybe I should have started off this way. And I'm not very good with promoting my own organization sometimes. But, you know, our vision and our mission really is to sustain, grow independent community practices or physicians, if you want to call them that. There's been a trend both at a local and national level where that number has been decreasing over time. But we think community physicians play a very valuable and critical role in healthcare delivery, not only in Hawaii, but everywhere. Yeah. It's an interesting theme you mentioned, the importance of the independent physician, independent community physician. What was the thinking behind setting up an organization like HAHO? How did you go about organizing the pieces? Because it's very complex, you know, the space and very critical. What type of planning was involved to put it all together? The, fortunately for me, you know, I had the opportunity to work with the IPA and medical group in California. And in managed care and in California, they call them RBOs or risk-paying organizations. Those structures are relatively common. And it's more established. They never, it caught on in the 80s and it sort of stuck. There may have been groups that had, you know, sort of either consolidated. Some of them sort of, you know, weren't successful. But the ones that stuck around, they have established structure. California itself is a little bit more, what would be the right word, rigid in terms of monitoring and controlling sort of risk-bearing organizations or entities. They have a department called DMHC, department of managed health care. So I have experience in doing that. I understand what the structures are, how the operational flows are, how the financial risks are set up, how the contracts are set up, you know, what's needed to really be a successful risk-bearing entity.  So they're all interrelated in my so we can talk about all those things. Yeah. Yeah, that's a good segue for someone who doesn't know what value-based health care is. What are risk-bearing entities? How can you unpack that for people who may not be familiar with the lingo? Sure. I get accused of using way too many acronyms. I think in health care, we do use a lot of acronyms ourselves anyways. In terms of risk-bearing, so when you look at, when people talk about health care in the United States, and you talk about health plans and health systems, it's still anchored by insurance, it's health insurance, whether it's Medicare, Medicaid, commercial private insurance, Medicare Advantage, it's health insurance. And it used to be, and unless so now, most health insurance companies didn't provide the actual care. They don't deliver the care directly themselves. What they do is they engage in our terminology providers of health care services, whether they be physician or non-physician, hospital-based, and used to be the older model was it was very transactional. You provided a service and someone paid you a contractual amount. More recently, it's either the Medicare fee schedule or the Medicaid fee schedule. In terms of trying to get to quality-based outcomes or outcomes that have been proven to show improvements in overall health, whether it's for a larger population or a community, health plans, payers, health systems started recognizing that there were leading indicators or leading outcomes that downstream proved to be valuable to predict whether a population remained healthy or stayed healthy or whether they continued to deteriorate if, for example, they didn't have access to really good health care services. So slowly, and it still exists, there's still a mix, but slowly the trend is to moving towards some value-based outcome where entities, organizations, accept the responsibility, both clinical and financial, to take care of a population. Typically, it's related to health plan beneficiaries that signed up for the health plan. And with that responsibility, you are given, I don't know how much, at what level you want to have me use the terminology, but they're given a capitation. The way I look at it is you're given an allow it, so to speak, and you have to provide the services associated with that capitation or finite amount of money, and you take risk on it. So to really kind of unpack that, these are organizations that you're part of that take care of patients and measure based off how populations do from an outcome standpoint. So from taking care of them, you'll get, let's say, for example, $100 from an insurance company. And within that amount of money, you have to take care of X amount of members. You have to stay on top of them, make sure that the preventive care is in place, that they're getting all the checkups they need, and there is some financial risk that you're taking by obtaining that $100 in a very simple example. Yeah, in sort of straight numbers or easy numbers, I like that you used $100, it's easy to break down. But that $100 is what we call a capitation amount, or a finite set of dollars associated with it. And there are camps who support this methodology and there are others who still believe the older FIFA service model is still better or still valuable. And quite frankly, there's a mix of it depending on type of providers. But the data to date so far shows that under a capitated structure, physicians, providers, systems who are paid more based on quality, start focusing on outcomes that improve both the quality of care, the quality of life for members. And when you focus on that, it translates to not only better health outcomes, but it also translates into what Medicare, Medicaid also need is accessible, affordable health care services. Where I don't know what the number is now, Vikram, and if it remained FIFA service like 100%, probably we'd be past 20% of the GDP for health care by now. Whereas now I think it's still pushing up to 17. I don't remember the exact number, but it's still pretty high, still creeping up a little bit. Yeah. So you're getting paid for how patients do versus the more you do for patients. So taking care of them versus let's order this test and do this and this and this and then get paid for it, which is a much more efficient quality based model in terms of how you take care of people. Yeah. You know, when you look at the FIFA service model, because it's transactional, it's really granular and no one take, not no one.  I think when you look at a population level, that's where you can see the benefit of having a reimbursement structure linked to quality programs. You can see the benefit and the improvements that you see at a population level.  But when you step back and look at it at a population level, or even at a national level, you do absolutely see the improvements associated with it. Definitely. Definitely. Now you're working with medical staff positions across the entire state. Are there specific islands that you're focused on right now? What's the trajectory looking like in terms of, you know, who you're working with as part of the medical group? Yeah. Right now we work with positions on all the islands or put it another way. We don't exclude any islands in terms of engaging with physicians. Based on density of population, whether it's patients or physicians, the bulk is in on the island of Wahoo. There's a little bit Kauai, Big Island, Maui. I don't think on the smaller islands, I don't think we have a physician in Molokai. But yeah, there's no exclusion, maybe to think of it that way. Yeah, that's great. Now, when you're approaching the insurance companies on that end, what types of information do you provide to them in terms of who you are as an organization and what your goals are and how you can work with them? Yeah, the way we approach health plans, whether, you know, the plan, if you want to call them that or the payer, is Medicare or whether they're health plans, the larger health plans in Hawaii. We present to them, like I said earlier, as a medical group, first and foremost, or collective of physicians, but the group as a risk-bearing entity in that we're willing to engage them as partners for their members and beneficiaries, which become our patients or the physician's patients. And we provide the bridge to the local community physicians. Instead of health plans working with 100 individual physicians, they get to work with a medical group who is able to coordinate programs, coordinate messaging, and then provide additional support to the independent doctors. Yeah, I'm sure when you are having your discussions with the independent doctors, there are some common themes in terms of what's important to them, what they truly value. What are some of those things that come up when you're in your discussions with your current group, as well as in the process of obtaining additional partners? Yeah, I think the biggest thing is, and it's a fairly general term, Vikram, but it expands and touches a lot, right?  And transparency is both with measurements, whether they're outcomes-based, transparency in reimbursement across the system, not just for themselves. They want to be good stewards of how the medical dollar is spent, so to speak. And then last but not least, either however you want to negatively administrative burden, positively support structures. So how is the medical group and what support services do they provide to independent practices? Those are the three main themes that we run into most commonly with doctors. And what kind of support services do you provide for your partners? Yeah, so one of the things that we think is unique is we invest in what we call member relations and provider relations. Member relations is the outward facing with their patients. We help them with questions, with claims or bills. You know, sometimes the department even helps with non-healthcare stuff, quite frankly, because of the cultural competency that's required for some of the communities when they can't get a hold of anybody, because they have a relationship with a member of relations, they'll ask them to figure out, you know, why is my electric bill this way? You know, why is my telephone bill? But most of the times their healthcare bills, whether it's co-pays, whether it's coverage, whether it's helping them coordinate a referral with a specialist or, you know, prepare for an outpatient visit to a hospital. In terms of provider relations, it's the same thing. We do that at the provider and the provider staff level. You know, when they have questions about what's covered, you know, who's in network, who's not in network, you know, I submitted a claim, where is that? We provide more granular support. I think sometimes, you know, to no fault of their own, larger health systems don't have the boots on the ground, so to speak, locally to be able to provide that support. And we do and we provide it for our physicians because we know them well, there's a relationship. So things are a lot smoother and easier that way. On the clinical side, we've started programs for care management, care coordination, and complex case management. Those are, and we can dig into that a little bit more, but you know, that's probably maybe another podcast. But then we also provide, you know, data and analytics down to the provider level, down to their panel and patient level as well. We chop it all up, reorganize it, present it to them in a user interface platform that's really easy for them to digest. We have, and maybe you should talk to them one of these days, we have a tech partner in Elation Health. They're a technology company. Their main focus is electronic medical records, but they do also what they call a tech stack, I guess, in their field, which is, you know, EW, analytics, reporting, you know, clinical outcome support. So it's, we provide all that through the medical group. And it's at a very individual, almost personal level for the physicians. And that's something that we think is valuable. Yeah. I mean, that's a robust set of services and not only provides significant value to the practice, but it sounds like it, because you're helping these practices so much, it allows the providers, the physicians to really focus on patient care. You know, they do what they do, what they want to do, and knowing that they have this night's support structure behind them. When we look at it, maybe we're, as a medical group, maybe I am a little bit biased. It's like a win, win, win. It's a win for the patient because they get added support. It's a win for the doctors. They get additional support. And it's a win for the plans in that we become the intermediary support structure that the physicians and their staff and the patients are very familiar with. With that transparency, it leads to an even more broader term, I think. You know, transparency then leads to trust. And when you have trust, then you start getting engagement and participation. But that engagement and participation is not just with doctors, it's with patients and with doctors. Yeah. Yeah, definitely. And what are your thoughts, John, on an asset like telehealth, for example? You know, it can help support patient care. It can help keep costs down, open up more access. What are your thoughts on something like telehealth? Yeah, I think telehealth is, you know what everybody is saying, Vikram. It's here to stay. I think with the pandemic in the last two years, it unfortunately, you know, unfortunately, in that it required something like a pandemic to show it. But it was almost a proof of concept as to is there value to telehealth? There was incredible amounts of back and forth argument. No, it doesn't work well. No, patients aren't going to like it. No, you're going to kind of get uptake on it. No, it's not effective on outcome, just on and on, just back and forth, pre pandemic. However, the data and I guess some people say data doesn't lie, you know, the data coming out of it is showing that actually it's the opposite of all the naysayers from what I can read. I'm sure maybe someone pull up something. But in general, it's been proven to be extremely valuable, both in access and in clinical quality, especially for those patients, and I'll call them patients, patients who have difficulty accessing services, whether it's due to socioeconomics, whether it's due to their lifestyle, whether it's due to their, you know, physical inability to go somewhere, right? And so now telehealth has given them a platform to communicate with providers, with physicians, with support structures. I think it's going to expand quite frankly. I haven't heard or seen telehealth being used or leveraged as much on the administrative side of things, but I think it's going to, I feel it's going to, right? Because there's still there's still stuff lost in translation when somebody sends you a paper bill and it's like four pages long and you don't have to understand. I mean, you know, getting someone on the phone is great, but for me personally, you know, like we're talking now, in person would be better. Hey, let's go over this piece of paper. But, you know, through some virtual platform or telehealth, which I think is a part of the whole thing. I think that could be approved upon as well. But telehealth has been shown, I don't think, I think slowly, and I thought there was a new release. I was going to talk to you about that later. I think CMS has extended, I think coverage for the current services all the way to 2023. I think ultimately, once the data continues to flush through, it's not going to go anywhere. And I think it's going to be a part of the healthcare delivery system. I still do, however, don't view it as, it's a piece of the delivery system. I don't think it'll ever be, you know, the only mechanism to deliver healthcare. And I think that's what people worry about when they hear telehealth. They're like, Oh my God, I'll never get to see my doctor again. It's like, no, that's absolutely not true. You know, that's a misconception, I think, that's put out there, you know, people who worry about that happening. I don't think that'll ever happen. Yeah. You raise a great point. I mean, where I see it as a, as a complimentary asset, let's take, for example, behavioral health. So I'm sure many of your, your medical staff have patients who have behavioral health needs and people like the opportunity to see a therapist when they want it and in the format in which they want it. And then something like telehealth, if it's easy to access, they could talk to their therapist from the privacy of their home, the comfort of their home. I would think something like that would be very beneficial to the patient, like you said, to the provider, the primary care provider, as well as to the insurance company. Yeah. I think having the opportunity or the choice of, of how you want that interaction to occur for behavioral health is really important.  Other people, quite frankly, may want to start with a telehealth visit. I've even heard, you know, the companies are flexible enough. It's like, you know, is it okay if I don't do video and just talk to you? It's like, yeah, that's okay too. Whatever the comfort level to engage individuals and that in, and I think it could be a broad spectrum, whether it's temporary and transitional, whether people are going through a loss and a tough time and they never need behavioral services again. Having telehealth to be an easy access format to have someone to talk to, get them through, you know, a tough period in time. And then of course, the more chronic conditions, having regular constant feedback that's easily accessible, I think is important. And I think telehealth fills that need rather well. Right, right. You know, John, you're, I give you a lot of credit, you and your team, a lot of credit. You're really changing the landscape in the way healthcare is being delivered, the focus on value, the focus on the independent community physician and what's important to them as well as what's important to the patient. And I really appreciate you being on the show. You really have broken it down very nicely in terms of the vision of Honahoe Medical Group, where you're going, why the, what's the mission of the organization. And it's just really great work and congratulations on your progress so far. And I know it's going to do very well in years to come. Mahalo and thank you for being on. Hey, thank you for having me, Bikram. It was fun. It was and you were right. The time passed in the blink of an eye. But I really appreciate the opportunity to talk with you. Hopefully, this message gets out a little bit more. And we really are trying to support not only doctors, but the communities in Hawaii as well. Thank you very much. Absolutely. We have much more to unpack in future episodes with you. So we'll pick it up again soon. All right. Thank you very much, Bikram. Mahalo. Thanks, John. Mahalo. Bye-bye. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, and LinkedIn, and donate to us at thinktechhawaii.com. Mahalo.