All right. Good morning. It is April 14th, and this is Senate Health and Welfare Committee. We are meeting today to talk about two bills in particular, but really the overall topic is healthcare reform and how we can move forward. And we have a long list of folks interested in testifying this morning. So before we begin, just a couple of words to everyone. If you're not speaking, I would ask that you mute yourself please. And because a lot of us here. Secondly, there we had some difficulties yesterday with completing the invitations and getting everyone on the agenda. So we'll go through the list that we have. You can speak to either 120 or 132. That is your prerogative. If you can speak to both, fine. I'm not going to make a distinction between the two bills as we go forward, because I think there just might be some more general comments as we look at the issue of improving our healthcare affordability and access. And by the way, that little phrase, accessibility and affordability, our committee decided to use for whatever bill we send out of this committee. And then I understand that now the governor is using it for summer program. So this is a heads up to the committee. We may have to think more creatively again and build a new title. So that then also for committee interest, because I don't think I'll have time at the end of the meeting to let you know that tomorrow we're working very intently on H171, the childcare bill. I'm going to send some language that I received from Sarah Kenny for improvements to the bill. I'll send that to Katie so that we can have that should the committee decide to include it. And then I also have one suggestion and if you have a small suggestion on wording, please get that to Katie and copy me for the H171. Then our goal is to complete that bill as quickly as possible so that it can be considered and included in the budget. That's a priority. So that's all I wanted to share with you. And I just welcome everyone. It's good to see you all. I think there are some common interests in this room for improving accessibility to health care, but also increasing affordability so that people aren't making the terrible choices between food on the table and health care and childcare. All those things that are so necessary and that we've seen gaps around during the pandemic. So we've been through the bill. I'm not going to turn to our Ledge Council unless there's a specific question that comes up about language. And I'm just going to go right down the list that we have. And if you are listed twice, that means you get to testify once. So include your... Ed Paikman is not here. I see he's on the list twice. So we'll clarify that as we go forward. But thanks all for being here. Greatly appreciate it. So former Senator Debbie Ingram, now Executive Director of VIA is here. And welcome. We'll listen to your testimony. Thank you very much. I appreciate it. It's great to see everyone. And thank you, Senator Lyons, for inviting me to testify on this. I have since leaving the Senate my role as Executive Director of Vermont Interfaith Action. And VIA is a faith-based grassroots community organizing group comprised of 68 member and affiliated congregations that are primarily in five regions of the state, the greater Burlington area, Barry Montpelier area, the upper valley, Brattleboro and Bennington. And our congregations collectively include 15,000 Vermonters approximately. The 14 years that I've been at VIA making health care affordable and accessible for all Vermonters and for all Americans has been one of our primary issues. At the state level, our leaders years ago helped to get the Catamount health care program passed and persuade Governor Douglas to sign it. We were strong supporters of the proposed single payer system. At the federal level, we were we worked with some of our sister affiliates in other states through the national network that we belong to to get reauthorization of S chip more than once and to get the passage of the Affordable Care Act. So the volunteers that I work with are no strangers to comprehensive health care reform that seeks to create a universal coverage at a cost that everyday families and individuals can afford. And then of course, since the advent of this pandemic, like everyone else, we have become aware both of the gaps in our current systems and the unprecedented opportunities that we're seized upon to address this once in a lifetime health health care crisis. So to the volunteers that I work with, it seems like this is the best time in a long time to take bold steps and to make strides towards major reform once again. So when Peter Sterling, another name from our past brought the idea of forming commission and launching a statewide series of public listening sessions to Vermont Interfaith Action, our board jumped at endorsing it. And although we would prefer to see a universal single payer system, a Medicare for all model instituted immediately, we know that this is not really a reality. So what we feel can be accomplished in the interim is other steps, perhaps universal primary care, perhaps extension of age eligibility and Medicare or Medicaid or income level eligibility. But whatever it is, we need to start exploring what those small steps could be and really move forward. So in Vermont Interfaith Actions opinion, S120 meets some of these these needs. And we think that there are really four things that we need to do immediately. Number one is we need to signal to Vermonters that we know that their health care is inadequate and that it's unaffordable and that we care about that. Secondly, we need to listen to Vermonters to hear what they consider to be the top priorities in improving their health care. Third, we need to give a new group of legislators the opportunity to dive in deeply to the key concepts in health care reform to increase their understanding of possible solutions. It's been a while since there was a lot of public attention to health care reform. So we have some new legislators and they need to really be able to dive into this. And fourth, we feel that we need to demonstrate to the Biden administration that Vermont is ready and willing to consider some of the concepts that the president campaigned on like the public option or lowering the age of Medicare eligibility. So that's why the volunteers that I work with really believe that S120, as it's written, meets those four objectives and that the structure of holding public hearings is that's very near and dear to our heart. That's exactly the way we do things. We listen to people and get their ideas and their contributions. And as for the makeup of the commission itself, although we certainly would support seeing one key legislator who has a lot of experience and may perhaps serve as the chair, perhaps somebody like Senator Lyons, for instance, who has extensive knowledge. But we would also like to see opportunities for learning for legislators who have not been in this discussion over the years and who are not overburdened by the responsibilities of being committee chairs because I know they're probably exhausted at this point. So this new S120 commission provides those opportunities. And then lastly, I would say that S120 provides for a knowledgeable coordinator who can help the new commission set up the public meetings and navigate the reform possibilities, including the ideas that the Biden administration has brought into the public discourse. So, senators, I really believe that time is short now. I know that I know how things work in the process, but I would really urge you to pass this out of committee, pass it on the Senate floor and get it over to the House without delay so that the crucial task of healthcare reform can take one more important step forward. Okay, thank you. And unless there are burning questions about understanding from the committee, I'm just going to continue to move through folks with, but greatly appreciate your thought and testimony. And if you have, and this is for everyone who is on the call, if you have testimony in writing, that would be extremely helpful. So you can send that into Nellie. Probably a good thing you didn't send it in yesterday because her system was backed up in more ways than one. So we'll, thank you. Thank you, Senator Ingram. Thank you very much. Executive Director Ingram. Okay. So we'll, we'll keep moving along. And I think Dr. Richter, you are next on the list. And Dr. Richter is muted, which is not a good thing. Not good. Okay. All right. There you go. All right. Thank you for inviting me. I am also, I'm chair of Vermont Healthcare for all, but also a practicing family physician in Cambridge, Vermont and addiction medicine in Burlington. I, again, would, I think my experience as a, as a practicing physician really gives me a bird's eye view of, of what's going on in the healthcare system.  And when they finally come in, it's often too late. And many of them are sicker and die younger. I mean, that's been shown in previous studies, but it's an even worse since the onset of COVID. So we know that like 36% of Vermonters are underinsured, meaning that was prior to COVID, that was from a 2018 survey. We really don't even know how many are underinsured at this point. So clearly the idea of looking into how we can make it more affordable. And again, I'm looking at it again, mostly from the patient perspective, patient costs. I think we often kind of forget and we're, we're seemingly looking at sort of trying to do things in a piecemeal way. So Vermont healthcare for all can support S120, but we would like to make the following changes and add to the bill. We are suggesting framing changes to S120 that would whatever measures we take and suggest that they be ones that everyone must be included in whatever measures we take. And that payment into the system has to be based on people's ability to pay. That is one of the glaring problems with the American healthcare system, with the Vermont healthcare system is that it depends on what job you have. If you're lucky enough to be able to afford healthcare, health insurance, but certainly there are many that don't. So we would like to change the framing. So on page three, after item six and section one, an additional item is needed. We suggest item seven, which frames this within the goals of healthcare reform and universality, stating that the state of Vermont is committed to universal healthcare according to state statute. This is already in state statute 18 of VSA 9371, which states the state of Vermont must ensure universal access to and coverage for high quality medically necessary health services for all Vermonters. Systemic barriers such as cost must not prevent people from accessing necessary healthcare. All Vermonters must receive affordable and appropriate healthcare at an appropriate time in the appropriate setting. In addition, 18 VSA 9371 states that primary care be preserved and enhanced so that Vermonters have care available to them, preferably within their own communities. Reforms must therefore take place within the enunciated goals of universal access without cost as a barrier to care. And as we all know, our primary care healthcare system is imploding at this point. I believe that the latest figures are at least one third of primary care physicians are over the age of 60. They're planning on retiring. Patrick Flood, I know, has experienced this one in the FQHC in the Northeast Kingdom. It's very hard to retain primary care clinicians, and we certainly need to include that in when we're looking at costs and access. A second change, again, this is based on an opportunity we have, I believe, with the Biden administration. So, on partnering with the Biden administration, so under section one, I think it's item six, on partnering with the Biden administration for demonstration waivers, wording should be added on the idea of phased implementation of Act 48, again, which is already in statute. So, we are still committed to universal publicly financed healthcare. President Biden's new secretary of HHS Xavier Bechera is favorable to statewide single-payer waivers, as certainly is the chair of the Senate Budget Committee, Senator Bernie Sanders. So, we have a unique opportunity at this point to add that as one of the things that we consider, partnering with the Biden administration. A similar addition is needed under section two C, item five. And in terms of the public hearings, that is the third change that we would like to make. The public engagement sessions listed under section two, page five, line 12, should not be opportunities for local stakeholders to speak at a panel, as often results in much time being used, a little time to hear from the public at large. These sessions should be actual listening sessions for the general public to speak. That is the best way for us to truly assess what is going on for Vermonters. We often hear only from the same people in hearings, and we really need to hear from everyday Vermonters who are struggling under healthcare costs. So, there should be actual listening sessions for the general public to speak. Stakeholders, again, have many opportunities to weigh in, generally, in the legislative process. And indeed, this bill provides a committee with additional opportunities to reach out to them. So, I'd urge you all to add those three changes, and I will send those to you. Thank you. Good. Thank you. Thank you for the clarity of your comments and for sending those along, because we were all trying to get it down quickly. All right. Thank you. Michael Fisher is here, and he is our Chief Healthcare Advocate. Welcome, the Honorable, Former Representative Michael Fisher and our Healthcare Advocate. Thank you, Senator. I'm happy to be here and happy to say a few words about the bills in front of you. I will, I think I'm going to be doing something a little bit different than many of the speakers who have spoken before me and who are coming after me. So, I just do want to pause and thank and appreciate the frame of the previous speakers, and if I could be so presumptuous, the ones coming after me and attach myself to their thoughts about the real importance of us thinking in bigger terms about system wide reform. Very important, and I'm in fully in support. But I've come to do something a little bit more that sort of is typical from the Healthcare Advocate to talk about some of the details. And so these are, I want to talk about two details that I'd like to suggest that are not in either bill. And I'm not suggesting them because I think they should be studied by the legislature, but I am suggesting them because I want the legislature to have these items on your mind. I want it to be on your plate to come back next year to take a look at some opportunities that are before us.  So, I'm just asking if you could clarify before you begin your testimony that you will share with us either a summary of or the complete testimony. That would be helpful. Yes, I can share. Terrific. Absolutely. Thank you. So, the first one is a little known part of ARPA is a state option to expand postpartum coverage for a full year for Medicaid. Current coverage is for 60 days. We think this would be a tremendous improvement, very important improvement. I've talked to the administration and they, to Diva, and they have said that they will look at it. And after they do the very important heavy lifting that they're doing to comply with other parts of ARPA, premium tax credits, and changes in others. So, I'm not suggesting that they do this quickly. They've got their hands full. And this state option is available to states starting April 1st, 2022, and available for five years. And I'm really saying it to you because I think it would be important for you to be asking for an evaluation of that option, the cost of that option for next year when you come back. Because I want it to be on your agenda, honestly. The second one is it's maybe a little known fact. Many of the people who experience tremendous affordability problems in today's nutty healthcare system are older and disabled Vermonters who are on Medicare.  And so, some states have done something about it and we think Vermont should consider doing, in addition to the major system-wide reforms that are being contemplated in S120, we should contemplate changing our eligibility for the Medicare Savings Program. In Medicare and in many places in healthcare, we confuse things by calling things, by having multiple names for things. Some people maybe know this as Quimby, Slimby, and QI1. You know, those are three different eligibility limits for the Medicare Savings Program. Currently, Vermont has eligibility for Quimby at 100% of the federal poverty level. Many states have done better, or maybe I should say a handful of states have done better. Maine, for instance, has 150% of FPL for Quimby, 170% for Slimby, and 185% for QI1. These are really important programs that help people afford part A, part B, and part D premiums, cost-sharing and premiums. And we think that it would reduce some people's need to be on the VFARM program. So there may be some state savings if we expanded eligibility for the Medicare Savings Program. All this is to say, it needs analysis. Diva is the right people to do that analysis. And we would ask that your committee consider asking Diva to come back next year with that analysis so that we could do a full analysis. And I have given some of that already to your alleged counsel, and I'm happy to write it up again. I think, thank you, it's important that you send it into Nellie so we can get it up on our webpage. The committee needs to see it, I think. Yep. But thank you. That's good. Lastly, Senator, it's a little bit hard for me to judge or know what's moving in these two bills. And so I do need to sort of make a high-level statement about a concern about the essential health benefit discussion around hearing aids. I have heard testimony and understand that DFR is doing an analysis about that, and I think that's very important. And I'm supportive of it and supportive of the time change considered in that suggestion. Additionally, I have a little concern that we don't know the outcome of the study. And we need to know the outcome of the study before we bind ourselves to a specific change. I'm supportive of adding hearing aids to the QHP to state coverage for hearing aids. I think we should do it, and I think there's a ways to pay for it. I actually think we should just pay for it. And I think there are ways to do it that are not burdensome on Vermonters, as well as other durable medical equipment. But I want to make sure that if we are changing the EHB that it's done thoughtfully and carefully with an awareness of the potential for the requirement of losing of reductions in other areas. And additionally, if there's room in the EHB to add new benefits, those benefits should be added after a full public process where people have an opportunity to come forward and say what they think is most important to add. So I wanted to make those high level statements about that and about the opportunities to raise to cover more benefits and opportunities to raise the money. I'm not talking about the traditional things you always hear. I'm not about to say do a payroll tax. Some states are doing some really creative things that are not costing their states more. New Mexico just covered all co-pays for mental health. Pretty phenomenal thing to have just done at this time. And I'd be happy to talk with individual members or the committee more about that at another time. Thank you. And as you send your written comments in, please do include maybe a link to what New Mexico is doing. That would be very helpful. And then on the EHB, of course, there are other things that can be included. I know that members of our committee and also a finance have been asked over many sessions to expand for coverage of hearing aids. So there may be some creative way to keep that moving forward. But we understand your comments. Any questions of clarification, Senator Hardy? Thank you, Madam Chair. And thanks, Mike, for your testimony. So just on this last point, you may have heard our discussion the other day with DFR about their, you referenced it, about their plan to do a study. And we were sort of talking about giving them essentially a list of things that we wanted them to study with hearing aids being one of them and doing the actual actuarial analysis of it. And if you have other things, we had a couple other things on our list, but it would be helpful to hear other things because I agree that we need to have this data before we jump into this. And this is certainly something that we could, you know, they're about to get started with it. So we can tell them right now, these are some things we'd like you to look at. So getting more information about other things you're hearing about in your work would be helpful. Yeah, happy to. Thanks. All right, good. Senator Hooker. Thank you, Senator. Thank you, Michael. Good to see you. So, Michael, you're here testifying on 120. And I just wanted to know your thoughts on, do you think this bill goes in the right direction? Yeah, thank you. There's always sort of this question, you know, I've been hanging around the legislature for a long time. And, you know, there are various other groups, you know, that have been looking at health care joint committees, I should say. I think there's something refreshing, something good about pulling together a group that's focused specifically on system-wide reforms. And, you know, I heard Deb Richter's comments, you know, to some degree for me those details, those are important details, but, you know, bringing together a group of legislators, you know, with a mandate to really look at system-wide reform, not to be stuck in, maybe honestly, not to be stuck in some of the kind of details I just mentioned to you. They're important details and we should do them, but we need somebody to be looking beyond how do we put band-aids on. So, I'm supportive. I don't know if that's what you were looking for. That helps, thank you. Okay, we're good. Thank you. So, we're going to move on to Susan Aronoff of our policy analyst from the Vermont Disabilities Council. Susan, are you still here? Yes, you are. I think it's Esquire. We're trying to use appropriate titles. So, thank you for being here. Yes, Susan is just fine. As you mentioned, I am the senior policy analyst for the Vermont Developmental Disabilities Council. And I want to first of all thank you, Chair Lyons and the committee for providing the opportunity to testify today. But before I take up this bill to testify, this is my first time before the committee this session, what a strange session it is. It's really my first time visiting with you since you did all the heroic, heavy lifting last summer, last fall, the emergency COVID bills. And I just want to thank you. They have made such a difference in the lives of the people our council serves. Anything from the funding for family caregivers so that they could stay home with their loved ones when services just came to a grinding halt, everything you have done, it has not gone unnoticed and appreciated. So, we really appreciate it. So, thank you for all of that and for all of your service. And I've really enjoyed listening to the committee this year. It's a very different committee. And I really appreciate the efforts your members are making to the new members to learn the system. And I just want to say, as your Developmental Disabilities Council person, I'm available. If you have constituents with questions about services, you know, where does autism fit in? What about this? What about that? Please feel free to refer people our way. We're here to help. So, I'm just going to say a little bit about the council because it's a strange thing in government. And it really sort of focuses where my, the rest of my testimony, my comments are coming from. So, the Vermont Developmental Disabilities Council is a statewide board. We were created by the Federal DD Act. That stands for the Developmental Disabilities Assistance and Really Important Bill of Rights Act, the DD Act, Federal Law of 1970. And our constituents are basically healthcare users. I don't really want to get too far into the definitions of what's the Developmental Intellectual Disability. Basically, as that disability is defined in Vermont, there are approximately 86,000 Vermonters who would experience a developmental or intellectual disability, with about 5,000 of those Vermonters receiving services, some kind of community-based support through Medicaid. So, those could be home-based services, school-based services, some kind of service, usually from a designated or specialized agency. So, under Federal Law, the DD Council is charged with advocacy and systems change work. And really what we're charged with, and we're not doing today, so I apologize for that, is we're supposed to be providing our council members with access to you guys. So, today you get to hear from me, the staff or the policy wonk, in better times, you'd be hearing from our council members, people with disabilities and their family members, and they'd be sharing their lived experience. And it's my job to connect you guys. So, last year at the State House, you met a lot of our members because we had a really popular program called Make a Date. Make a Date with Sue. They'd come to the State House, meet their senator, meet their rep, get introduced. Some of you have met our members at our Leadership Training Series. So, I'm supposed to be connecting people with you. Today you get boring old me. Maybe when you take up H10, the health equity bill, which we're so excited about, we can bring in some people with lived experience to talk about health disparities and health equity. Anyway, going on, because I know we're short on time. I just want to explain a little bit. Those of you who get email from me, see that it comes from a Vermont.gov address. So, I just want to say that all 50 states have a DD council, Developmental Disabilities Council. Some of them are freestanding nonprofits. Some of them, most of them, are embedded in state government. Sometimes in an agency of education, sometimes in a healthcare agency, we happen to be located in the Agency of Human Services Secretary's office. So, I am an AHS employee. We are almost entirely federally funded. But to get those federal funds, Vermont has to sign a set of assurances. And one of those assurances is that the state will not interfere with our advocacy efforts. And so, I get to speak to you today as a state employee because I'm speaking on behalf of an independent council, not on behalf of the Agency of Human Services. So, just want to get that clear at the start. So, the Vermont Developmental Disabilities Council has a lot of committees. We have a very active public policy committee and we have a legislative platform. And the issues addressed in 120 are on our legislative platform, which I've sent to you and Nellie's posted this year. And they were on our platform last year. And the issues specifically that I'm talking about and that we really strongly support are the ability to have some kind of independent study on our all-payer model, specifically on the return on investment of public dollars. But just an independent look at it, as well as an independent review of the Green Mountain Care Board's conflicts of interest in regulating that model. Both the auditor and Alcar have raised concerns about conflicts of interest. We definitely think it's worth an independent study given that they are a party to the all-payer model agreement. It's hard to study yourself objectively, Ditto Agency of Human Services. If I were just to add something that's not in my written testimony here, what we would probably like to see added to the bill is to also include in the section where you are talking about reviewing the all-payer model, adding and looking at alternatives, really adding a contingency plan because it is an experiment. We have put all of our eggs in one basket. We have no plan B. One care could fail or decide not to do this for any number of reasons that have nothing to do with whether or not it's a good idea or in Vermont's best interest. And yet we have no contingency plan. So I would suggest a contingency plan. When you had that in the legislation for the Vermont Health Information Exchange a couple years back, you had contingency plan language. It was very effective. And look at the behind now. So I would just say that would be good. I think I'll go back to my written comments at this point. So the issue that we're really concerned about, we've really focused on Medicaid. And so the return on investment, we're really looking at the millions of dollars in Medicaid funds that have been given to one care with very little state oversight or transparency. Under the leadership of both Secretaries Go Bay and Smith, all of the Medicaid funding intended to support what were known as the Medicaid Pathway Organizations. And I can get you all the documents that were submitted to the Joint Health Care Oversight Committee on the Medicaid Pathway Organization. These are the providers of community-based services. All of that funding went to one care. None of it was given directly to a Medicaid Pathway Organization, such as a designated agency, to use for their own delivery system reform activities. So I have extensive comments about this for the last two or three years in my Budget Appropriations Act comments. And I've attached this year's set. There are documents embedded in those that if you're interested in this issue, it really is an important issue. And going forward, we would really want to see if there is another agreement that those Medicaid funds for Medicaid Pathway agencies get to those agencies. And there's some kind of equity for the delivery system reform investments that one care of private for-profit corporation owned by two hospitals received actual Medicaid dollars straight to one care. Those funds need to go to the Medicaid designated community-based agencies. Okay. The other thing, and this is something that I don't think anyone else has talked to you about, and it is really our biggest concern going forward, is that the renewal, and I'll just start to talk a little bit here about 132. I didn't submit written comments of 132, but 132 presupposes an automatic renewal of the all-parent model agreement. We would really like this committee to decide yes or no. And so that could be added should we renew or not. But anyway, if it's renewed right now, it calls for an increasing pool of our state Medicaid spending be added to the financial caps. This is the really important part. Right now, we always talk about what's in and what's out. What's under the cap? What's not under the cap? So the all-parent model has its own financial spending cap. And the only services under the cap right now are the ones that are like Medicare Part A and B hospitals, doctors, physicians. Under the next agreement, because of both the agreement itself and because of language in Act 113, the new agreement is supposed to include under the financial caps all of the Medicaid spending for including for home and community-based services. And the reason why this is a problem is not because we don't want to live under caps. It's because in the Medicaid world, there's a huge difference between what are called optional services and mandatory services. And so just to give you one really clear example of an optional service and a mandatory service in home and community-based services. In Choices for Care, we pay for long-term services and supports for Vermonters who qualify. Choices for Care will pay for a nursing home. Choices for Care will pay for the services and support someone needs to live at home such as meals and meals and home health services. Nursing home services are mandatory, home health and community-based services are optional. So in general, all the Medicaid services that are equivalent to the Medicare A and B hospitals, doctors, specialists are mandatory and most non-institutional services for people with disabilities, community support, facilitated communication, those are optional. So if you start including the cost of the optional home and community-based services under the same caps as the acute care, that we consider is going to be bad for people with disabilities and anyone who relies on the optional services. And the reason is simple. As Ramon's total Medicaid spend approaches the cap, which it will, optional services can be rolled back but mandatory services cannot. So in relying on caps for cost containment, the all-pair model agreement is going to turn Vermont's decades of investment in home and community-based services on its head. Vermont should be proud. We were leading the country in what's called shifting the balance, spending more of our Medicaid long-term dollars on home and community-based care instead of nursing home care. We were leading the curve. We've sort of fallen to like middle of the pack in many measures of that. We should not risk really gutting our fragile enough home and community-based care. Vermont should remain committed to serving people in the least restrictive settings, allowing for full choice the option of aging in place. We support S120. Because of the oversight and fresh eyes, it will provide at this critical juncture in Vermont's health reform efforts. This issue alone, I will just say on the house side, it's really problematic the way Medicaid issues are dealt with in the Human Services Committee and health care reform is dealt with in the health care committee. So when Act 1113 was passed and swept in all of the Medicaid funded services, it never went to the House Human Services Committee. And when I talk about these human services issues and Medicaid funding and optional and stuff to the health care committee, not because they're not bright committed people, but they don't get, they don't do Medicaid, they don't do the stuff. So your committee, I love your committee, you get both the human services and the health care. And this is where health care and human services, where the rubber really hits the road as soon as these long-term services and supports come under the same caps as, you know, heart attacks and point replacements. So that's our concern. We don't expect you to fix that concern this point in the session in your committee, but the process that you're setting up in 120, we think could get some fair hearing to this issue. It's a really important issue. So as for 132, I'll tell you what we do support. We love the hearing aid coverage. Go forth for hearing aids. What we don't like is, as I said, it really does presume a renewal of the all-payer model agreement. And we don't think that we, that should be presumed at all. We like that you're starting to address the issue of Green Mountain Care Board, kind of getting them a little bit out of the business of health care innovation and more in the business of regulation. But we think that that issue really needs far more scrutiny. I can forward the Elkar letter from yours back saying, please look at this. Chairman Mullen, when he was, new chair was asked by Elkar, how would you feel if we looked at this conflict of interest, this EB-5-like issue that the auditor identified of regulating and innovating Chairman Mullen, welcome that. I think it's an awkward thing for him. Getting back to that Medicaid money, he actually had to lobby the legislature and the governor to get more Medicaid money, more of those dollars to one care. That's not what you want your head regulator doing in my humble opinion. But yet the all-payer, the way they're party to the agreement, that's what he has to do. So I really welcome that you guys want to set up a process to look at it and we would really enjoy being part of that process and supporting it in any way. Thank you. Okay. Thank you very much. And please send us your testimony as much as possible in writing.  Yeah, terrific. I think it's posted. It is posted now. Okay. Great. Thank you. Good. And it's good to have you in committee. Great to see you. Questions of clarification. Okay. Yeah. Okay. Thank you, Madam Chair. And thank you, Susan. And I don't want to take too much time with because we have so many people, but the sort of, for lack of a better term, and I don't mean to dismiss, but the weeds that you got into are exactly the kind of weeds that I think Senator Hooker and I envisioned when we were talking about setting this kind of thing up is we have, as new members of this committee, not been able to get into those weeds. And when we do it feels, we feel rushed like right now. And, but I wanted to ask you, because it seemed like you were talking about two different things. There are two sort of things coming up. One is the global commitment waiver renewal process that's at the end of this year for the Medicaid global commitment waiver. And then the next is the sort of all payer model, one care, and that's a year laterish. And so it seems to me like there was a sort of mixing of those a little bit in your testimony. But one thing I just wanted to ask is the Medicaid pathways agencies, your comments about that, is that something that is covered in the waiver, or is that something that's covered in the all payer model? Or is it both?  Yes, both the global commitment waiver is up for renewal and the all payer model waiver renewal. When those were last done at the end of 2016, they were done in tandem. And so the global commitment waiver created a new kind of spending. That's where the delivery system reform dollars live. The administration like to describe it as a new permission slip. They could spend money in this new category. And that was for ACOs. And for the Medicaid pathway, it only went to the Medicaid pathway. But it was part of the waiver that delivery system reform dollars live in the waiver. But the all payer model agreement, which is up for renewal. Also, the existing one said, Hey, you guys, when you renew next renewal, Vermont Agency of Human Services and Greenmont Care Board together as the parties have to submit a plan for the new renewal that will include all of those community based Medicaid funded services in the new financial caps for the next agreement. So those are the services that are laid out in our waiver. And those are that waiver is up for renewal. And so we do want both things. We want equity in the renewal like, Hey, if you do the new waiver and you have delivery system dollars this time, really give them to the Medicaid pathways agencies because believe me, they need them. Thank you. And, and, and, you know, maybe we need a longer conversation offline, but because we don't have a lot of time today, but the I'm interested in seeing what we as legislators and as health and welfare committee that covers the whole spectrum here can put in language to, to guide diva and the administration in their renewal of the waiver, because that is happening before our next session. And we're going to be gone and not able to do much about it. And so I want to give them direction. And it seems to me like this is important. And I hadn't heard about it before. And then we the all payer model ACO thing. I want to lay the groundwork so we can tackle that next session. And that's what part of 120. That's the thinking around 120. So anyway, thank you. Thank you. Bring up another complicated thing, Susan. Thank you. There's a sign I think I think I once read once that it's never that simple. Now, what does the sign say? It's all complicated. More complicated. It's more complicated than that. It always is. And it's right in our committee room. If you turn around and look at it, you'll see it right now. I can't wait. I can't wait. And just just last year. Oh, gosh, it wasn't like it was the year before it was the first year of the last biennium. I think we passed age s 107, which included the the combination and building building what you're talking about and reinforcing what you're talking about because we had it have had it in legislation many times about including our designated agencies and other social services within the reform efforts. So now as we're getting to waiver renewable renewables, please do send your suggestions. We'll do it one more time. It doesn't hurt. All right. Thank you. And we're going to move on to Ed Pacwan of disability rights. And Ed, thank you for being here. We're we've asked folks who were on the list to testify on both bills to cover both of them one time. So if you don't have to stay, you're welcome to leave or you're welcome to stay. But just to make more efficient the time that you have for your testimony. That's great. I appreciate that. So by way of introduction, I'm Ed Pacwan. I'm the executive director of disability rights Vermont, which is the state's designated protection and advocacy agency for people with disabilities. And that is a designation that's an appointment of an agency made by the governor. And this was made way back in 1978. Once that designation is made, the state has very little direct control unless we really mess up and then they can try to redesign. But we are federally funded. We get our funding streams through a variety where across disability organization. Part of our funding is through the developmental disabilities and Bill of Rights Act that Susan just mentioned. And we work closely with partners at the university center on community inclusion and at the DD council. We are empowered to investigate abuse, neglect, and civil rights violations of people with disabilities. We employ lawyers. We do outreach to facilities. And we do a lot of individual case work. And we also do advocacy work like I'm doing right now. And we've also got a designation as being the state's mental health care ombudsman. And so through that, we look at the uses of force that are used in psychiatric units against people with psychiatric disabilities who are in the custody of the commissioner of mental health. And there's a lot more to it than that. But I don't want to spend all my time explaining who we are. But you can see we're an advocacy organization. And we work across all disabilities. And so health care reform is an extremely, extremely important to us. We don't generally look to the policy details in the way that Susan has, although I've got a background as having been a legislator for six terms and having served on a special committee that designed a system that never passed for universal access for the state as did Cheryl Hooker. Nice to see you, Senator. And so I've been looking at these issues for a good long time. And what I would kind of like to do is give some comments directly on the bills, but also to do some maybe what I would call gross oversimplification for you that I think is important to do in certain ways. First to comment on the bills themselves at S120 looks good to me. I think you're hitting on areas that are close to my heart, universality of coverage, challenge of rising costs. Since being in the legislature, I've been the director of a small nonprofit agency. And when I first started, if the inflation raise of our insurance was less than 20% a year, I said, oh, okay, that's not too bad. There was one year in the last 18 years that I've served where we didn't have inflation. And that was the first year that the Affordable Care Act went into effect. And then we got back on track. So now we're not inflating at quite the 20% range, but we're working our way up to that. I think it was 12%. I think it was last year. So you're on to an issue that is of import to all of our citizens. And at least the question of what you, I think the heart of what you would like to study, which is why is it so darn intractable? And now I'm going to get into more systemic issues as I would look at them. And a concept that I really want to leave with you that I've carried with me since the 90s. And that is that any of the healthcare systems in the developed world that have been relatively successful at covering their population and at maintaining reasonable levels of inflation have had a nexus of public control over financing. Whether they're multi payer or single payer, and there's or anything in between, there is all they all have in common that there is a way that the public controls what is spent. We don't have that in our system. We have a system where the acute care system can balance what it sees as its needs by raising the cost of insurance to entities and agency and to private private businesses. So if the government decides that we're going to hold the line on on costs through acute care Medicaid, they can make up what they need. And now obviously it isn't simple as simple as that. And it never is. But I think it's important to remember that the basic money flow is not under your control. And if you are going to have a system long term that serves all of the people equitably and well, you're going to have to figure out a way that that money flow and how it is spent is under public control in some way or another. So that's a concept that I would leave with you. And I think it's really important to remember that. And there's a million ways to do it. But every system has to do that if it's going to work. And now I'll get a little maybe come down to earth a little bit more. So I think your bill is studying the right things. You know, your make findings about inequity, cost, availability and lack of providers and lack of universality. And you're looking at out of pocket costs, the issues of the ACL model and the uninsured rate, health disparities, opportunities for expansion. I like your allusion to those. I think where what you may find that you need is some another level of input from expertise. And you've got a consultant there, but you may find you will find in your public hearings, and this may be a cynical thing to say, you may find things that you already know from your constituents. And from, you know, many of you have years of experience and working in these issues. But but I think you need to be hearing from people with expertise in systems in some format or another. And so you might want to look at means of doing that. And then I think that you need to I guess it's sort of as struck me as it's kind of a short time frame, but but I understand the time frame, you do need to be doing this in the in a course where you'll be able to take report and take action next biennium. So that may not be the issue. It sort of struck me as, oh, boy, it's a lot to cover in a short period of time. So I think you need to understand how our systems actually function now. And I think you need to get down to a level of understanding of where the dollars go and who is controlling the flow of the dollars. So now let me get I'm sort of getting now closer to 132 than 120 in that in I'll express this as a personal opinion. Some of the basic ideas in the all payer model, I think, strike me as as good ideas, you know, refiguring how we fund the system based on developing primary care, moving away from fee for serving fee for service and coming closer to what, you know, you would call global budgeting, you know, looking at the system as a system. However, it's intrinsic. It's in the heart of the system that we've adopted that it is provider led reform. And that's the second major concept that I would ask you to think about. And it, you know, I have to say I agree with with the comments that Susan made. In general, I can't think of anything she said that I would disagree with strongly. What I think is behind it that is really important to remember is that if you put me in charge of something, I am going to make sure that I take care of my own interests. I now to get personal. My costs have not gone. I get my case of my health care in general in central Vermont. And if I need a specialty elsewhere, I go elsewhere. In some ways, we got a wonderful system in that basically I can get the health care I need. And I'm in a good position because I have I have good insurance. However, I will tell you this, since we've reformed the system and we've watched the system consolidate, I now pay for UVM medical center every time I get a service from central Vermont. And I think you're going to find that throughout the whole darn system that we have consolidated a system. And instead of that consolidation, bringing efficiency to the system, it brings security to key large players in the system. And I don't know exactly how that plays out. If I had to document that statistically, I probably couldn't wouldn't be the person with the expertise to do that. But I don't think it's hard to understand that if your reform is led by the providers, it will be very helpful to the providers. It will at the very least, they're they're certainly good people trying to do good things for the public. And you know, we've seen I'm alive because of the good things that our acute system does. And we've seen incredibly good work under pressure during the COVID-19. However, they will take care of their own infrastructure and things that have been pointed out in S 132, you know, mandates that you talk about in there regarding their salaries and things like that. I mean, okay, I can see that they're in there. I can see that somebody has a handle on understanding that they will take care of their own infrastructure first and foremost. And that's clearly shown in the some of the comments that Susan made with regards to Medicaid pathways. So the next thing that I would hope that we think about pretty darn seriously. And this has to do Susan, I think talks better than I can about the details of how the caps function and how current law is going to be painting us into a corner that's uncomfortable. Because in those caps, if they go through a system that is essentially controlled by providers, and the providers who are essentially controlling it are the acute care hospital consolidation that we've seen going on, then your long term care supports and services system are going to be a poor second cousin as they are now. And that is something that worries me tremendously. And I think when I think of healthcare reform, I am coming from the Middle Ages, and I am probably going to be unpopular with everybody here. Because instead of seeing a glorious integrated system, I am fear a glorious integrated system that is controlled by the acute care hospital system. Because we deal with clients all the time who are who get mixed up and who are lost in that shuffle in the in the great difficulties of that are created because the systems are disparately functioning, disparately controlled, and often the steering happens at a level of there's a lot of control on that acute care level that really doesn't serve people well, who have long term care needs. You have tremendous expertise and an incredibly good history in de institutionalizing developmental services, de institutionalizing mental health services, and other parts and especially de institutionalizing you've equalized and through choices for care you've equalized the entitlement to home care with that of nursing home care. So we've done incredibly good things and we have to ask ourselves where does the expertise lie there? Well, it doesn't lie in the hospitals. It doesn't lie in the acute care system. Really it lies in the community mental health system, the community developmental services system, the triple A systems, the home home care, home health nurses. There is a different kind of infrastructure at work. It has different needs. And I got to tell you, you're not it's not going to get the attention it needs. I don't believe from the people whose primarily interest primary interest are the patients they see and the infrastructure that serves the acute care needs of our system, what what Susan referred to as the you know, part A and B type health care needs. And I really think that we should you know, I know this is unpopular because it sounds like I'm speaking against integration. There should be excellent coordination, but it requires different thinking to do acute care, long term care and public health. And we need to be thinking about a triumvirate or a three legged stool, maybe a better way to put that. We need to be thinking about what are the strengths and what are the needs of the other. And if we need a health care reform that's essentially addressing the issues of affordable acute care, then let's pay attention to the funding and the delivery of acute care services. They need to be coordinated, but they don't need to control our long term care system. If they do, I think you will find that the inclination towards institutional care or towards squeezing of costs, squeezing of services is going to be more the rule than it is even now. And so I think we need to be thinking about who controls the who's the center of the system. The public should be the center of the system. Where is the nexus for that to happen? It's in the governor's office and it's and it's in the state legislature and the courts. And that needs to be controlling health care reform or I don't believe it's going to in the long term be successful. And so I think I've made the major points that I would like to make. I would say another, just a couple of little details. I would agree with Susan. The hearing aid part of that bill is excellent that it's been included. A little flag went up when I read the phrase suitable for in-home use in the discussion of durable medical equipment. I think that should probably be elaborated because in my experience, a lot of times the term, especially as used in Medicare suitable and for use in the home buys equipment that's only suitable for use in the home. And we've seen fights over the years over people getting Medicaid chairs who should or Medicare chairs, wheelchairs I'm thinking of, who really should have a chair like I use, which is a lightweight, easy to get you around, good and sturdy, something that is designed for all kinds of use. And so anyway, there's there's details to be looked at there. And it's always a flag for me when I see suitable for use in the home. And I think the issue of inclusion of specialists in the reference that you have in S132 is important because we've got to figure out how do you have a system that employs uses the expertise, but isn't dominated by the cost of really expensive specialist services. The last thing we would want to do is not have access to that. But we have to face a real challenge that some services just plain break the bank almost, you know, and I think the reality is that other systems where the nexus of control is centralized, address better how we remunerate professionals and how we allot the resources so that people have real access, but don't necessarily. But it's done in a more in a more rational way. So I would be happy to answer any questions. If if people have that, I think I've made the main points that I'd like to leave with you with regards to these these two bills. And I really think it's it's good to be looking at this the timing that Senator Hardy brought up about as you renew these things, holy mackerel, a decision that's made partly in the dark is going to affect you for the next five years and will profoundly affect the structure of the health care system in what could be really negative ways. Okay, thank you. Thank you very much, former Representative and Executive Director, Paikwin, we appreciate your comments and anything you can send in writing would be helpful. If it's not already there, I'm not keeping track at this point. But so thank you for that. I think we're going to move on. I don't see Grace Benenson here. Is Grace here? Hi, I'm Ellen Schwartz. I'm Ellen. You are here. Yes, and Grace is with me and I'm just going to introduce our organization and then I'll turn it over to Grace and then sort of okay. So before you begin, I'm going to say that we're going to listen to you and Grace and then also to Patrick Flood, then we're going to take a short break so the committee can refresh itself. Okay. So thank you for being here, Ellen, and please give us your testimony. Great, thank you for inviting us and for having us here today. And so I am here on behalf of the Vermont Worker Center. We're a grassroots independent organization and we have been organizing for the human right to health care since 2007, I think. And Grace is going to share her personal experience around the issue of affordability, which is what S120 is about.  And due to the confusion yesterday, we actually thought that we had to give separate testimony on 132. And so Jessica Morrison is also here from the Vermont Worker Center and she's prepared to give testimony on S132 whenever you're ready to take that. So I'm going to turn it over to Grace. Good morning, everyone. My name is Grace Benenson. I live in Brattleboro. My story goes back to 2014. On March 8th, I woke up and went to work and did all the usual stuff that I have been doing for almost 20 years at the same company. And I came home from work that day and I just had a headache. There was really nothing weird going on. I sat down, had a cup of tea at the kitchen table. My daughter came home and found me and I was unresponsive. The upshot of all that was that I had had a massive stroke and 911 was called and they took me to the hospital and ultimately up to Dartmouth, Hitchcock, where I spent about two weeks and then to rehab. But how this ended up happening was that my company that I worked for had just switched over to a new policy that for single people had a $5,000 deductible for all services. So I really essentially couldn't afford to go to my regular doctor because I'd have to pay out of pocket. And in addition to paying premiums and whatever prescriptions I'd have, I have to pay them like $150 per visit and at my salary, which to me seemed reasonable, it just wasn't financially possible. So I didn't go to the doctor for a couple of years and they found out that I had undiagnosed type two diabetes that resulted in the stroke. So anyway, that changed my life forever. I can't even tell you how many ways it changed my life, but the fact of not being able to afford to simply go see your physician for regular visits is insanity. I mean, I don't know how much my entire care for the stroke has cost, but over time it's got to be in the hundreds of thousands of dollars. So if we look at the cost over time, it makes sense to give people at least reasonable care near their homes that they can afford so that we don't have these catastrophic outcomes. That's pretty much all I have to say, but thank you for listening. Have a wonderful day. Bye-bye. Grace, thank you so much for sharing that. It sounds like a really difficult time for you and we appreciate your being able to explain exactly what's happened. Thank you very much. Well, thank you. I'm lucky to be here, I guess. I'm lucky to have you here. I'm lucky to also, you know, really be fighting for healthcare as a human right because that's what it comes down to. We have to take care of each other and the healthcare system is a tool to do that. And if it's not working for the people who need it, what good is it? That's all I got to say. Have a good day. Bye-bye. Thank you. Thank you very much. And Alan, thank you for being here. Do you have anything further to add at this point? Yeah. I was just going to add some comments related to the issues of affordability and access. So as a grassroots organization, we talk to a lot of people around the state of Vermont and the kind of story like what Grace just shared is like one of the many stories that we hear when we talk with folks. The main problems that we hear about from people are named in that bill. They're obviously affordability and access. People can't get healthcare either because they're uninsured or they can't use their insurance because of high deductibles like Grace just talked about or the services that they need aren't covered by their insurance or they can't find a primary care provider. Those are some of the main themes that we hear about over and over again. They were also in the healthcare advocates report from last year. There were similar findings. And just last week, we weren't surprised to hear Senator Hardy say that when she talks to constituents, healthcare concerns were the number one concern that she hears about in talking with her constituents. So it's really clear that all of us like everybody on this committee and everybody testifying agrees that the purpose of our healthcare system should be to optimize the health of our communities. And that means making sure that everybody can afford and access healthcare. So we at the worker center are calling on the legislature to focus on guaranteeing care for all by taking public control of our healthcare system, not handing the keys over to private corporations with their own interests. The state should not be supporting the creation of a healthcare monopoly in private hands. I think Ed Pequen spoke to that just prior to our testifying. In order to do this, the legislature needs to deal with affordability head on, which S-120 does. We support the proposed joint committee that would be created by this bill. And we support it's being charged to consider the suggestions in the bill, including the evaluation of the ACO model and considering alternatives to that model. We also think that it is crucial that the committee hear from the public, as is proposed in the bill. The listening sessions that Dr. Richter described are what we would imagine that that public, the public process would be. Every year the legislature has to tinker with things like expanding dental care, expanding Dr. Dinosaur, and currently hearing aid coverage, which we also support. And we support all the expansions that the legislature has done in those areas. And at the same time, we're aware that what happens is by having that kind of a piecemeal system, one kind of care gets pitted against another. So it's like, is it hearing aids or is it dentures? When, you know, for the person who needs hearing aids, it's hearing aids. And for the person who needs dentures, it's dentures.  And that happens because our current system delivers healthcare and pays for healthcare in a piecemeal way, which inevitably leaves some people behind. And so what we think we need instead is a unified and universal public system that addresses all healthcare needs and is funded equitably. The legislature has also taken a lot of testimony on payment reform, specifically the all payer model. We also think that that model will not get us to universal healthcare and in fact takes us further away from that by privatizing healthcare in the hands of two large hospital networks and by employing a managed care model. So we think that instead of tinkering with coverage that puts band-aids on some problems or regulates private actors a little more, that what Vermont really needs to do is to address the root causes of healthcare unaffordability, which are privatization and profiteering by various corporate entities such as the insurance companies, the ACO, hospital conglomerates, the pharmaceutical industry, and the for-profit nursing home industry. Establishing a committee dedicated to this task, which is what S-120 proposes to do, is an important first step. And some of this work, I'll also just mention some of this work of looking into affordability was done previously in former governor Shumlin's financing proposal for Act 48, which calculated that 93% of Vermont residents would have seen an increase in income and had access to healthcare had that plan gone forward. Ultimately, we think that the legislature will need to take action to make healthcare affordable by moving us to a system that provides healthcare as a public good under public control to all Vermont residents. Thank you. Ellen, thank you very much. Clear and concise. And if you have that in writing, we would please send it along to Nellie and we can post it. All right. Terrific. Thank you. All right. So Patrick Flood is here. Welcome. It's good to see you again. And we look forward to your testimony. Thank you, Madam Chair. It's good to see you too. It's been a while. I don't know how you folks are doing your business in these times. So you deserve a lot of credit. I will send written testimony. I don't have it prepared today, but I'll have it to you in a day or two. I thought I might quickly introduce myself to the committee members that don't know me. I worked 29 years in state government. I was a commissioner of Dale for seven years. I was the deputy secretary of the agency of human services for four years. And then I was the commissioner of mental health for a year after Tropical Storm Irene. And that was quite a year. After I left state government, I ran a federally qualified health center up in the Northeast Kingdom, Northern County's health care for three years. And after I left that, I was called in to work for a year in a housing organization up there that was in deep trouble. I was going to let you know that I started my career as a nurse. I was a nurse for seven years and worked in a wide variety of health care settings. Some people say I've had a checkered career, which is true. But during that time, I learned an awful lot, especially about some of the issues that you're hearing about today. I'm not working for anyone now. I'm not being paid. I'm not part of any organization. But I feel that health care in Vermont is at a tipping point. And I think it's way too important to the average Vermonter and to businesses as well. I was on a school board also for 11 years. And to watch our rates go up every single year and be powerless to deal with it was very frustrating for school members, school board members. So what I'd like to do is be as brief as possible. Madam Chair, do you want me to include my 132 comments now or wait? Because I know you're bumping up against the break. No, I think go right ahead. I think it saves you time and it's much more efficient to put them together. So please do that. Thank you. Okay. I'll do my best not to be repetitive. I think a lot of what you heard this morning, I agree with completely. And as I said, I'll try to be brief. I am more than happy to answer questions now or another time or to go into more detail if any committee member wants me to. But in S1-21, right in the finding section is a mention of exploring cooperation with the Biden administration. I have got to say, I think there are going to be tremendous opportunities working with the new Democratic administration. One of the things I did in my state government career was negotiate a waiver with CMS on the long-term care. You've heard people refer to the Traces for Care program. That was something that I led the charge on. I know how to do it. I know what's involved. And I do think there's tremendous opportunity. And I believe it was Senator Hardy who brought up the global commitment waiver and the all-payer model renewals. I really think we have an opportunity here to combine those two initiatives and do something truly comprehensive and innovative in Vermont. We are so poised to do that. I want you to be clear that I support the notion of an all-payer model. I support the notion of alternative payment methodologies where some of us may diverge as I'm not such a big fan of the ACO, and I'll touch on that briefly. But the overall concepts I think are really important and open an important door for us. I made extensive comments at a public hearing on the global commitment renewal, and I'll be happy to include them in my testimony. So I think that's a great provision in this bill. I also think the proposal to evaluate the efficacy of the ACO model is critical. As you all know very well, we are spending a ton of money. We have not seen the results that people hoped for. In fact, I have to be blunt and say, and I've said this in public before, I believe the model is failing badly and we really should be moving to an alternative approach, which I think there are a number of options. And I truly believe, I truly believe and be happy to talk about this more at another time, that we can achieve universal care in this state that's affordable. So I'll just leave that out there as a teaser because we don't have time to get into all that today. I fully support exploring a public option. I will declare my bias and say that I am a supportive Medicare for all, but that's not going to happen anytime really soon. I think we all know that. But I think we can negotiate with the federal government in helpful ways. We can get ready for what I believe is inevitable, which is some kind of a single payer system.  Primary care. It doesn't do any good to have universal coverage for a service if you can't get in to see the doctor. If there aren't enough doctors, the promise of a universal system is hollow. And I'd just like to quickly say that I believe having run an FQHC for three years, having dealt with these issues, having talked to many primary care physicians over the years, this is a solvable problem. This is an eminently solvable problem that we're just not addressing it in an effective ways. I believe there are things we could do in the state of Vermont to make Vermont a mecca for primary care doctors. And again, I'd be happy to talk about it more. We just don't have the time this morning to go into the details, but it's actually pretty straightforward, a simple, not very expensive at all. And I think it'll be extremely helpful and it would help us get ready for an expanded system. I also fully support the proposal for a commission to study affordability. The notion of having public hearings around the state, to me, is critically important because we have made our healthcare system so complicated. The average for a monitor simply can't understand what we're talking about most of the time. Most of them don't even know what an ACO is. They certainly don't know what attributed lives are. It's become so complicated when, in fact, what people want and what they really need are simple things like access to a doctor, like help with their prescription drugs. We don't need a hugely complicated system to achieve those things, in my opinion. The complexity itself, in my opinion, has made it unaffordable or contributed to the unaffordability of our system.  We have overlapping systems. And I know Ed Bacon been like the idea of an integrated system, but there is a very humane way to do that kind of thing. And again, without going into a lot of details, I'll give you a quick example. The people we refer to as duly eligible that are Medicaid eligible and Medicare eligible, to this day, those two systems are cost shifting to each other. It doesn't have to happen. It can be easily resolved, especially, I think, through a global commitment renewal or an all-pair model renewal, we can make life easier for those Vermonters and we can save money. It's too complex and it doesn't need to be. So those are my thoughts on S120. And as I said, I'd be happy to expound at any point with anybody. Moving on to 132, this bill has just a number of very positive changes, in my opinion. And in no particular order, I'm not tying my testimony to the sections in the bill. But number one, of course the auditor of accounts should have access to the ACO information. There is way too much money going through the ACO and more in the future, if it continues, correct, to not have full and open transparency and accountability. And I will remind you, I'm sure you know, every state employee's salary is a matter of public record. And in most school districts, every teacher and every secretary's salary is a matter of public record. And the reason is because those are our taxpayer dollars and people want to know how they're being spent. And I think that certainly applies to something as massive as the ACO and the ACO proposal. Number two, to take a look at the idea of covering hearing aids is a great one. Now, as somebody said, I think it was our friends from the Worker Center that, you know, are dentures more important than hearing aids? Well, that's a hard discussion to have. I believe, and it may sound fanciful, but I believe that being able to hear is actually critical to good health. It certainly is critical to quality of life. But if you cannot hear well enough, you're not even going to go to the doctor because you're not going to be embarrassed by not being able to communicate. You're not going to access services because you can't even talk to the person at the other end of the phone. So I believe that actually covering hearing aids will save us money. So I certainly support, and I know a lot of people do support the notion of pursuing at least an evaluation of what it would cost. The next comment is the proposal to control the salaries of the ACO administrators just makes plain sense to me. I don't understand why we're funding a system where the administrators are paid two and three times what the governor's paid. Or never mind Dr. Levine, they're paid two and three times what he's paid. And look what that man has had to deal with in the past year and done a very good job in my opinion. But it's a more general problem because bloated salaries in healthcare is a problem and it's one of the things that contributes to unaffordability. The proposal to include specialty care in the all-payer model is way more important than it probably seems to most people. Specialty care is one of the drivers of the high costs of healthcare. For example, in the past 20 years, between 2000 and 2018, the number of specialists in Vermont has gone from 895 to over 1800, double. Meanwhile, our primary care workforce continues to decrease. We are going the wrong direction and it does drive costs. So I'm not prepared to talk about what should happen with specialty care in this state, but it absolutely should be included in any system that we're putting forward. It's hugely expensive and a driver of healthcare costs. The proposal to provide two free visits of primary care is certainly something a lot of people would support. It's a very positive development. My only caution or concern is that people are having trouble accessing primary care doctors today. Many practices are not taking new patients. You have to wait sometimes months for an appointment with a primary care doctor, and as I said a little while ago, and we'll say over and over and over again, this is an eminently solvable problem that we should be working on right now at a relatively modest cost. In fact, I'd say maybe even modest is too strong a word, but it's just it's just so frustrating for everybody that they can't even get in to see a doctor. So another two visits is a great thing. But what provisions are we making sure that you can or to ensure that you can actually use that benefit? Let me see. Moving quickly here. I think that the bill includes several provisions related to what I summarize as transparency, openness. There's a provision that eliminates confidentiality agreements. There's a provision that creates additional oversight of contracts. I think all those provisions are good. Transparency is really important. And in fact, it's one of the key principles in Act 48. I'm sure you all remember that. So I think these are worthy changes and they should all be implemented. But my criticism of the bill, and I mean this with all due respect, is that it doesn't really get at the underlying problems. It doesn't solve those things that are really holding us back. Like, as I've said now for the third time, sufficient number of primary care physicians. It would be great if the bill would have put a plan in place to deal with that. I know you're talking about it in other bills or other testimony. There's no provision to expand insurance coverage. As you all know, many people lost their insurance coverage, and the ACO is not designed to increase access to insurance. It just doesn't address it. So that problem remains unsolved. There is no provision yet to actually spend more public dollars on actually keeping people healthy, which I think is in the end the solution to health reform. We have to find ways to keep people healthy and not utilizing higher end costs. I think it's very doable, but we're not making the right investments, in my opinion, so far. There's no provision to expand mental health coverage, which I got to tell you from my, especially from my time at mental health and also my time at the Federal Qualified Health Center. It became increasingly clear to me the important role that mental health plays in health. That mental health issues, and sometimes they're relatively minor and addressable, like depression or anxiety, either cause or exacerbate problems that otherwise could be dealt with. So I'm a huge supporter of expanding mental health to deal with those things, because I think we'll see an almost immediate payback in terms of reduced health care costs. And we're all frustrated with the increasing cost of prescription drugs, which there's, again, no provision at this time to deal with it. So I want to make it clear, I support a lot of the provisions in the bill. I think they're positive and I think they should be implemented, but I still think we haven't gotten to the heart of the matter until we move away from putting all our eggs in the ACO basket and start focusing more on primary care, prevention, mental health, and the non, what we call the non-medical determinants of health. We're not going to achieve what we're looking for. We're simply not going to. So maybe the whole process of having hearings this fall pursuant to S120 will help bring all this out in a way that you can then come up with the proper solutions in the next session. I certainly hope that'd be true. So I will send written testimony and I'm more than happy to talk to any, answer any questions or talk to anybody on the committee at any time. Thank you very much, Patrick. This is very helpful. And so I think that unless there's a question of clarification, we're going to take a quick break and then come back. So I'm looking at the committee. We're all good. Okay. Senator Hooker. I'd just like to ask Patrick, Senator Lyons about the kind of continuum of care between what the ACO offers and the community agencies, you know, you talked about mental health. I mean, are you seeing any movement towards that kind of continuity of care? Well, keep in mind I'm not actually in the system right now. So my answer to you is going to be based on my impressions of watching and learning what I do believe is going on. And I may not be completely accurate. But what I hear from people in the community, especially the mental health folks is that it really, the advent of the ACO has really not helped them very much. I do know that they, they do work together, they do talk together, they have contracts. But the nature of mental health care in the community is such that, boy, the last thing they need is another data system to try to satisfy, which is one of the things they have to do now as part of the ACO. You know, what they need is more people in the field. What they need is higher pay for psychiatrists and therapists. And that the ACO is not bringing them that at all. And I, you know, I would just say that the kind of coordination and I think this is referred to in S132 that's really needed is is really solid communication and coordination between the medical system and the other services, especially mental health, but also the area agencies on aging and home health. And while I know that exists, I think the problem is manifest in that the ACO is creating its own cadre of care managers. I don't believe there's any good evidence that that has had a significant impact on costs because of course, the ACO's costs are over budget almost every single year. I would, I would suggest what we should be doing is bolstering our existing community agencies, including mental health, the AAAs, home health, and create better coordination that way. I think we're creating duplication. I don't think it's effective, and it's just costing us more money. Does that answer your question? I think so. I mean, that's always a concern is that we have that kind of continuum of care and that it works across whether it's a physical care that the ACO is concerned with or the other care that's not hospital driven or hospital centric, that this is the type of thing that's going to make the system whole and create the cost effectiveness that a holistic healthcare system would deliver. So I guess I'm getting my head around this. I know that Sue Aronoff talked about the cap and I can see where that would be a real problem with the nonmandated areas of healthcare that should be on equal footing with the medical care. Senator, I'm sorry. I am going to interrupt at this point where we're getting into conversation and I understand discussion, which is critically important, but also we have a lot to cover. I will say that the efforts that we've had with our hospitals to reduce waiting time in the emergency room for mental health patients has directly resulted to care management that has come through the work that we've done here and with the ACO. So I don't think we can lose sight of some of the benefits that are there. It's hard to throw the baby out, all the babies out with the bathwater. We want to keep those things that are working and bringing our acute care providers into the system of care in a way that perhaps they haven't been before. So in that sense, there might be some benefit as we go forward. We'll have to keep our ears open. So I do want us to have an opportunity for a short break. I'm going to suggest to the committee that we take a break. Nellie will pull off YouTube for seven minutes please. So we'll be back here at 10.55 and that should give us time to go through the rest of the testimony.


Hi and welcome to the session. I'm Kanika and I'm going to help you to solve the following question. The question says if the fourth, tenth and sixteenth terms of a gpr, x, y and z respectively prove that x, y, z are in GP. Let's now begin with the solution.  Question, it is given that fourth term of GP is equal to x. That means t4 is equal to x and t4 is equal to x implies a into r to the power 3 is equal to x. It is also given in the question that tenth term of a GP is y. That means tta is equal to y and this implies a into r to the power 9 is equal to y. It is also given in the question that sixteenth term of a GP is equal to z. That means t16 is equal to z and t16 is equal to z implies a into r to the power 15 is equal to z. Now we have to prove that x by z are in GP. Since x is equal to a into r to the power 3, y is equal to a into r to the power 9 and z is equal to a into r to the power 15. Therefore x, y, z will be in GP if a into r to the power 3, a into r to the power 9 and a into r to the power 15 are in GP. So x, y, z will be in GP if a into r to the power 3, a into r to the power 9 and a into r to the power 15 are in GP. Now this will be in GP if ratio of second and fourth term that is a into r to the power 9 upon a into r to the power 3 is equal to ratio of third and second term that is a into r to the power 15 upon a into r to the power 9. Now this implies r to the power 6 is equal to r to the power 6 and this is true. Therefore a into r to the power 3, a into r to the power 9 and a into r to the power 15 is a geometric progression and hence y and z GP. This completes this session. Bye and take care.