 Thank you. Now streaming live. This is the afternoon committee of the house appropriations. Committee we on our agenda today at one o'clock we are going to continue our discussions on H 611 the Olders Vermont at Vermonters act. We have Nolan Langwell here from JFO we have Jen Carvey here with us with ledge council and Diane you're going to be on speed dial with the two representatives from human services if we need help is I think their committee is meeting at this time. Is that correct. So, we had had a request for Jen to put together information regarding the similarities and differences between what we offer nursing homes at this time with rate setting, and what 611 proposes to do Jen thank you for putting together this work. I hope it was a quick cut in pace but I think that you probably have some time invested in this sheet. I've asked committee members to look this over, while we had a break between our meetings and we're, and we're either another meetings are doing other things so I'm, I'm hoping that there was time there to ask questions. regarding the differences and what it means for this bill and, and where it will lead us in order to make a decision on it. We also have Nolan here to look at the fiscal note to see if we make changes. And if that impacts how the fiscal note should be written as it leaves House of Appropriations. So let's first open it to committee questions. Madam chair, can I just say Commissioner hut has joined us now. Okay, welcome Commissioner hot. And then I, and I don't see you so I'm just going to talk to you. Monica, did you want to weigh in, or are you here just to. Did you have anything you wanted to say first I should ask or are you just here to join in the conversation as questions arise. You may need to unmute yourself. I'm just trying to talk. Good afternoon or good morning. Oh good afternoon. No I didn't have anything specific representative toll I just wanted to be available. Thank you we appreciate that sure. So with the language in section five to determine exactly what it means and how it relates to the fiscal note that we received and then the direction going forward, basically leave the bill as it is, and, and take a vote, or look at section five and to make the language say yes we are supporting a definite rate increase, or look at section five and decide that we wanted to be more informational than a directive, or to simply remove section five so that's those are the options that are before the committee at this time. Any questions from the committee members to either the side by side comparison that was compiled by Jen, or if anyone has a question for Nolan, or for the commissioner. I'm not seeing hands am I Teresa, am I a. You are a co host yes. So, I have a couple of hands I have Peter and Dave. So kitty I'll be the one to state what may have occurred across the board with all of us. I was too busy doing other things to be able to even look at this in between our 1130 and time and now so I'm trying to read down through it now. It might be helpful to actually have Jen present it because I'm reading as fast as I can trying to listen so just say just saying what happened. So Jen let's start with that that that's an excellent idea thank you Peter let's pull the side by side up and if you could just do a quick review over the similarities and differences between the two groups. Sure. So Jen carbine legislative council. So, yes there had been an interest expressed last week in a kind of a comparison of what the law says around how nursing home rates are set and what age 611 would do around home and community providers rate inflations. And so I just set out the nursing home rate setting chapter with a link to it if you want to actually look at the language. So the nursing home rate setting chapter starts with stating some reimbursement objectives what the what the objectives are in setting the rates for nursing homes that there be an equitable and fair balance between cost containment and quality care. Encouraging nursing homes to admit persons without regard to source of payment, providing an incentive for nursing homes to admit and provide care to persons in need of comparatively greater care. And that'd be manageable administratively for nursing homes and the state, and to prevent unnecessary cost increases. So as a rate setting section and I skipped some of the provisions in the chapter their definitions there's some other stuff about the composition of the division of rate setting which had been a standalone division in the agency of human services. But has now as I understand it been brought into the Department of around health access diva. As far as rate setting itself the director of rate setting must establish by rule procedures for determining payment rates for care of state assisted persons, which for our purposes here is is Medicaid. So Medicaid rates for nursing homes and other providers as directed by the Secretary of Human Services. It allows gives the AHS Secretary the authority to establish rates that are sufficient to ensure that certain quality standards in the long term care facility statutes are maintained subject to some facility payment requirements in 33 vs a section 906, which you'll see in a couple of squares here. So then on the next page. We hit the is where I put the inflation factor because it's the first time it showed up so on the nursing home side. It says beginning in FY 2003, the Medicaid budget for care of state assisted persons in nursing homes so the Medicaid budget for taking care of people on Medicaid and nursing homes. And they have an annual inflation factor that is reasonable and adequately reflects economic conditions in accordance with the division's nursing home rule, and they have a very extensive nursing home rule that includes a rather extensive inflation factor formula and and parameters. So the nursing home rate determination and we'll look at that a little bit more in a minute, but it uses a base year, and then it adjusts the base year amount annually by inflation factors and it allows for different inflation factors for direct care and for other costs. So if we compare that with the with section five the home and community based service provider rate inflation factor from H 611. That requires the director of rate setting to establish by rule procedures for determining annual inflate an annual inflation factor to be applied to Medicaid rates for providers of home and community based services, authorized by diva or Dale or both. The provision in collaboration with Dale must calculate the inflation factor annually and reported to Dale and diva for application to home and community based service provider Medicaid reimbursement rates beginning on July 1. The combination of Medicaid rates for each fiscal year must be paid based on applying that inflation factor to the prior fiscal year's rates, plus any additional payment of amounts available to these providers as the result of legislatively enacted policies that are applicable to that fiscal year. The first five applies to home and community based provider service provider rates beginning on July 1 2021 so for the FY 22 year. Back to the nursing home rate setting the basis for determination of rates in statute. The home payment system developed by the nurse by the division of rate setting must include at least three cost categories. First direct care costs, including nursing salaries and nursing assistant wages fringe benefits and payroll taxes. So there's a direct care costs then indirect costs which it describes as all other operating costs and property and related costs at the top of the next page. For reimbursement in the direct care cost category must be a resident classification system that groups all residents into classes according to the similarity of their assessed condition and of their required services. The direct care component must reflect necessary nursing staff time and costs to address the residents care needs. The rates must be determined prospectively based on cost reports and it says the director must certify the rate for each facility annually by selecting a base year, setting the base year rate and adjusting the base year rate annually by inflation factors. And as we said inflation factors can differ for direct care and other costs. The payments for nursing homes for each nursing home may be changed at different intervals for direct care and other costs, but the changes must occur at least once every three years for direct care costs and once every four years for other costs, unless the secretary certifies to the legislature that it is not necessary to do so. The payment for each nursing home is the sum of its per diem allowance for each cost category subject to limitations prescribed by rule. The payment for direct care costs is the function of the number of resident days of each resident class and must be adjusted in a timely manner to reflect changes in residents assessed needs. Also payment limits the director must establish payment limits consistent with statutory reimbursement objectives to encourage the economic and efficient operation of nursing homes. The payment limits must not act as a disincentive for nursing homes to address residents assessed needs or improve residents conditions. And then finally the AHSH secretary may with 90 days notice to a nursing home reduce the number of days of nursing home service or number of nursing home beds that are Medicaid eligible in order to meet state budgetary goals. As long as they are maintaining the standards of care required by statute and by rule. So that is nursing home rate setting versus the home and community based service provider rate inflation fact. They're kind of two different systems except rate setting is involved and has experience with inflation factors in both. I was talking and nobody was hearing me. I was on mute. Okay. Thank you kitty. So the going back up to page two of four the inflation factor as it pertains to 611 reading this and then Jen based on the way that you brief this to me it doesn't sound as if we have the ability to to say may this is a definite this is this inflation factor will shall be done each year and shall be applied to rates in order that rates will go up by that inflation factor annually there's no there's no advisory to the legislature so the legislature may do something or may not do something this is a shell. This is a shell I had I had written it and read it to be something that that would be required to happen short of the legislature's ability to not withstand or to not appropriate the funds. But it was my understanding from last week that there was ambiguity there was confusion among some people about whether it was required or not. And so I think if there is confusion then it probably needs revising to make to make it clear assuming that that as it leaves here that is the committee's intent or for the I suppose for the members on the floor who are proposing the strike all amendment. Thank you. And Peter is that is that you're like okay that's the end of your question. And then chip. Yeah, thank you. So to sort of state the obvious. I'm very much struck by the level of detail under the nursing home rate setting and the more wide broad language that you find on 611. I'm just wondering how that impacts JFOs ability to prepare a fiscal note and then the other thing I'm just wondering is because we're talking about home based care, given that we're in coronavirus world and that there may be additional waves. How might we expect the population to which this applies to go up. I believe the first questions for Nolan. So Nolan Langwell the joint fiscal office. Well, one of the things that I said in my fiscal note was that we couldn't determine at this time what the rate might look like, because the division of rate setting hasn't yet been told to come up with a formula for calculating the inflation factor. That's what they're doing in this rule law, which is why I said every 1% equals 900,000, but I couldn't tell you what the increase will be. I think the bigger question here is whether this is a shall or a may and because that was the question that had come up and and as it's as it was written. I'd interpreted as a shall and then also based heavily on the fact that human services it was clearly their intent. So, so I interpret this as this that's the intent of this, and therefore it is a shall increase the rates. So I think that's where the question comes in. Representative Yacobo and raise the very important point last week and I think that's why we're here again. Thank you Nolan Kimberly give a follow up for Nolan. Do we expect in that they're maybe this is for commissioner would we expect a large growth in this population given the world we're in right now. I mean there might be more people who are at home with kin care or other arrangements or is that simply always the case and we know that our demographics are such this is going to be growing population anyhow. I want to go up for the record. Representative Jess if I think you're absolutely right the demographics indicate that this is a growing population. And this is the home and community based portion of that population, and we continue to work really hard to make sure that people can receive their services at home and communities so I would anticipate growth. But even if we weren't working on that. Again, the population of the demographics indicate that it will increase. Thank you commissioner Kimberly follow up. Let's see chip and then Mary. Sorry about that. So Kimberly sort of pointed out, or did point out what one of the things I was going to notice too which is that it is telling that the, you know that there's on the nursing home rate setting side there's a fair bit of detail and and on the other side the comparable thing is in the input in setting the inflation factor. And that just points out to me something that I'm hoping Dave will speak to later but he brought up a great great point I thought earlier which is that that what's missing from this is sort of the objective the part that's on the top part of the nursing home setting side that it's not clear from this what the what the objective of raising the rate is specifically and I think that would be an important thing for the committee of jurisdiction to consider and to put in there as as intent language. So, I guess that's really what I wanted to say, other than ask are we, did you want kitty to have a discussion now about the, about our position on whether or not this should be sort of a do it or don't do it kind of thing or do you want to have a discussion a little later about. I think that the questions need to go out to Monica and Nolan and to Jen so that we don't keep them through our committee through our committee discussion, however, if your discussion is going to lead to a question that you know if it's better to get it answered by the group that's here now, instead of Dave doing the follow up after. Okay, it just depends if we need more input from from the three that are joining us. Are you finished chip. Thank you, Mary. So, so I think we have clarification that at least the intention of the language was to make the rate, the setting of the rate obligatory that Jen said that it was her intention for it to say this shall happen not that it may happen. So, Dave's comment this morning was very very interesting and on point in that the a question I think this is to what chip was raising. What are we inflating is what we're inflating the right dollar amount and I don't know if that budget has been looked at and we even know that we're raising the right amount of money to provide the system of care that we need to be providing to this population which is to Kimberly's point about its growth and what what the changing environment is. So, I guess I haven't asked a question yet and I'm just making observations and the last observation that I'd like to make is, I think a significant difference between the nursing home world and this is in the nursing home rate statute that last piece that says that there is an ability to adjust what the reimbursement is based on what the budget is. That sounds to me like a directive to AHS that they may adjust the nursing home reimbursement with a lot of provisions provides us that is not mirrored on the other side, which says to me, you can't adjust this you have to make a payment, regardless of of of whatever the other factors are. Maybe I'm interpreting that implying an intention that may not exist, but it's just interesting. It's so clearly stated on the one side and is so silent on the other. So maybe I do finally have a question, is that significant, Jen, do you think. All right. I don't think it's significant because it was not. I did not draft this nor did the committee, the policy committee look at aligning the nursing home rate setting structure with this inflation factor. So you had asked for a side by side comparison and so I've given you one but it's not that I don't think it's fair to read the lack of similar language and the inflation factor as a conscious intent to do something differently than what is done in the rate setting chapter. I mean, it's not apples and apples, apples and oranges, will at a later date, somebody say, Hmm, apples and apples mean, how do you project that, I mean, I, you know, to this. As the legislature, you always have some degree of control over what happens and what doesn't happen because you do or do not appropriate the funds to carry out what's required in statute. I think there are a lot of things that are required that don't actually happen either because they get not withstood or because insufficient funds are appropriated for that purpose. You know, so whether I mean it's sort of an, it seems like it could be an artificial construct in the rate setting statute to reduce the number of Medicaid eligible beds with 90 days notice in order to accomplish budgetary goals I mean I'm not sure that that is. You may still have the same number of people in those beds but you're not counting as many I'm not sure how that works from a practical standpoint, but I think you know sometimes what ends up happening as a way of backing into a result and I think that may happen in either case. I would just point out that section six of the act has a home and community based service provider rate study and a report coming back specifically looking at the reimbursement rates. They're adequacy and the methodologies underlying them to try to get I think at a lot of what you're bringing up which is, how do we know if these are the right thing if you brought up, how do we know if these are the right rates. I think depending on who you'd ask you get a different answer to that but this has diva and Dale doing that rate study and coming back to this committee and the policy committees with the with the results. If you didn't have the statute and the proposal in front of me would would you remind me when the report is due back. Yes, the report is due by April 15. It was originally I think going to be January 15 but because of pressures from the COVID-19 response there was a request made to the policy committee and that date in this amendment would be pushed out a few three months. Okay, thank you. Thank you. A statement and then a question. I guess to representative Jess up question about increased services that might result. In my mind. I don't imagine unless you can pay people adequately that you'll be seeing more services in the home and community based setting. Unless you provide an inflation increase, you're not going to be able to help pay people adequately. So, Commissioner, a couple of questions if I may, and Jen's comment about section six is very helpful. I don't know if your licensing and protection rules for nursing homes speak to the requirement that nursing homes quote, 18 and maintain and quote highest level of functionings for residents. Is that a federal and state requirement. See it nursing homes specifically are regulated primarily by CMS. So yes, there are standards of care set out in CMS and that's what survey and certification surveys nursing homes on. So the nursing home reimbursement guidelines speak instead to reasonable and adequate and economic conditions. Does that in your mind include maintaining and entertaining. Or is that something separate. I'm sorry representative I'm not sure that I'm understanding the question. The nursing home law that speaks to what the rates are trying to accomplish reasonable rates that are sufficient to meet economic conditions. Correct. Does that to you also include requiring homes to attain and maintain the highest level of functioning of residents. Would that be considered a condition of reimbursement or not. I mean I, it's, it's an interesting question we require them to maintain that highest level of care, I guess regardless of the rate. You know it's not as if we would link a rate to. It's not as if we would say well if we don't give you a rate increase we totally recognize that your standards are going to slip I think that we continue to require them to maintain the highest level of care. This is not necessarily exactly how that legislation is written, but I can't see any scenario where we would allow for a less of a quality standard, if we couldn't adequately meet their rate requirements. And today answering your question at all. Yeah, I'm probably not very clear to so today on the community based side of the ledger so to speak. There is no similar provision, correct. There is no in very simple language, I have always assumed and operated my budgets over the last five years with the assumption that there had to be a rate increase increase for nursing homes there is nothing similar to home and community based. I will say and I know that we've talked about this is a as a as a group before and I believe I've testified to it, and I believe you even spoken to rate setting about this. There are multiple levers in that rate setting strategy for nursing homes, where they are impacted negatively by less than 90% occupancy and numerous other factors, where that rate increase doesn't necessarily. As as great as it sounds initially so even from a nursing home industry point of view I would say that it's not entirely true that that's always as helpful as it might be perceived or be seen on paper. And Commissioner does the administration support the language that requires the annual inflation increase. I will say and I testified in the same way to house human services that certainly I support this bill. I have been confused by that language and wondering what it actually meant. I don't think that the administration, even prior to this crisis was comfortable with an automatic rate increase, and I testified to that early on in the session. And I continue to be a little bit muddy in terms of what the language requires or doesn't it's that shall may conversation that you are having now but at the early in the session to beginning. The administration, I think had been clear that an automatic rate increase was not something that could be supported. So even if that were made more clear, you would not support it. I could not support that at this time. Thank you if and I'm almost done Madam chair, thank you. Could you support it if there were similar language way at the bottom of the handout, whereby the secretary could manage the number of the quantity of services purchased. In this section on the nursing homes. I don't know if it's ever been invoked, but it says that the agency of human services upon 90 days notice could say, you know we normally buy 600,000 patient days a year. I envision because of this inflation factor, we're only going to buy 575,000 patient days this year is managed accordingly. If there was language, I'm not advocating I'm just asking if there was some type of budgetary limitation in the right hand block that's currently empty along the same lines. Would you then support it. Well, I would, I would argue, um, candidly and reflect back on what Jen said earlier I don't know that that's really a realistic mechanism, could we really just say no we don't really want you to have three visits from home health we're going to pay for two. I don't know that that's how the program has been designed up till now and I'm not sure that that's a realistic mechanism. I think that it, you know, I think it has to be linked to what's available in the budget and the danger of a bill like this is that you're looking into budgets into the future. I have never had the luxury of being able to plan quite honestly far into the future you're almost always living within the budget that you're working with at the time. Do you currently put limits on sections of the choices for care program and set caps and say we're only going to serve a certain number of people. The only program that has that and again I apologize I wasn't necessarily prepared to answer a lot of questions so I don't have all that information in front of me. But the only program that is kept in finite in that way is the moderate needs group. And then of course we have the option of waiting lists in high needs and highest needs. In the history in this department, we haven't had to implement that waiting list, but I don't believe it's kept within services because those services are built on individual need and individual plans. I think what we would end up doing is is activating a high or highest need waiting lists so people that met higher highest need would in fact be waiting for services, if we had inadequate funding for the program. So today, you do on the moderate needs group set a limit. Moderate needs is a is a finite pool of dollars and so we have to match those dollars to manage for that. Correct. Okay, thank you. Sure. Do I have any other questions for Nolan or Jen or Monica thank you Monica we really didn't prepare you for that but thank you for your answers. Okay, so if we open it up now to committee discussion. The three guests if you want to stay you're more than welcome. I just didn't I just didn't want to monopolize your time if you needed to be off for other work. I'm going to mute myself so I don't have to hold on to this space bar. I, what is the committee thinking about a direction forward with this bill. Dave, your hand is that for us a new hand. No, I put a new hand. There we go. I guess you'd like us to speak I guess to whether to keep section five is that the. Well I think I think what there's a lot of policy in here that I think that the committee can have their arms around it appears that the piece that that the committee is going to struggle with is in section five. So I'm going to move on to the next slide here. Whether we wanted to indicate for sure it's an increase, not automatic inflator, whether we want it to be informational that what one would look like and what would be, you know, what would it would be encompassed in it, and then deliver it back as an informational purpose or to remove it all together. So I think those are. The following legislative council, it's mandatory mandatory to get an increase and that was, I believe, joint Fiscal's interpretation also, and it was written as such, and the committee believed it to be as such the administration said it was a little murky. I don't know. I don't know if it's our place to make it less, less unclear or not. It's our place to make it very clear with the position we're going to take so if we want an automatic inflator we've got to make sure that the language has no questions to it. Okay. Okay, and I think Jen you made it you made it clear that it's it was the intent of the committee that the inflator would be put into place into action. To my understanding I certainly can't speak to legislative intent but it was my understanding that the request had been for language that would create effectively an automatic inflation factor. So, to the extent that there is not that there is more than one read to the language I think it would be important at some point to address that. Thank you, John. Dave you have the floor. Well, I guess I believe in the concept of helping people in need. And I, and I as I'm sure the committee does. But if you go to the core of what governments all about it ought to be to help people cannot help themselves. And when you're talking about a population of people who need assistance with feeding with bathing with toileting with moving from bed to chair with ambulating. I can't think of a much more vulnerable population except for abused children and they should receive the same kind of help. So it goes to my personal beliefs are that if government can't help folks who are so disabled, what, what can it do. And you can't do that in my mind unless you pay caregivers sufficiently. So I, and an inflation guarantee is part of that adequate rates is another that's a different issue left in section six. So if we believe, you know, that we should help these very vulnerable for monsters. To me it rises up to, if not the highest priority certainly certainly one of one of many. And I would look myself I would work hard to make reductions elsewhere in order to accommodate it without it. It just pays lip service. People say the vulnerable are a top priority, but there's never an increase to increase their wages. It's always up to the, to the legislature to do it. That doesn't set well with me and it doesn't set well to helping those that are in the greatest need. I respect and understand totally that I may be in a minority and no ill will it's just the way I feel. I already take so long to explain that. Never too much time to secure a position to help vulnerable for Monter's Dave so thank you. I have Chip. Bob Kimberly. Sorry now I put my hand up right after Dave's because I'm going to try to argue the other way after he's been so eloquent about why this is important. But I did want to have observations first one. I forgot to say when I was speaking before just just to thank Jen for this really good work as she always does but it's just so clear and concise. It was helpful and easy to read through it. I wanted to sort of recognize that, you know, much of much of what's in here on the nursing home side has to do with the actual setting of the rates how those are set and the committee. The Human Services Committee said they chose a different path. You know they were going to have rulemaking and allow people who are knowledgeable in this area do that work and I respect that direction. I do still think that if and when, you know, I said our inflation rate is added that today's earlier point that having something in there about the objectives about what it is you're trying you're intending to do with these rates, and what the inflation factor should do would need to play a role but all that said, you know, an eloquent argument about why we should think about doing this and and then normal for lack of a better word circumstances. I'd be, you know, I'd be paying and I'd be thinking seriously about whether we could do it or not. I just can't imagine though at this moment, given how up in the air that our, our budget is for the future what, what we're going to be able to do across state government that it would make sense to put into the law. It's a mandatory and I think it, I think, and Jen has made it clear as I read the legislation that that that this would create create the inflation rate and it would be how you would determine it would be applied to the reimbursement so I, I just don't think it. Right at this moment it, I could. We're going to increase spending state government spending by an inflation factor and from here forward, given that we just don't know what we don't know exactly what that would mean in terms of the fiscal impact and that we don't know what our budgets are going to look like over the next two years, but alone. Just, you know, the next six months or 12 months so I just, there's not a, you know, my argument against trying to move forward with it, adding an inflation rate right now is really about not being able to predict. So I think you're frozen do my back. You're back now. Okay. Anyway, I was beginning to ramble so I'll stop I just don't think I can't. I can't imagine that we could do this right now I wouldn't be able to justify saying yes at this very moment, adding inflation factors that's going to go into effect. That is something I could agree to. We have Diane Bob. Thank you madam chair and others. So I'll just I'll just add my, my voice to the discussion at this at this point. And plus I've heard back and forth that members from human services are listening in and texting so I'm trying to interpret some of what their input and bring it out well. But, but for me I just I also just want to make clear that this bill comes to us with the full that in discussion of 11 members of the human services committee which is bipartisan strongly supported position. And so I didn't come to us from some sort of weak position or, or others that didn't understand what they were bringing forward. And so I just just wanted to bring that to our point that that they have vetted this for not just this year, but as you've seen me at the whiteboard for many years now every year, needing to have to come forward with these ways to increase this and often we're not going to be there and many times when groups come forward to what I would consider to be the fair inflationary piece. They're met with Oh, why are they asking every year for something they are. They, we're, we're not making it in easier for them. So number one is that this comes with their full support with what they're bringing on shell. Number one is that I'm going to look at my notes here that Teresa had said that the waiver, which I'm assuming is the waiver the 1115 does not allow for nursing facilities to be capped as we as as indicated here at that last section. So it would would not even be enforceable. But where I personally stand on this. I think it's important to place is doing what's right is one thing, and then figuring out whether or not we can afford to do what's right is another question for whatever day, but from where I come from pretending or acting as if not having the knowledge of what is is sort of a backdoor of not doing what's right and it goes to a lot of things beyond inflationary here there we we struggle with it in many other areas of the budget as well. And we, more than anybody else understand the pain of the property tax transfer and the, the notwithstanding and the issues that that has been, but we're perfectly capable of notwithstanding if we can't afford something. I believe that this would at least give us the information of what would as this side by side indicates a very small piece, and it goes to Dave's well said, and later on top of an inadequate rate is not really going to be helping sustain the system. And this goes back to that last bucket system reform. If we want to stabilize systems, we need to recognize where the problems are. So, with that I'll end Madam chair, thanks. Thanks, Diane. I have Kimberly, Bob, made up and back to Dave and I'd like to in at some point, but I'll wait to hear. Yeah. So, I share the goal of keeping people at home and I think the system reform in the long run you come out ahead. The piece that I'm trying to understand in tags with what Diane just said is about, and what Dave said earlier about raising putting a generator on an inadequate wage and the question I have is, I know in the past before I was sitting here on this committee that you all added, or you raised the designated agency rates. And, and I'm just curious whether that ended up leading to less vacancies, or does this sort of, and again I'm not trying to get down to tangent but does this get us into the workforce issue like even if we had rates that were higher levels, we have a nursing shortage that we would still have these vacancies. And, and I don't think we exactly know the answers to that question so I think where that leaves us is do we go forward with the best information we have now based on the needs that we're aware of. That's to me, it seems like what the question before us is. Thank you Kimberly. Bob wasn't before me. Oh, I might my hands Bob made of Marty, Mary, and I'll start back with people who have already been Bob. I won't be again, but I just want to say, I know a representative who was asked for an inflator for years. And he never got it. And he never got it, because nobody wanted to step forward enough and put a dollar sign that's inflatable annually in front of another legislate slater. And so it never happened. And consequently, the ones that I wanted the inflator for are now barely in business. And I do mean barely. I think I don't need to go too much further on that. So I understand the use for an inflator and David I'm not going to say that this is the particularly good time for it. I think it's a very bad time for it. But I understand under certain certain circumstances. There's a need for an inflator. I'm not going to say if my cause had been given an inflator it would be any better due to this last virus infection thing that brought it into a whole different world but other than for that, it would have helped a great deal. But, and so anyways, I guess I'm supporting you Dave, but I'm not sure this is the time to do it, but I'll listen as we carry on if we're all back together again. Thanks. I made a thank you Bob. So, I don't disagree with a word that Dave said, or a word that Diane said, I agree wholeheartedly. And I support this bill on really troubled though, with regard to what to me are unknowns in that section five. As to so how much money would this be. How much money moving forward in a timeframe. When we don't know that we have enough to support to support ongoing programs. And I guess I have a question as to if we say. Yes, and my God my heart wants to say yes, but if we say yes. How do we say no, when something else which it will I am sure when something else that we care equally about that's new comes forward, and how do we say no. I don't know if my concerns are clear or not, but that's just what I'm going to say for now. I just don't feel comfortable at all with regard to saying this shall be at this point in time and with regard to the inflation of inflation later. Is there a way we can do everything else without making the inflator mandatory in this timeframe. Thank you. Thank you made a question is obviously yes we either the rest of the policy could move forward and there's certain things that our committee could agree to with the budget to prepare it, the information for the future if if we choose to or not to implement now. I just I don't want to leave the conversation I just I was answering your question. And Mary circle back around with Dave and Diane and I did want to jump in. My concerns are that we, I just don't feel that an automatic increase in any area of the budget is the right way to go because I think we need to. We all always talk about going back and looking at the whole budget the whole factors that are out there and determining what priorities are, and I know certain topics come up where we get enthused about them and and we are putting a lot of extra money in some areas, such as when we went into child protection with the DCF issues and we put in any extra into middle health at one point because we felt that was necessary or into childcare. And those are not things that happen every year. And that's kind of one topic that seems to come up every year and we put in in flux in there and hope to set it off on good stead for 456 years and then we may have to make adjustments later on. But I don't think the automatic increases make sense in that regard I would rather look at it in context of everything else that's in the budget that particular year. And not withstand is, I don't think a good fallback position sure we can use it, then I think that just leads into that much longer report on unfunded budget pressures that we see every year. And I don't think that makes us very good that we've obligated these funds and yet we don't fund them, I would rather say we intentionally decide where when we do need to. The other thing that I'm concerned about in this particular bills that I don't think they're very good parameters as to what factors should be considered in developing the rates and then therefore developing the inflation rate as well. So I would, I would not want to see section number five at all. And have us simply look at the needs as they come along and try to balance them with everything else that's in the picture that particular year or look ahead to three years in any particular topic area. Okay, so for Mary Peter Diane and Dave we're going to have to come back to the conversation is in four minutes we do have transportation here, and I do see Kurt McCormick and so I want to keep us on schedule. I do have the unfortunate privilege to have to sometimes look at things more holistically and I just want to, I'm not driving the conversation or any determination in any way that I want to remind the committee that when we look at things with the COVID-19 money and we look at a very difficult bill like the older Vermonters Act and we have more bills coming in. We have to ask ourselves some questions to help guide us and one is, you know, is it ongoing money or is it one time money. And after we do that what money is available. And then after that, if there's money that that is available what are our priorities and I think it's been stated very clear here that this vulnerable Vermonters is a high priority. If money is not available, which is the circumstance we're in now we're right now we're between a 200 and a 230 million dollar gap. And first, if we were to agree to move forward with this inflator, we would need to know what we are not going to do. So once we figure out what we're not going to do then I want to move to the next step which is, we have asked the administration and asking ourselves that in the quarter in the first phase bill, our transition bill, that we do not make major reductions to programs at this time until August, because in August we'll have a consensus forecast. So between now and August, I have to ask the committee, do we put for a major bill. How do we I'm not saying do we how do we put forth a major bill without any money to pay for it. This is money but in order to do that we need to make reductions on top of about $200 million, but those may not all be reductions by the time is we have no idea what's going to see our F money and other dollars, but we have to make some major connections and system changes, but at this point right now, what would we reduce. Are we in a position right now to make a reduction because our committee generally does in my time on the committee for the last 10 years has not gone out of balance. We just have to that path forward is what I want us to think about. I do not believe, I know CRF dollars are never going to cover this because it's an ongoing expense and it won't go away on December 31. So it's ongoing dollars that we need to be very clear about, and I don't mean to be the skunk at the long party. I just want to make sure that when we make decisions on this bill justice reinvestment, and whatever other bills are coming in the way that we always keep the whole picture in focus because that's our job is the whole picture the whole budget. Sorry about that I feel, I feel, I feel like the wicked stepmother is what I feel like that I have a child in need and I'm saying sorry I just don't have enough to go around. That's the answer. What else. What do I need to do differently in that household to make something important happen, and until I can figure it out. It's difficult to make a change. I want to give us with that because it's at two o'clock and I want to transition now into trans.