You may be getting out very early today when we ran into the snag with the insurance bill. I cancelled the cigarette testimony because I didn't want a lot of people tracing up here and I was not getting to them, you know, until two, three o'clock on Friday. Since then, I had a meeting with the chair of appropriations this morning trying to figure out what we do with S96. The best, it needs to come out of here ASAP because it needs to go to a probes because there's money appropriated but not raised. There is money being worked on to be raised in the other body. So what I've been asked to do is just pass it out, let appropriations deal with it, but it is going to have to be dealt with as part of that entire end game because the only new money in there is the eight million dollars from the inheritance tax and whether or not it's no, that's what the governor's funding plan is. There is no alternative funding plan in here. There is a proposal approach therefore has to find a way to fund it. So anyway, we're just being asked to pass it out. We can do what we did last year without recommendation and send it to approach because it's going to be part of the bigger money mix at the end. We're going to have to come out to even meet the governor's 48, I guess now 50 million number. We're going to have to replace the eight million dollars he's booked from the estate tax because that is also generally booked in the budget and we probably won't like what he took out in the budget. And there will be a funding, they're working on a funding source and I've asked to have some numbers calculated on some funding source I've thought of when it comes back to the funding source. I think we're all looking at the present property tax surcharge and transfer, property transfer tax. Yes, property transfer tax. That's been the only thing we've done to fund it, to raise new money. I think the house is looking at raising that, that surcharge my feeling is now that the surcharge which started out as a one or two year has been made permanent, we probably are and it hits everybody. I would like to look at what it would, you know, what kind of money would generate by maybe doing the more folding it all in just saying yeah, this is the property transfer tax and maybe tearing it. Doesn't have anything to do with water. Well it never did. Well, but those would fall. Are you guys, let me think in a historic way. We've been through these battles. The funding sources that we've had, we've always been reassured that these were temporary as we worked. To get a life that were a proper program up and running that coordinated water use and taxation, etc, etc. Right. That is, we had something out of here. Actually, we did an occupancy tax at one point in this committee to fund. Initially, we voted out an occupancy tax. So you don't want to look at the clean land, don't you? That's right. That was another form of income. I had paid occupancy taxes to build stadiums, redeveloped downtowns, you know, but we need to get it out. If it's going to survive and keep moving, it needs to go, and it needs to go to a probes. I'd like to make a motion. Regarding Senator Rockins' bill that raises additional money on the property transfer tax from these corporate transfers that have been in the loopholes, whether they will wind up getting included in this, if we don't have some language excluded, and you're assuming we may want to do that because some folks have already got that money for some other purpose. Well, we don't see Senators Rockins' bill, so I don't know what else is coming in. Oh, it's in another version. We've actually talked about it here, too. Right. That's sort of the point, right, is all of this has to fit together. It's all... Are there any questions or anything we should do with that here before it goes over there with that in mind? Well, you know, we haven't even seen it, so we'll exclude it without seeing it would be difficult. But if we vote to send it out and we vote to use that money, that will be excluded. And it will come out... Is that going to approach, too? Would you vote now, Siebel? Yeah. Okay, so, approach will get all... Yes, they will. Okay. But that one will come here first? Yes. So, yes. If I might, Madam Chair, and given that I don't... There are multiple people who sit on natural resources or have sat on natural resources in the past, and are probably more up to speed on what has happened prior to this. I just need a little bit more explanation of why we're at this point of passing a bill that has no funding. I don't understand. So, if... Natural resources, in my understanding, could not reach agreement on how to pay for this. Do they have agreement on how much money was needed? Yeah, and I would say, I think we just felt in the end, Senator McDonough, if I'm wrong, this was really a finance decision around money, how we would raise it. But as I'm understanding from the chair right now, that we have a couple different ways to do this, that House Ways and Means is working on some funding options. So, this definitely is the end of the story. And whatever they might send us, we might add to it. Give us more time to take testimony and learn about some of the different options out there. And there's a timing issue. So, I think ideally, in an ideal world, how to send natural resources and energy, I've sent this to us... Two, three weeks ago? Okay, we would have time. Last year... If I'm misrepresenting something. Yeah, no, last year we went through the same process. We got two strike-alls sent to us, I think, two days before crossover. And we sent it out without recommendation. And a third one presented in here. And we, yeah, had like two hours to do it. And I know that Mark wants to say something, that I don't want to forget my thread of like how much... Senator Campion was correct. We didn't see a good consensus that we're going to go with the maintenance of effort number that they presented. And we didn't debate that. In the committee, we talked about per-partial fees. And whether everybody in the parcel paid the same or they were connected to how much, you know, what the permanent services. But we didn't persevere to vote on that on any of those things. And we sent it here to the committee who raises money. And if we don't raise it here, it's going to come from somewhere else. Right now, the administration has 48 million. And we've got the numbers here. The last year, we looked up last year's bill. And what it basically said was there was a study that, you know, we should look at how much we should spend, which would include, but there was no commitment. Last year, I think we spent 56 million. This year, the administration has 48 books. We have been told that the reason it came down is there were several major water, like filtration, water sewer projects that were done about Lincoln and and so that money's been spent and that good is there and therefore this year it's lower. So there's 48 million on the table. To do what we did last year plus inflation would take, I'm trying to remember his numbers, I think it was like another, it comes up to about 15, because included in that 48 is 8 million from the estate tax, which has, last year and before that, gone to the general fund. So the general fund has to cut eight million dollars. What's in the budget is 57 million, 811, 342. Yeah. Yeah, we've got that document. And but the other thing we're doing today. So we are, if you don't want, if you want to exclude the estate tax, we are approximately $14, $15 million short. We're not changing the estate tax. The governor has also changed the estate tax, which that hasn't happened either. That we will have to do and we have not done that. No, he is proposing to raise the threshold of the estate tax so it would bring in less money. So yes. This is not traditionally our role? No, it is not. Which part of our role? Pardon? What part is not our role? Chair appropriations community said we've got revenues coming in, we don't need the money. Please don't raise any money to clean up the order. Or are we just, are we going to do what the last committee did, which was to say we're not going to pass along to someone else to make this decision? Or are we going to say at this moment we're not going to make this decision? Well, in which case, then we're going to say that we wouldn't suggest to ourselves that the solutions have already been planned, unless they haven't been already planned. No, the solutions are not planned. We have been asked to keep this bill alive to get it over to appropriations. We will be receiving miscellaneous tax with some ideas in it. We will get the miscellaneous tax. My understanding is that water funding is not on there. When they send the water bill over, ways and means is working on ways to fund it. They work all day and they don't do insurance and banking. So they just traditionally have been able to do deeper digs into things like this. So we're being asked to keep it alive. Right now, the big question is the eight million that Props will have to come up with. So we need to get it to them. No, I respect that. I appreciate you coming along because I don't want it to. I don't think anyone wants to die. No, I know you do. And we have not at the time. I know there is some concern about the regional planning commissions, you know, and how well vetted that all is. I'm a little concerned that I'm not seeing any new money going to them. But I don't have time. They said they they had that when they do grants or contracts that There's there's an oh, yeah, you can put a 10% overhead cost. That's fine. But we haven't done these water grants before, right? Well, if you don't mind that, I asked Mr. O'Grady just to come up. So I don't miss speak. All right. You know, if we are not putting new money in and we are going to be doing grants to the RPCs and we aren't raising new money, then what aren't we doing? So the grant amounts will have up to 15% available to do administrative costs. Right. So the RPCs are going to be getting new money. They are, but what isn't getting old money? Well, that's your decision, because that's what part of appropriating money from the Clean Water Fund is going to be about. That's why that's what appropriations will look at. And that's the yearly, yearly deliberation that you have about how to spend from the Clean Water Fund. It's typically based on the recommendations of the Clean Water Board. And they have, with this mechanism goes into place. They will be making recommendations for the four grant programs that are in it, and then it's up to you to fund. So those are the grant programs they're talking about? Yes. Okay. The RPCs have been now based on committees, and the based on committees will make recommendations within their own basins as to who the winners and the losers are on the grants. And they will make those recommendations to the Clean Water Board, which will either approve, deny, or rearrange those local recommendations and make their recommendations in the governor's budget. Okay. That's what will take place. The concept then is that the RPCs will work with the basins. The basins. Vizory councils. Okay. This is all agreed to those of us that do insurance and banking. Okay. Sea whips. Sea whips. Sea, all right. Sea whips for being our service. They will not be able to adjust. So the idea is that they will just be almost a pass-through to get the money out based on committees that are actually doing the work. They're a pass-through, but they are expected and required to be the ones that are going to oversee the operation and management and efficacy of the projects funded through the grants. Okay. And they are limited in the amount they can use to do that. The senate natural resource thing was very clear that there was a 15% cap on administrative cost on all of those grants and through the process. So the big block grant goes to the RPC and the RPC starts making the little grants out. 15% limit is on that as well. Sea whips. Right. Not the RPC. We know what our RPCs are. Right. Sea water resources. And the regional planning commissions are separate entities from the new government created. That they may be able to make recommendations. So the key point that I brought up the other day, one of the points is the operation and management costs of those projects that are funded by the grants over time. I think you heard from the secretary of natural resources that the budget doesn't account for that. Right. And she said, well, the regulatory programs, they don't fund operation and management, which is true. Many of you have been on institutions or have been on part of this committee. You don't fund operation and management for the capital funds that go out in this water. That's crazy. And you don't do that. But those are regulatory programs. Remember, these projects are above and beyond the regulatory programs. And so will the cost be borne by the RPC in doing the operation and management over time of that project? Will it mean that less money is accounted for in the grant for the capital, the hard cost of the project? That is what is not accounted for in this. Right. S96 says that their money should be available, but this doesn't have that. This is just building the ditch, but it's not talking about who's responsible to make sure the ditch stays clear that it doesn't, yeah. Right. So that's the question for across the hall as well. Right. And there is adequate money to do a lot of this. Maybe not to do the same amount we did last year plus inflation, which is, I know, the ideal. But I think we don't even know what it would cost to fund the ongoing maintenance of management and maintenance of all, I mean, we're talking a lot, potentially a lot of small programs. One thing that I'm curious about is the money that's contemplated after we send the money out in this bill to the whatever the regional entities. What is left, like is that spending all of this money or do we have half the money in the state that wants to be able to do the other half or not understand that relationship? So remember that, that all of the money that's available for clean water doesn't all come from clean water funds. There's the transportation fees. There's the capital monies and EPA for drinking water and clean water. There's the capital monies from NRCS for IP and P's. They're not going to be affected by those. Pots are still going to be there. Maybe I should ask you this, like what, how much money is going out the door in this total? That's going to be up to you based on the recommendations of the clean water board once this gets up in the line. So this is a structure? Yes. Other questions? Is this going to be up today? Yep. This is a storm water. It has to go across the hall. The rate it's going to be, we, they will not get it until Wednesday and they have to have it out by Friday. This is an example of what happens when a storm water goes down until fast and you can't deal with it. You're right. It washes right through committees of jurisdiction and goes where it wants on control. It will go across the hall and I have, you know, I have a feeling it will end up in that final allocation mix of the budget. If they want to get rid of the governor's plan to use the state tax and they have an eight million dollar hole in the budget and theoretically we should be helping them fill that void, right? Well once they get to looking at the budget and seeing how the other body either has or has not filled that hole, I don't know now how the administration filled that hole. I know some of the cuts that have been made I'm uncomfortable with but I think they're still figuring out how the parts are moving in the budget. Once they do that, if they don't have the money, we have a miscellaneous tax bill. They will tell us if they need to raise money and we will raise it. Well somewhere as the revenue committee, if you're changing the rates for the estate tax as part of this process, that should be this jurisdiction. It should. It clearly is. Yeah, I believe that's a revenue bill so it will start in the house and now if they will ship it over to us or they may just kill it but that doesn't mean that we can't take it back up in the miscellaneous tax bill. It will be there as something they struck in that bill if that's what they decide to do. The miscellaneous tax bill is our Christmas tree and it was traditionally where this committee does most of its work at the end of the session because that's when all those moving parts start there call us and we know what we need to keep them all together. Okay, other questions about the bill from Mr. O'Grady? Thank you. All right, so committee, we can pass this out. Yes, we can pass it out without recommendation which I don't feel like I've had enough time. Yeah, well that's my motion. Okay, Sir Clark, are you ready? Okay, we have a motion from Senator Campion without recommendation. Is there any further discussion? If not, all those in favor say aye. Aye. Oh, say no. No. One, so that's six. Okay, one, two, three, four, five, two, zero. All right. Maybe as Senator Sorak has suggested, the bill should be retitled as an act relating to not establishing a court assessment. Yeah, I thought it could be possibly one day. This has probably been one of the hardest things to crack. I am not happy that we're still limping along with the present funds, but. But I feel confident maybe I'm I fear that we're going to get somewhere in between the house and conference and our further conversations. I think we have to. It's a A, the system is complicated. B, that makes the funding complicated. I think this committee has demonstrated in the past that we're willing to raise funds. I don't know at this point that we even know how much we have to raise because there's an eight million dollar at least appropriation in there that is not decided at this point or not decided without knowing the cost. Senator Campion, you want to report this? It's a real hard one. Okay. Okay. We're going to go on to another really easy fund, one, one, three, one, our insurance sandbox. I'm assuming that everything else in the insurance bill is fine except the sandbox. And yesterday we sent a message, I think about quarter five over to the Attorney General's office asking what they thought. This had come back to us with, oh yeah, I wanted to come back to us about with the fence. They said they thought they're doing rules, but lots of fences put around the sandbox. There was some concern about national letters and for national proposal that had been handed out. The insurance agents who had originally been concerned are now happy with the bill as we written. But we asked the Attorney General at five o'clock last night if they could give us any enlightenment. And Chris, you want to tell us if you can enlighten us? Absolutely. Thank you, Madam Chair, members of committee. For the record, my name is Christopher Curtis and the Chief of the Protection Division at the Office of the Attorney General. I here to share with you the eight most feared words in English language. I'm from the government and I'm here to help. Unfortunately, in this particular instance, we have not had enough time for our office to thoroughly consider this proposal that is before you. So we cannot take a position at this time on the bill. I very much appreciate you flagging it for our attention and we will certainly thoroughly review the proposed legislation and take that into account if and when you elect to make any kind of determination about it. But unfortunately, we just have not had time, the Attorney General has not had time enough to really absorb this in any terms about whether or if there are questions, concerns, or comments that might be useful to your committee. So I regret to pass that on to the committee at this point. However, we are aware of it now and we certainly follow. Sophie, if you get some real red flags that we're missing, you could we will thoroughly work the other body you fill. So so your office signed on to this letter from that's I guess led by the Attorney General around is this a federal proposal? Yes, this involves there's I think what Senator Pearson is referring to is a letter to the Consumer Financial Protection Bureau involving no action letters with respect to I would say that I'd like to distinguish the letter that you're looking at from the legislation that's before you for a wide variety of reasons. First of all, that letter specifically dealt with goods and services under the CFPB that would have a direct impact on essentially all of the Title IX goods and services that we deal with in terms of unfair deceptive acts or practices. That is a wide ranging variety of things. The no action letters referred to in the regulatory sandbox or waiver provisions associated with that would actually go on in perpetuity. And they also would potentially one of the objections raised by the Attorney General would potentially give some third party immunity or protection from liability for potentially full industries or trade associations. So it's a very broad sweeping proposal at the federal level that the attorneys general are objecting to there and requesting that those rules not be promulgated. By contrast, I think what's before you is an insurance bill. So because that is the particular province of the Attorney's General with respect to consumer protection writ large, that was a special concern I think to the Attorney General to sign after that letter. We're very fair. It means we just handed out there was no explanation as to what they were. Okay. Any other questions? Okay. Thank you. Thank you very much. Mr. Mickenburg. Yesterday, and maybe it's Mr. Gaffney, question came up. There are exclusions in this bill and the question was raised by Mr. Mickenburg as we were going out the doors. Could this be workers comp or come on up? Yeah. Is that one of I know health insurance is excluded? Yes. Kevin Gaffney, you have to be Commissioner of the FR. Workers comp is not currently contemplated in the bill as an exclusion. That being said, it doesn't seem like a likely candidate for the sandbox because there's obviously some pretty rigid state laws, mostly in Title 21. So we could consider that. I mean, that's something we just discussed, but that was one of the things we talked about. The reason we didn't exclude it was that we did think that there could be innovative products. One of the challenges with workers, there's a couple of challenges with workers comp. One, there's still an underserved market. There's a lot of exemptions that avail people to exempt themselves from the system, and they certainly have every right if they're within the law to do that. A lot of that is more cost driven than finding the benefit of the workers comp protection. Could there be a more innovative workers comp product that comes to market at a lower cost to serve some of these underserved markets? That potential is there. Could there be an innovative product that integrates payroll because workers comp is based on your payroll and the type of work you do? Could there be an integrated product that builds weekly, that maybe makes comp a more affordable product? You know, these are just the type of innovations that you just don't know what you're not availing yourself to, but that being said, we don't anticipate that being the thrust of the sandbox. I would say most of this being property casualty. Property casualty, generally. That's what workers comp is. It is property casualty, but it's obviously a regulatory regime for workers comp is both in the labor law and in the insurance law. Page 4, 19, if I get the right spot. And there's a whole lot of numbers. It excludes chapter 107, 112, 129, and 139, which I have down as health insurance, licensing requirements, consumer protection. I'm not sure what the fourth one is. Yeah, life insurance, insurance rating practices is 129, and the licensing is 131. Is there another, is an easy way to just put workers comp in there or is it so complicated that? It's not its own chapter, but it is part of the chapter. So we could identify it as whatever it is we could identify and carve it out. Which of preference is not just... I think what I testified to is that the likelihood of comp being a suitor is probably lower than other types of products, and that's only based on the experience that we've had to date, like when we engage in some of these innovative presentations there. They haven't been about workers comp. But what I thought you said is that potential because there is a need for innovative products to serve and underserved our portion of market? Exactly, and that's what I think all of the committee members have raised different questions of give us examples, and I think the example I give is certainly a plausible one. I mean, there are individuals that don't carry comp because either the law allows or there's ambiguity. And loggers. Can you remind the new members? I know it's a big problem, but loggers. Who they might be. I wonder if the witness would remind the members of the committee that they served here before on what the exemptions are being. The exemptions. Well, the exemptions in this bill? In this bill. To workers comp. To workers comp? Well, that's Title 21. That's not our title, but we certainly are familiar with it. So, I mean, Section 601-14F deals with the definition of employee and, well, F is specific to sole proprietors, and then there's a whole host of requirements that a sole proprietor could comply with. There's actually six requirements. It's independent contractors? Yes, well, independent contractors is not actually a defined term in the law. They're actually sole proprietors, I guess. Yes, yes. Correct.  The nature of what they do has to be separate and distinct. They have, it has to be part of a written contract. I guess I didn't know a little bit about this. Yes. It is, it is. But the biggest tripping point is the written contract oftentimes. Yeah. There isn't a written contract, so they then are deemed a statutory employee. And so the hiring entity has been responsible. So, this has been one of the probably the most contentious sections of, this is the one I think we've spent the most time on, probably held them all here, economic development, is proper classification, because workers comp is expensive. And then you get into the competition and I'm very bad at it. Workers who don't realize they're not covered and aren't, and so I don't know. I don't know if, yeah, I don't know if, I mean, it's a two-edged sword. If you could come up with an innovative project that would make it more affordable, you would have less incentive to try and find ways to get under the rules. But there would be some risk involved in that. And maybe for the first go-round, because we are dealing with injured workers, we might want to think about excluding that. The disability insurance. That's part of the health. That'll be out of this. In terms of auto insurance, that's in, right? It is. So, we spent hours and hours developing policies of policy limits. What would stop the commissioner from coming along and saying, I can lower premiums and reach some people who are not getting it now by lowering the limits of coverage? Yeah, you still have to comply with the motor vehicle law. That's a motor vehicle law. That's a motor vehicle law? That's not an insurance law. That's a motor vehicle law, Title 23. Yeah, so this would not undo any mandated coverage, you know, financial responsibility in the case of auto insurance. Also, uninsured motor drivers in the case of auto insurance. All those things would have to be afforded per the motor vehicle law. I think we all know that if you just didn't insure things, or insure them at a low rate, you could be costly. I'm not saying that as the purpose of this bill. Just saying, well, you can only get $100 worth of liability on your card. The reason we put those regulations there is to make sure that people are protected. I'll give you a good example for auto insurance. The millennials, as I think I mentioned the other day, you know, they really don't purchase and own as, you know, in their 30s, traditionally as other generations have. And so are they in vehicles? Certainly they are. They're not in vehicles. They own. They're in rental cars. They're in Uber's. And there are protections maybe in the TNC world, but in being in someone else's car, a friend's car, they don't, if they don't choose to carry what's called a non-owned policy, which means they don't own a car and want to buy a liability, which is very expensive in the traditional market right now, then they go without coverage. So could a carrier come up with a non-owned auto liability product that is maybe on the go? It's when they, when they are renting a car or when they are, you know, going to have a need for a vehicle, provide protection. That limit of that policy is going to have to comply with the more vehicle law. And this would go through your standard insurance agents, right? I'm thinking of, because we went through this, if the kid at the rent a car had to be in a, you know, licensed as an insurance agent, as he says, would you like to get automobile insurance? He knows nothing about what my automobile insurance covers. And we accepted it. But on this one, it would be a standard insurance product, and you would be buying it through, well, maybe you buy it online? You buy it through any source you can buy it to them, you know, which is, you could be self-directed online, it could be a number, it could be an agent, there's a hole. And I think consumers value all those sources. I think millennials, we're just having that problem. They, they use the internet to educate themselves. But when they really want the security of making the decision, they often still want to talk to somebody. Yeah. I think it was you said yesterday that you have the ability to do some of this today and weigh certain things for products that come your way. So can you help me understand why you're not just doing that? Well, I think there's a, I think the commissioner testified to this. You know, we really think this creates a more even level of line field. It allows for more structure than that would currently exist. We have kind of an existing law that would be now there for innovators, for insurance innovators, insurance carriers to work within. A lot of times what, what the challenge is, the innovators don't come to the regulators, they just look at the law and say, I don't, I can't do that. So we don't even, we don't even get exposed to that. So I think there's an opportunity for an innovator to find out. The regulators aren't going to say yes on all these. There's more no's than yeses typically in this process. But what it does, it allows us regulators to really look at the details behind it and actually, by doing that, have better consumer protection by looking at this in greater depth and having the reporting.   And there is a cash or security set aside, so that if something goes wrong, there's a protection for the consumer. And it's a two-year limit. So it's... Yeah, it's a 12 month with a, you know, where the applicant can apply for a 12 month extension. Where is your authority to do that? Well, I think there's, there are just certain... Right, just a statutory set.  But we also have a seasoning requirement in, for company licensing. That's five years of profitability. And that is something that we, if we had, someone had four years, but we thought maybe the product was going to provide to an underserved market, we could do that, right? That's what I'm looking for. The authority to do that, I mean, if you have a law, and there's no counter bail authority, you can't do that. Where is the authority to do it? I have a feeling, and we've written some of those laws, that we have, you know, there's that phrase over at the commissioners, discretion that gets added. They're alerted. I don't have those that have the ready, but there are, there is light. We'll take a while to find them. I don't think there's one law that says the group, like the rulemaking authority is frequently set aside. So maybe that in certain instances, there's that description, but this would give it a much broader situation. And when we gave it before, we gave it in those specific situations by the General Assembly. Now without looking at it specifically, we're giving broad authority across all of these laws. We struggle to pass. I don't know that we're giving it that broad authority. You can't change license, you can't change any consumer protections. There's still, and there's all kinds of time limits. I don't see it as wide open. Yes, we're giving them permission in this, and I keep getting the image of the TV commercial. I think it's Capital One. You know, this was your old bank with the white Gothic killers and the tellers and we're creating the new bank and they clear all this stuff out. And you can now do all your banking online. That's the millennials. My husband still goes down and personally pays bills. My son is outraged if he can't pay a bill online and has to put a stamp on it. There's just a whole new way. I'm still getting used to people getting mortgages online. I would never think of making that kind of a huge investment with somebody I have never met, never seen, and frequently there's seven or eight somebody's involved. But we don't know what's out there. I just want to, if you don't mind just, what the potential outcome of this is after the sandbox period is won. At the end, we find out that the applicant isn't going to continue their product in the market. That's one. Two, now they are able to actually graduate and actually get a traditional company license or we identify something that requires a law change and then we come to the legislature and then we decide, okay, this seems like a product that is actually serving a market that hadn't been previously served. The law, our current regime, doesn't allow for it. Then we decide whether we want to launch it. Then we have the ability as a legislature to weigh in on your recommendation and whether you agree with that or not and change the law. This, as I understand it, will be the only law of this type in the country. Is that correct? As far as you're concerned. For insurance, I think it's very simple. So that gives us, again, a competitive advantage to begin with. Now, one of the things that we talked about yesterday is the possibility of monetizing in some way the participation of someone in it in the development of a product that ultimately can become nationwide, much like a provider of patent assistance might have to somebody in the intellectual development business. And I asked the commissioner yesterday to perhaps come to us today with some language that either creates a study or some mechanism for that to do it. I'm wondering if you can give me that kind of language. We do. This is Jill Rickard, director of policy with the board. And we did come up with some language which I've sent over to Maria to do a study of monetization. I'm sorry. I'm not a director of the board. The language that we discussed was the Department of Financial Regulation shall study the feasibility of requiring a person who offers a product or service in Vermont pursuant to an innovation waiver agree to pay the state a small fee or royalty based on the subsequent success of successful licensing and or sale of such product or service in one or more other states. Something to that extent is what you had in mind. We'd be happy to look into that study. I'm a big fan of raising money, but I got to say my first reaction to that was let's give a percentage to policemen for issue of tickets. Well, there's a balance in terms of how you structure something like this so that you don't have a regulator in a conflict of interest position of doing something regarding monetization. So the actual wording of this I would ask the Legislative Council perhaps to look at just with that background in mind as to how we word something like this so that we at least anticipate that issue. But if we're taking a risk to do it the other way and doing the oversight like it's worth thinking about. I'm not against innovation you know this is a creative thinking but I'm really concerned about the unintended consequences and just getting in the wrong hands and I'm also concerned quite frankly that once this bill passes even though it's sunset it's very likely to continue and we'll get less scrutiny I think in a couple of years and I look at these all these statutes and all these voltage of regulations that we're scrutinizing very carefully I don't know what's in them but it seems like in the wrong hands they can be waived even with the fences we put up around us and we'll take the risk. I wouldn't take the risk nationally I think the Commissioner said he wouldn't take the risk nationally. To me this the one thing Vermont can do because of our small size and because everybody is somebody's cousin is there's no arms length here and my thought is if something starts to go seriously wrong and I doubt you're going to have something come in sell 10,000 policies in this state I'm not sure AAA sells 10,000 policies in this state that we will know very quickly if strange things are happening down in the city center and we can put a stop to it you can have the governor do an order we can have a special session we'll be back in session and usually just a warning I mean to me it's a balancing but I have no reason after an awful lot of years not to trust the Department of Financial Regulation to regulate that's what they've done that's why captives like us because we regulate and based on what I'm seeing here I'm comfortable that as we balance the risk-reward ratio or the fault from between the two that this is a prudent risk because we have a Department of Regulatory Agency that's capable of managing the risk and the risk is not of sufficient magnitude that gives me great concern when they're done is it possible for us to have John Hall to come back up since he was the one that gave us the original list of all the yeah I'm ready because I just feel like we got this list from him and then he testified yesterday and he said that if I don't have a word to this mountain that I'd love to give that back on the record that felt like that what we've done in this list that we've got all the matters from all these attorneys general that they are not I just want to remind people of that that it's not that we're ignoring this we're going back to the source who had brought this to our attention we can disagree but I would like to that's fine he's not the source of the state laws no no no he's the one that I think this is a risk of state insurance this was yeah when it's you know okay are we finished John you want to come on have to talk to us you seem to in defense of your clients spread a lot of fear in this committee and would you like to see if you could settle down some of that fear so I appreciate it John Hall I'm John Hall here and we have people on insurance agents association so you know I was that my client raised concern at a pretty high level about this bill and as a result of that I raised concerns with others and with and presented the committee with that list which I thought was relevant if you're going to consider this broad scope I thought that it would be relevant for you to see the actual list of but that is a list of all the insurance regulations and both of those that would be subject to waiver that's all the same that's what it was and so that was what it was and what that doesn't include anything that the bill would include at this point it does I think we I carved out from that the I didn't include on that list the statutes and the that instructions that would be subject to it wouldn't be subject to waiver subsequent to that my client had some very productive conversations with the staff and I think the commissioner at the department and as a result of I testified the other day or maybe just they narrowed significantly the scope of the authority both in terms of what can be waived and how long and I from that reached a level of comfort that it's not open-ended and I think that time well I think probably in both senses both the definition of what can be waived and the standards but also the duration so that it's one year and I think it could be extended a year ahead of significant impact on their ability to be comfortable with it so as a result they are comfortable with what's before you so I hope that's helpful and you represent I'm a G.J. concerned insurance agents yes have you read all these? no no I that's no exactly it's not right Michael's working at it what I was telling you was that a sense of what is subject to waiver and it is a lot but and so that's what triggered their I think alarm at the outset because what they didn't have is to overwork the phrase that an adequate of fences around the sandbox and I think after those discussions they felt like there really was adequate yeah I mean I'm looking at things like repealed 1971 number 185 adjourned session number 237 effective March 29th 1972 I don't I mean that's just the list of computers it was I don't know what you're waving in there well I didn't mean to suggest that those were seriously going to be considered waiver what I wanted to give you was a list of all of the statutes insurance statutes that would be subject to waiver yeah something tells me we're going to get many many many organizations but they're all here they're all subject to waiver and that was really the only way of that so John and I have done a lot of battle over the years over workers column do you have any problems with exempting workers column from this law my clients wouldn't have a problem exempting that from that no you mean in terms of not allowing the department to have a waiver or something no you can work with that workers column cover yourself no I'll give it up no no I'm going to I think it was a shafted point at most of the underlying statutes that govern the workers column since tomorrow is set for title 21 not title 8 so I really I think these really deal with the insurance where I mostly focus on solvency the carriers not the actual statutes that's in my club how plays okay so when this discussion originally started it was insurance in case you lost your camera on a height insurance for perhaps being on an airplane flight that got in late enough so late enough so you missed your Caribbean cruise you missed you lose your fishing pole more on the fishing and they all all the examples were you listen to you went oh well that's an interesting insurance policy but where does this list end and I can't imagine insurance companies that work on Monter they make a living on on those sort of sort of things your TV goes sour during the your Super Bowl party insurance but I don't know so or your dip goes sour or anyway that this this is making now stuff which is selling something that could end up being kind of stuff not making a mess so where's the where's the line well I think you have to look at the scope and I think from our view the scope with the definition of what is that subject to waiver narrows it to the point where I think it would address and not mainstream policies but I think you were comfortable that it's narrow enough that that's it's not going to be broadly used um to exempt general you know sort of you know insurance classes would it make committees more comfortable if we ask the commissioner to give us an interim report of what's been requested what's been accepted what's been denied January 2020 so we will know my biggest fear is we aren't going to get anything but we will know if it's Mickey Mouse or if it's Moby Dick that's come in for a waiver you'll lose your fishing pole later yeah I mean but we we will at least get this is you know we'll at least get that will be probably six months in an idea of if there's a whole bunch of insurance companies waiting out there to rip off the Vermonters or maybe we're getting no response or maybe we're getting a very limited to your fishing pole or spraying your back marlin fishing or bungee jumping I mean who knows but would that make it better at least we know that we would authorize it at least we know what we were authorizing yep okay so this goodness knows when you buy insurance there's three pages of fine print on what you have of us what has to with our this this says can this would just be asking you to report back to us January and next year the number the title so how much confidentiality okay how much confidentiality you have but you know the number type what briefly description pardon it is in the bill for next January oh you're just meeting the timing of the report I apologize I think we would I think the committee is very concerned that we're opening the game and they're not sure if Mickey Mouse or Moby Dick's going to come through and if somebody's going to be asking to make major changes in liability insurance so you know or I think some of us are thinking maybe we're too you know maybe we won't get any takers but either way just you can do this is a verbal I don't mean to tell you maybe not me to do it but it does seem in the bill uh January 15 2020 page seven page seven okay so it's twice a year beginning okay so we're going to get a report in january yes as to the activity all right I'm sure of the timing but I thought it was no okay that's good do we have any other questions for Mr. Holland thank you for us thank you for us Mickenburg you want to say this to us anybody else want to speak how it's she David Mickenburg on behalf of a few organizations ARP Vermont and Vermont Association for Justice just so you know we've sent the bill down to ARP's insurance expert who is taking a look at it and we'll get back to you and at least perspective looking at it now uh but as you know ARP is a conservative national organization that cares deeply about protecting consumers other than 40,000 members of the line so um from the from the Vermont Association for Justice I'm glad Mr. Holler's not fearful anymore that sort of makes me fearful in some ways because oftentimes there's this yin yang on the issues we work on I just my concern one I raised with you yesterday about workers comp but also related to liability insurance when we see the practitioners that I work with seek catastrophic injuries and the uncertainty and unknown about an insurance product that may or may not cover them and how it covers them and the intricacies of it is disconcerting to us and we're in the process of analyzing this bill as well but it just certainly raises some given the amount of I don't say turmoil the amount of conflict that we have naturally built into the system as it pertains to seriously injured individuals and the civil justice system knowing that insurance products could now be innovated in that world raises some concern so okay you know when you might hear back with folks sounds like they're both you're both not by five o'clock not by five o'clock today but certainly appreciate the openness to exempting workers comp I think that's it's helpful but even beyond that I understand the point I'm not against innovation you know cell phone needs some innovative insurance coverage for cell phone lost cell phone or something like that but when it comes to catastrophic injuries of individual show my past yeah that that is an area where yeah we have some questions so well we've got a couple options we can strip out this section and send out the rest of a fairly innocuous bill we can leave this in with the safeguards we've got insurance agents that actually work on the ground floor and it's their licenses they're on the line feel comfortable if AARP or the association for justice I require capes next time you come in come off with some really severe concerns we can amend you know we can do an amendment on the floor to address those or if it's really serious we can we can strip it on the floor but I don't think we're going to be able to make any more progress this afternoon I think it's time and at this point unless we want to have Maria go grab something that strips out workers comp or we just wait and see if any of those folks that are looking at this along with the attorney general come running in here next Tuesday and say oops then we can do that all at once and not have to wait for Maria to go put in as well so if Maria could address the addition regarding monetization language so that when we come back to this we okay maybe you want to do that as a floor amendment rather than wait for her to well again is if the likelihood is that there may be some change to this anyway right this week and we're going to look at it again next week we probably ought to do it then and do an amendment then and she'll have time to just you know put it in the in the bill as it comes to us and going on okay and we'll get we'll get the amendments in the calendar on the floor if there are any yours I think we'll look at as we'll have you do it on behalf of the committee or ever makes secretary okay so committee what do you want to do I wasn't supposed to do a study but we're going to do we're going to do it I wasn't supposed to go back session was tidied up and that and down well I think they're feeling that the study is do you have to test the market and see if there's a market and they they're what I've heard that in the department saying is they won't know until they get there what if anything's out there and they've done sufficient study to establish a control environment with which they feel comfortable I would rather that he just move forward without the slight same box rigidity that we'll go back I'm looking for a way I'd like to keep it in I'd like to keep it in also so I'll I'll move that we move the bill forward with the same box provision intact something to these amendments that we're talking about and something to visit to review I'm just looking Maria have we done anything that we need to we have not made any changes to this have we no nonsense we went over the latest draft yesterday the latest draft and there have been no subsequent revisions so if we vote draft 1.1 or do we have to amend the date before that strike it and I've been seeing it dead in both ways that's we have to amend bill that's what I thought health and welfare has been just doing moving draft 1.1 okay so with your motion to strike the bill and replace it with draft 1.1 which is what was brought to us amend the bill amend the bill strike all amendment which was the the bill with the fences that was brought to us yesterday thank you is that your amendment to have a motion to amend the 20 order that is your motion okay so we are striking the bill is introduced and substituting strike all amendment draft 1.1 3.20 3.14.19 is the date on it we've been what yesterday yesterday yes


Welcome to this month's, hello cat. You get to say hi, and then you get to go away now. Welcome to this month's Prometheus team functional update. Let me start the screen share. Everything look good? All right. So welcome, I'm Ben Kochi, I'm the Prometheus team lead. Joshua Lambert is the product manager, Powell, and Kevin and Julius are all engineers on the team. So getting right into it, 9.4 is a great release for us. We have now additional metrics in 9.4. So what this means is users can now add additional metrics to the display page for all of their CI jobs. And this allows for monitoring other common systems and other service metrics. This is super nice because it now allows us to not be limited by simple things like CPU and memory metrics. And we can now start getting into actual business metrics like request handling and latency and things like that. Well, we're also going to be adding, we've also already added support for engine exit and other load balancers for Kubernetes, which is super great. So you can get application metrics and load balancer metrics directly from Kubernetes ingress controllers. We also have been working on instrumenting the Rails app itself. We now have histogram metrics for web request, which is super, super useful. This will be fantastically useful for monitoring the latency of production at GitLab.com. But also users who run large installations of GitLab will also be able to get this useful data out of Unicorn. We also have moved the metrics access from a token that was in the database to a simple whitelist. This allows for much easier configuration, which means we can now include Unicorn metrics by default in the omnibus package Prometheus server, making it much easier for users to be able to monitor their GitLab installs. Coming up at nine five, we're going to be now adding the ability to display multiple time series in a single chart. This will be super useful for looking at both, for example, looking at the 95th percentile versus the median latency on under quest. We're also going to be working on for enterprise edition. We'll be monitoring canaries in production since canary features are enterprise edition feature. So you'll be able to get canary graphs into your projects. We're also continuing to support Prometheus in GitLab.com production using the MTail utility. We've been able to instrument a bunch of things quickly and easily. We now have Wally as the backup utility that we use. We now have production backup metrics and the last status of all the backups. We had some problems with Unicorn worker killer and timeout problems. So we instrumented using the Unicorn logs for that. We also were able to put the sidekick metrics we're also able to put the sidekick metrics back into production and we'll be making improvements to sidekick metrics that we can get much better information about the running sidekick jobs. In FlexDB, the Prometheus bridging is still a work in progress, but that's moving along slowly. Another fun one today is we can now use one of the best things that metrics can provide is it can provide a way to make decisions about running applications. For example, we needed to know what would be a safe threshold to adjust database query timeouts. Instead of just guessing, we were able to go through and process and generate metrics using MTail to find out that, oh, we can adjust timeout down to 15 seconds and only affect a very small number of requests versus the current default of 60 seconds. So you can always use metrics to make decisions and it's much easier to make decisions when you have numbers to back up what you've been working on. And that's pretty much it. Thanks. Does anybody have questions? Are you sharing the slides? Oh, did the slides not show up? I mean, I saw them, but like, my bad. Yes, the URL, I'll update the calendar and invite with the URL. Cool. Thanks, man. Yep. All right. Well, that was easy. Have a good day, everybody.


Welcome back everybody. I guess by now you really noticed it's a beautiful day out there. And some of you might start thinking about Friday night. Some of you have plans, exciting stuff to do. Some of you don't have plans and are totally fine with that. For myself, if I didn't have work to do tomorrow, I would really regret that I didn't have some social activity or dinner or party to go to. But for those of you who feel the same way and don't have work tomorrow or maybe you're just stronger than I am, I have the good news that we have some free tickets and seats for the meal and music arrangement event tonight at the Music Hall. If this gets you curious, you have to go to the reception in the break and talk to them about joining this evening's dinner. Pretty soon we'll have our fourth keynote. After that we will have a small exercise and after that we will have almost a one hour break. So as far as the exercise is concerned, I strongly urge you to stay in the room for just like seven minutes exercise. It's in the spirit of networking and making connections. So I really hope you will support the exercise coming up after the keynote. Our final keynote will address the very important theme of mental health and the importance of putting this on the very top of the global agenda. The title of the keynote is addressing the mental health crisis lessons of the global south. And please remember you can ask questions using Slido. But joining us now from Harvard is Professor Vikram Patel. Are you with us? Yes, I am. Can you hear me? You're with us, but we missed the sound Vikram Patel. Hi, good morning from Boston. Can you hear me? Yeah, we're working on it. Hi, can you hear me now? Vikram, I think we can hear you by now. How is spring in Boston? It's actually a very beautiful day and I wish I was, you know, with you in person, especially for your musical concert this evening. But I think like in like where you are, Boston is enjoying a beautiful spring right now. Sounds good. And we got the volume adjusted now. So we are almost ready to take it away for your keynote presentation. But before I set you off, please enjoy this big round of applause from the audience. Thank you. Thank you very much. I haven't even started giving my lecture, but thank you in advance. Please go ahead. So I hope you can see my slides. Are my slides visible to everyone there? Let me check. Is there anyone there to confirm the slides are visible? Oh, they are. Okay, thank you. All right, great. So what I'm going to be doing today is to really share with you what I think is one of the most exciting innovations that has emerged from low-resourced settings in the global south, which as you will see from my remarks, has a very important bearing, not just on how one can address the mental health crisis in the global south, but also in fact in wealthy countries. I'm not going to speak much about the nature of the mental health crisis, except to say that unlike most other health conditions, mental health problems seem to have shown no change in their prevalence or incidence over the last 50 years in virtually any country of the world, regardless of how much money that country is spending on mental health care. And one could have a great discussion on why that is. In contrast, for example, to how certainly wealthy countries, but I would say most countries in the world have been successfully able to address many health challenges, such as, for example, the challenges of cardiovascular health and cancer. Mental health somehow has not followed the same storyline. Today, what I'm really going to be addressing is one aspect of that mental health crisis. There are many aspects, of course, you know, the risk factors and protective factors, but one particular aspect of the mental health crisis is access to evidence-based care. And a particular area of care that I will focus on are psychosocial interventions. Psychosocial interventions in brief are interventions that are targeting either the psychological or internal mechanisms of mental health or the social mechanisms, the mechanisms that operate in the relationships that we have between ourselves and others in our social networks, but also the more distal social factors that influence our health and well-being. On this slide, I'm going to summarize what is really an enormous body of evidence on the effectiveness of psychosocial interventions for mental health problems. In short, as you read each of these bullet points, you will conclude that there is no individual who is struggling with their mental health who cannot benefit from a psychosocial intervention. For a whole range of mental health conditions, such as, for example, PTSD, psychosocial interventions are the first line and most effective treatment. For other conditions like depression, where there is a choice between medication or psychosocial interventions, psychological interventions have much better long-term outcomes. And for those conditions like the psychosis, where medication has a very important role, psychological interventions or rather psychosocial interventions can greatly improve upon the overall social and clinical outcomes when they are supplementing medications. In other words, everyone can benefit from a psychosocial intervention. So given this very strong evidence-based, let us pause and ask the question, what is the proportion of people with a mental health condition who access evidence-based psychosocial interventions, who receive evidence-based psychosocial interventions? And let me use the US as a case study. I use the US primarily because the US is the wealthiest country in the world, but also because the US spends the most in dollars per capita on mental health care. And the US enjoys amongst the highest numbers of mental health professionals, psychiatrists, psychologists, psychiatric social workers and so on, per capita in the world. So you'd expect, as you see for many other health conditions, that the effective coverage of evidence-based interventions should be really high in a country that is as wealthy and spends so much on specialist mental health care as the US does. It turns out, though, that when people with depression go and seek care, typically they do so in primary care, the overwhelming majority will only receive a prescription, only a minority receive the evidence-based psychological treatment. This is in spite of the fact that people with depression overwhelmingly express a preference for psychological interventions. And this is especially true for low-income and minority groups. And of course, as you can imagine, if you receive the treatment that you want, that you prefer, you're going to engage much more with that intervention and therefore you're going to derive much more of a benefit from that intervention. Now, I often do a thought experiment with my students and I'm going to do one with you today. Imagine if we were not talking about depression, but we were talking about breast cancer. And imagine we had two interventions, like you do for depression, two different interventions. In the case of depression, we have psychological treatments and medication. Let's assume we had a similar kind of choice of two different interventions for breast cancer. The equivalent of psychological treatments was just as good as the equivalent of medication when it came to remission. That is to say the breast cancer was no longer present. But the psychological treatment was associated with lower relapse rates, lower recurrence rates of breast cancer. And women overwhelmingly preferred to receive the psychological treatment for their breast cancer. Can you imagine a health system that only made medication available for the breast cancer? That, my friends, is a situation in the US today. And in fact, this is actually also true for most countries around the world. I can't speak for the country you're in right now, but hopefully the discussion will hear more about that. In the global South context, which is where 80% of the world's people live, in fact, almost nobody receives an evidence-based psychosocial intervention. And therefore, really what I would say is that one aspect of the mental health crisis is that it is a crisis of care. A crisis not of the lack of political will. A crisis not of the lack of resources. But the crisis is that we do not deliver the interventions that we know work, that people prefer to receive. And this has been beautifully documented from a very particular US point of view by Thomas Insel's recent book Healing. Thomas Insel was the director of the National Institute for Mental Health, which is the world's most powerful and richest mental health research funding body. It's a taxpayer-funded body in the US, in Tom's own words. While he was director of the NIMH for about 15 years, I think, he describes that the NIMH spent more than $20 billion on mental health research. And during this very period, every single metric related to mental health of the American people got worse. Unlike every other National Institute of Health, where investments in research seem to actually produce a dramatic reduction in the burden of that particular National Institute's health focus, not so with the NIMH. So I guess the question we have to ask ourselves is why do such powerful interventions that we've known work for more than 50 years not get scaled up? Well, there are many reasons that I've arrived at through my conversations with colleagues. The first is the hierarchies of health care, and particularly in the mental health care landscape. The biomedical or prescription disciplines, physicians, and particular psychiatrists have a much higher status. And because these higher status professionals prefer to use medication, medication will trauma psychosocial or behavioral interventions. But there are also problems to do with the interventions themselves. They are very complex. There are hundreds of different packages. Every group seems to develop their own particular package. Because they're very complex, they're very difficult to learn, and one has to go through many years of expensive higher education to learn these interventions. Ask any clinical psychologist, and they will tell you. And similarly, then you have professional skills, just like the skills for physicians and psychiatrists, you have skills for psychologists, which will resist allowing anyone else to be licensed to deliver these interventions. Because these interventions were largely developed within very specific laboratories of people working in university settings, mostly in the US and Britain and a few other countries. There were questions about whether these observations, which were really reflecting the psychological mechanisms that these academics were making, could apply across cultural settings. But I think the real elephant in the room is the fact that there is no money, there's no commercial incentive in the scale up of psychosocial interventions. As I argued in a recent commentary in the Lancet, if psychosocial interventions could be packaged into a pill that could be manufactured and sold under a patent agreement by a company, they would be the single most widely used intervention in all of mental health care, maybe all of health care around the world today. But because psychosocial interventions can't be packaged as a pill, pretty much no one is actually profiting from their wider scale up. So I'm going to turn to the opportunity. And the opportunity comes from, again, an initiative that Tom Insil, while he was director of the NIMH, launched. This was a research priority setting exercise that Tom invited me and Pamela Collins to co-chair. Many of you will have heard of the Grand Challenges in Global Health. So this was really an addition of the Grand Challenges priority setting methodology, but specifically focusing on mental health. The instructions we got was this. The NIMH was funding billions of dollars, almost entirely in biological research, but there was virtually no new dramatic discovery that was helping us understand any mental health condition. And so what they asked us is, can you go find out what are the other kinds of research questions that the NIMH should invest in, which may have a good or a better chance of shifting the needle on the burden of mental health problems globally. We conducted a pretty typical research priority setting exercise, a multi-stage Delphi panel, nearly 400 people in the panel, spanning all the different disciplines and a very global panel. And we arrived finally at about a 25 or 30 leading research priorities, which if invested in could shift the needle on the burden of mental health problems and perhaps not surprisingly, the leading research priorities were those that were addressing the no-do gap. That is to say, the gap between what we know in this instance, the effectiveness of psychosocial interventions and what we do with that knowledge, which is to say, how do we make sure that people who can benefit from these interventions actually receive them? This paper was published in 2011. And so about 11 years later, I can tell you that at least a billion dollars of new money has been invested by the NIMH and a number of other funding agencies around the world. Most of that money has gone to the global south and most of that money has sought to address one or more of these different grand challenges. And thanks to this enormous investment, there has been a flourishing of new implementation science or delivery science around the world. And just last year, the Cochrane Reviews published a updated finding of this body of evidence, a synthesis of this body of evidence, more than 100 randomized controlled trials across the full range of mental health conditions, clearly demonstrating that even in the settings where there are virtually no mental health professionals, the settings that I started my work in, such as what you see in this image in Zimbabwe, where when I started working there back in the mid-90s, I was one of 10 psychiatrists for a country of roughly 9 million people. And about eight or nine of those psychiatrists lived and worked in the capital city of Harare, leaving just one psychiatrist for 9 million people. So, you know, really what we really needed to do was to have a completely reimagined way in which mental health care could be delivered. And what I really want to tell you a little bit more about is the innovation that you see pictured in this slide. This is an innovation in which is called the friendship bench and you can see why. What you see in this slide is a primary health center in the capital city of Harare in Zimbabwe. And on this bench, you see two ladies. This lady is a lady with depression who has been screened and identified as suffering from a significant number of depressive symptoms by a nurse in the clinic at the back there. She's also, as you can see, the mother of a young child. And the lady on the right who looks like a nurse, but she isn't actually a nurse. She actually is a grandmother who works in the community that is served by this clinic. And she has been trained in a brief form of psychotherapy based on cognitive behavior principles. The treatment is called problem-solving intervention. And she has been trained to deliver this intervention to women who are depressed, to people who are depressed actually. And because the clinic is so crowded and there is no privacy in the clinic to deliver therapy and because Harare enjoys very good weather all around the year, unlike Boston, what the innovator, the program is led by Dixon Chibanda as a baboon psychiatrist. And he basically said, well, let's actually deliver the therapy outdoors in the garden of the clinic.  He then ran a randomized controlled trial which demonstrated this approach associated with very high recovery rates from depression. And this is one of the hundreds of randomized controlled trials that were included in the synthesis. There are many systematic reviews now that I have examined this body of evidence. Here are two examples from colleagues of mine, mentees of mine that I've really examined on the left-hand side, interventions for psychosis and on the right-hand side for mood, anxiety, and trauma-related conditions. And what this very exciting body of evidence is teaching us is how we can redefine mental health care in four ways. Firstly, the what. These are very brief interventions. They are intended to be the first step in care. The interventions have anywhere for as little as a single session to up to maybe the maximum I've seen as six to eight sessions. They comprise only one or two active ingredients so that they're very easy to learn. And by this, I mean, not just for the individual delivering care but also for the individual receiving care because most psychosocial interventions are skills building in nature. These are delivered where people are, for example, in community settings, primary health care or schools. They're delivered by whoever in the community is available and authorized to deliver care. My own work has predominantly focused with lay people and community health workers. But you also see other programs that have been used by grandmothers, for example, peer support workers, nurses, and so on. And typically, this is seen as the first step of care in a stepped care model in which there is a coordination of this frontline worker delivered care with the specialist system, whatever it might be in that country. So there's coordination and collaboration and people then receive the care that they need. And there is actually a continuity of care, recognizing that mental health problems can often be chronic conditions for many people. There are many benefits of this approach. Of course, the most important one that's obvious is improved access to evidence-based care. But beyond that, it helps free up the few specialists that are available around the world to work at the top of their license, which means to help address the needs of people with particularly resistant complex or severe mental health problems. It helps receive stigma, because when you receive care from somebody who's also addressing your other needs, your social needs, your physical health needs, who's visiting you at your own home to deliver care, well, obviously, that's going to help address the stigma and the shame associated with mental health care. It's very person-centered because it provides care when you need it rather than putting you on a waiting list to see a psychiatrist after three months. And of course, it also benefits the providers. All the qualitative work that's been done with frontline workers who are delivering this care has typically described how these workers feel fulfilled. They feel a new sense of purpose. They feel empowered by this new knowledge. And interestingly, how they use this knowledge for their own mental health and the mental health of their family members and friends. This exciting body of evidence is transforming mental health globally. Here you see examples of policy documents, both global policy documents, such as the Mental Health Action Plan of the World Health Organization, or the Disease Control Priorities Program of the World Bank. And on the right-hand side, you see country-level documents, such as the National Mental Health Policy of India, on the drafting committee of which I served, or the Rand Corporation's report on the U.S. mental health system. Across the board, you will find that policy documents are embracing this new evidence and calling for a diversification of the workforce to deliver evidence-based psychosocial interventions. And what this means is investing at the base of the pyramid of care on community health workers, peer support specialists, nurses, midwives, a whole range of other kinds of providers who are not trained in specialist mental health care, which has traditionally been the focus of financing and investment in the mental health care sector. So the question really is the how. That's where we are today. The large body of evidence is just about a decade old, and policy makers have embraced this. They say, we want to now invest in building and diversifying our workforce. And so we're now at that very interesting time in global health to ask the question, how do we rapidly scale up evidence-based psychosocial interventions? Now, we can't use the methods that are used by delivery scientists because obviously in randomized control trials you use a lot of resources. You use experts in small groups, workshop-based training of frontline workers, you're running a randomized control trial. You want to ensure that the intervention is delivered at the highest quality, but of course that is not scalable in the real world. So over the last three years, we have launched a new program at Harvard Medical School in partnership with my organization that I worked with for 30 years in India called Sangat, which has been really a pioneering organization. In fact, I think Sangat has conducted maybe at least 10 of the trials that were included in the Cochrane review to use digital tools to enable frontline providers to learn, master, and deliver quality-assured psychosocial interventions. The mission of MPOWER is literally to empower anyone anywhere to deliver these interventions with high quality. We use the accompaniment model that my late department chair, Paul Farmer Coingey was describing accompaniment really as the process in which a health worker accompanies an individual on their journey to recovery. Paul worked mostly with people with HIV and TB, chronic infectious diseases, but you could argue the accompaniment model is just as relevant for mental health problems. But we use the accompaniment model in a somewhat different way. We use it to describe how we need to build the capacity of the workforce. Imagine a community health worker who's never done mental health work before. To accompany them on their journey, we first need to ensure that they learn a new treatment skill. We then, once they have learned the new skill, we then provide them with supervision to actually master those skills by treating people with the target mental health condition. We then assess their competencies so that they can now be licensed to deliver care, allowing others who are licensed on a lifelong journey of supervision and quality assurance, ultimately so that a community health worker has a career progression to becoming an expert who can then support the learning journey of a new generation of community health workers, not only providing them with a long-term career progression opportunity for themselves, but also having a sustainable way of replenishing a new generation of community health workers. I mentioned digital tools, so let me give you four examples of how we use digital technology to rapidly facilitate this career progression pathway. First, of course, we deliver the curricula in a digital format on any learning management system. We use remotely delivered assessments of competency, including critically important the assessment of skills through role-plays. We are designing with the Boston Bay's community health worker tech enterprise called Dimagi a bespoke digital app for supervision and quality measurement. And we're developing data science-driven protocols for the evaluation of the rich digital data that arises from the training and competencies ultimately linked to patient outcomes to do all kinds of exciting things, including understanding better and predicting patient outcomes. Let me give you a quick example of one such treatment that we're scaling up. About 10 years ago, one of the trials that I led with Sangata was the evaluation of a six-session treatment for severe depression based on the active ingredient called behavioral activation. We call the treatment the healthy activity program. Here you can see the results of the trial at three months. The treatment was just six-session over eight to 12 weeks. About 60% of people with severe depression in primary care that treatment was delivered by lay people in primary care had permitted. At 12 months that was still nearly 60% and you can see the control arm was only about 30%, so doubling the rates approximately of remission. And recently we completed a five-year follow-up and showed again statistically significant differences five years later after receiving just about two hours of therapy for a severe depressive episode. We just completed a large randomized control trial demonstrating the digital training for this particular treatment especially when supported with a coach that's the DGT Plus here, showed significant improvements in competency but also importantly, it was non-inferior or equivalent to the gold standard face-to-face expert-led workshop-based model. We have now applied this to the field in the real world and as I speak to you today hundreds of community health workers of India's national health system that called the Ashas are delivering this brief six-session treatment to people in their own community, thousands of individuals in just a few months and we will soon be publishing our findings of this first scale-up of brief depression care in the hands of frontline workers in the coming months. But what's really exciting, if you remember I started my talk by talking about how there is a huge shortage, huge levels of unmet needs for care in the U.S. in spite of the large numbers of mental health professionals indicating that even in countries where there are lots of mental health professionals, there's a lot we do to diversify the workforce. A couple of years ago, right in the middle of the pandemic, in partnership with the Meadow's mental health policy institute and the American Psychological Association we reverse engineered the healthy activity program. We adapted it for use in the U.S. You typically hear about treatments being developed in the global north and being adapted for the global south. Not very often do you hear the opposite exactly what's happening right now. As I speak to you, we were very, very delighted that we won a prize in the middle of the pandemic. This was a competition to transform the lives of people living in Texas affected by the pandemic and we won the bid that we had to bring community health workers in Texas to deliver care for people struggling with their mental health and as I speak to you, the first batch of community health workers in the U.S. are delivering a treatment that was originally designed for community health workers in India and it just goes to show how the world is becoming a much smaller place and knowledge is flowing in all directions. In the interest of time, I'm not going to say much more so I can have some question and answer, but this slide just shows you how we're developing a suite of interventions across the full range of mental health problems from very early intervention early intervention, but always based on evidence-based treatment components all the way through to promoting the recovery of people struggling with their poor mental health. Some of these interventions are already funded so we're my lab in Harvard and Sangat are already working for example for emotional disorders and adolescents for autism and for peer support workers for serious mental illness. For others like trauma related mental health problems and harm for drinking, we're currently working towards providing support for our lab to roll out these different curricula and tools. And finally, what we're really in the midst of right now is that Harvard Medical School is working towards spinning off a enterprise that can actually then take all these tools and make them available very widely to people across the US and around the world, implementers like hospital systems, governments and so on because obviously a university is not the right kind of platform for actually delivering these tools and products around the world and so Empower now has a new enterprise called Empowered Scale that will take all the stuff that we're developing in our labs and make them more widely available. This is my last slide just simply to say that the big lesson from this exciting body of delivery science from the global south is that for all countries in the world that's why the global is underlined because it means every country in the world can benefit from this knowledge which is really the scaling up of psychosocial interventions by deploying digital tools and products to rapidly build the capacity of a frontline workforce to learn master, deliver and evaluate these interventions for those of you who want to know more about Empowered here is the website there is a paper that we just published last year which I'm happy to share with the match point organizers and you can also see the email address of my colleague Natalie Carmeo who is the program manager of the Empower Lab at Harvard Medical School so thank you very much for your patience and I think we still have about at least 15 minutes for Q&A and I look forward to the discussion. I can't hear you, now I can. Thank you so much Vikram Basil and thank you for leaving some time for questions. Here I have an iPad with questions from the audience but let's just get started by noting that what you really do is breaking down the monopoly I guess of university and professionals. Do you face resistance due to that? That's a great question honestly of course there would be resistance as you can imagine when you're trying to disrupt when you're trying to disrupt an orthodox way of doing things and in this instance the disruption is that you're disrupting the power and the hierarchy that very highly trained practitioners hold in global health. Of course there's going to be a pushback however the evidence speaks for itself and I think this is the power of science here. I would really encourage all of you in the audience to think about the power of science. If I was just simply saying what I was saying today with not a single body of research to back me up you could rightly critique me you could rightly say what you're saying is completely ideological and it's potentially even dangerous but when you have 100 randomized controlled trials all saying the same thing you see the power of science silences many of the critics and instead what I'm seeing right now is that wealthy countries are embracing this knowledge in the US today the government is actually rolling out hundreds of millions, billions of dollars actually to build a more diverse workforce the surgeon general of the US Dr Vivek Murthy who is very passionate about youth mental health himself is now calling for all the states in the US to start building a community-based workforce this would have been unthinkable 10 years ago so I do think one should put a lot of credit on the science the second thing I will say is that it's important to build alliances and I have done that you will have maybe noticed that I built an alliance with the American Psychological Association and we're very lucky that the American Psychological Association has adopted a completely new vision instead of spending all its time as it used to on protecting the territory of psychologists it's now decided to make its mission the expansion of the wonderful science that comes from psychology to the population it's launched its population mental health science program in fact in September there will be a major event of thought leaders around the US to examine exactly the questions that I've spoken to you about today and by allying with the APA it automatically means that the most powerful guild that is associated with these interventions is in fact fully on board with their scaling let's take a few questions from the participants one is about the stigma that's surrounding mental health issues so how can we work around the stigma surrounding mental health in many countries of the world I have maybe a slightly different view on how many stigma researchers have described stigma my view is that much of the stigma to do with mental health has been created by the mental health care industry let me explain what I mean for the last 100 plus years mental health care in most countries in the world was a very carceral model that means people were removed from their homes and placed into institutions with eye walls and locked doors within which there used to be profound levels of abuse and violence where people were treated against their will with medications that often left them completely unable to think clearly and oftentimes they had no freedom they had no freedom to leave now those models of care continue to be the most common models of care in many countries in Africa, Latin America and Asia because these are the remnants of the colonial systems that were built before these countries became independent now if in your society having a mental health problem meant you were going to be removed from your home, medicated against your wish and locked away in what could easily look like a prison wouldn't there be a stigma attached to seeking mental health care and why is that surprising and are we going to simply address that stigma by having campaigns oh it's the normal problem everyone has a norm, no I don't think it is just like the stigma with HIV AIDS you do need to address that stigma by providing care in a way that is non coercive that respects the dignity of the individual that is community based and that is evidence based I remember when I worked in Zimbabwe in the mid 1990s there was huge stigma to do with HIV AIDS and why was it a stigmatized because people feared the care delivery system if you went to the care delivery system back in the mid 1990s A you never received evidence based care back then the miraculous drugs that were transforming the lives of people with HIV were not available to Africans so you basically went there you didn't even care you were humiliated because you had HIV AIDS in some parts of the world you were locked up so that you wouldn't be actually spreading this disease to other people and you were very intensely feared today HIV AIDS is not a stigmatized condition and we need to draw lessons from the HIV AIDS story for mental health and I'll finish with one more lesson actually what are the most important lessons which I think is of course the single most important story about global health it is a story that it brings in not only elements of social justice and science but also it brings in a very important element of the power of the community and the lived experience and over the last 10 or 15 years I personally invested a lot of my time to make sure that the lived experience of mental illness is bang in the center of all our advocacy science and delivery of mental health care and I'd urge you all to look at the global mental health peer network which is a service user or lived experience network that was launched by Charlene Sunkel who is a person with schizophrenia from South Africa which now has a presence in 40 or 50 countries around the world Charlene is a dear friend and she won a very major human rights award last year that is what we need to see in the mental health conversation a far greater presence of people with a lived experience speaking for and on behalf themselves you mentioned in your presentation the hierarchy of health care how do you tip that hierarchy in favor of putting more focus to mental health so I say that well you have to always work against our hierarchies and this is not only true of mental health care this is true of society more generally I'm not going to go into all the other areas in which power relations creates such huge imbalances in the way we create a harmonious society but in the mental health space I would say we should be promoting a team based approach where every individual in the team has a very specific role in mental health care and of course psychiatrists play a very important role they are experts for example in the management of very complex mental health problems they are of course experts in the judicial use of medication and so on clinical psychologists similarly play a very important role so I think we should never pitch this as a competition between different providers what we really have to say is that the patient is the king or the queen and what we have to make sure is they get the time that they need it and in order to do that we need to have a team a team that is able to respond very quickly when someone needs care typically that first point of care should be a frontline provider who delivers brief interventions but equally if that person needs more it doesn't respond or needs more specialized care there needs to be a rapid referral system in place so that more specialized providers can see that person what I would say is that team-based approach and continuum of care are the key words that I will leave you with in terms of how we address the hierarchy of mental health care I'm sorry but the next question is a big question too but you will give some good answers the question is how can we shift the focus from treatment to addressing the underlying determinations of poor mental health that's a really great question I'm sure I'm really glad whoever posed that question asked that so let's be first of all very honest no global health problem has been addressed by only treatment let's be completely clear if maternal mortality and infant mortality have fallen it isn't only because of institutionalized delivery although that is of course very important if HIV incidence rates are falling it isn't only because about treatment of course in fact HIV is almost entirely prevention the best example is heart disease heart disease mortality has been falling across the world actually it's one of the most dramatic improvements that I can think of in recent years cardiologists think it's because they're putting in stands it's not it's actually because people are adopting healthier lifestyles they're smoking less they're embracing exercise more etc so prevention is extremely important now in the mental health space prevention means targeting the upstream social determinants as the question the person who asked the question rightly points out and we've often felt very very helpless how do you address things like poverty you know these are almost like political solutions how do you address things like inequality how do you address the fact that the global arms industry is fueling so much conflict including in Europe right now and those of us who work in this in global health feel very helpless these are powerful forces that are beyond our reach so I would suggest to you that what we really need to look at is the pathways through which these distal determinants affect our mental health and try to identify the mechanisms through which they affect the individual and look at whether interventions can help mitigate or modify the effect of those pathways and I want to leave you with two examples great examples I think of how prevention can be delivered within the context of healthcare systems or delivery systems more generally the first is cash transfers there is now a rich body of evidence I have a colleague of mine working in Brazil who is demonstrating that the massive cash transfer program the Bolsa Familia has led to dramatic reductions in suicide mortality particularly in indigenous and black Brazilians that's one example so you may not change the global taxation systems that ultimately should be changed but instead what you can do is have direct cash transfers the people who live in conditions of poverty so that income insecurity is no longer a daily lived experience the second example is supporting families who are living in low income context the children of those families to reduce the exposure to adversities in early childhood are the most well replicated risk factors for poor mental health I call it the tobacco of mental health that is to say adversities in childhood are the most powerful predictors across all contexts of poor mental health later in life we know how we can mitigate those adversities by parenting interventions home visiting interventions to support children growing up in poverty particularly their parents these are two examples even if we can't change the structural factors that lead to poverty inequality and violence all right we're running out of time but I'll try to squeeze in maybe one, maybe two questions the first is from the audience how do we address the mental health issues in indigenous communities who do not get their needs in life met by colonizing countries well you know I won't speak on behalf of indigenous people but I will paraphrase what I have learned from colleagues of mine who are indigenous in North America and work in this area what's really important in the context of indigenous peoples around the world is that we cannot address the high burden of mental health problems without a full acknowledgement of the historical trauma that these communities have experienced and the trauma is immense you know it's of course I think the person who has asked the question would know what I'm referring to it goes back hundreds of years the loss of culture has been profoundly important and I think in order for us to address the mental health of these communities we have to think of it from a community approach rather than an individual approach alone of course individuals do need care and I'm not denying the importance of that but we also need healing strategies and that is required to begin with an acknowledgement of the historical violence that these communities have faced of the provision of greater control on how they determine their own futures the incorporation of a range of cultural healing practices in community healing and so on there's a lot written about that the time doesn't permit me to go into all of that but I think in response to your question a narrow biomedical model is completely and totally insufficient All right, wrapping up I'd like to ask you the contrast to physical diseases when it comes to physical diseases you tend to measure success in terms of numbers of lives saved for you how do you measure success when it comes to psychosocial interventions? Well I mean that's a great question and it's been one of the big challenges of holding mental health programs accountable we just count the number of people we are treated rather than what happened to them and it is a huge issue what I will say is that what we need to do is to have systems in place where we evaluate the function of an individual rather than their symptoms person-centered outcomes are the most important and I believe with the advent of mobile technologies being so widespread being able to actually reach out to individuals let's say three to six months after they have been in a care encounter to identify how they're doing is not an improbable way of assessing people's well-being functional outcomes and that's the kind of way that we have to be thinking imaginatively about we can't use mortality for obvious reasons although I will say that suicide and drug use related mortality may be two examples of mortality as well as premature mortality that is to say one of the biggest crises for people with serious mental illness is that they die 10 to 20 years earlier than people without even though these are not fatal conditions and so looking at premature mortality in mental health problems I think it's also an important outcome that we should be thinking about Alright Mr Patel when I look at the audience I see many happy faces so please receive a well-deserved applause Thank you Thank you very much and I wish you all the very best for the rest of your day and the music this evening as I said I wish so much I could be with you but I am teaching right now in Boston and I could not have travelled so Thank you very much for inviting me and all the very best Thank you so much for your time