 Very good. Okay. Hi. I just wanted to give you a couple of updates. We just sent out feedback forms. We had a little confusion, but we're looking for your feedback on the first five lectures. So the second email that went out, if the first one was confusing, that should really make sense. Please send those back. We're now working on programs for next semester. So we really appreciate your feedback. We have a special event to tell you. Now on the 28th of October, Alice Boone from the Fleming Museum is going to give us a lecture. And then the, not the next day, but the following Saturday, which would be November 5th, she is going to give us a private tour at the Fleming of the very same prints that she's going to talk about. And I'm sure the whole exhibits 1230. And the reason we're doing on a Saturday is the parking during the week is abysmal. So on Saturday, you should not have a problem. We're going to send out an email with where the best place to park is and so on. So that email will be coming out in the next few days. So that's November 5th, Saturday at 1230. So that's a save the day for you. We're also working on trying to organize an evening to go seashell the heart. What do they call winter lights at the Shelburne Museum. That email just came out. So we'll send out some information on that too. Please turn off your cell phones. I do want to tell you a little bit about Bill. I think most of you know who he is. Bill Schubart. He was born in New York City. Just a couple of years after I was born. And also, you know, we're of a certain age. At the age of two, he moved to Morrisville, Vermont, where I think you still live. Is that right? I mean, Heinsberg. You're in Heinsberg now. I go back to Morrisville. Okay, okay. After graduating from college, he taught French until he entered the field of communications as an entrepreneur. And he co-founded Filo Records and in 1982 resolution. An e-commerce services company. Currently, he writes extensively on the media book publishing civic issues and healthcare. And he's a commentator on BPR. He was former chair of the Fletcher Allen Healthcare, which we all remember the name, and writes about healthcare and his common VT digger. He lives in Heinsberg. He says that right here with his wife, Catherine, a journalist. Today, he will join us for a discussion about the challenges facing Vermont's healthcare system and how it's impacting access, cost, and quality for Vermonters. He will help us to make sense of one of Vermont's most complex systems. Please welcome Bill Schubert. Well, it's really a pleasure to be here today with you all. I see a lot of familiar eyebrows out there. So it's just good to be here. And I'm going to try and pack a lot of information into a short period of time, because I think the best value is, you know, when you have questions and observations and challenges and we actually have a chance to interact with one another. So I'm going to try and keep my comments to about 40 minutes to give us plenty of time toward the end for questions. And it's challenging because healthcare really is a complex system. When I was a kid growing up in Morrisville, there were three doctors in town. Their fees were dependent on how much money they knew you had or didn't have. They did house calls. And they were. Yes, I'm sorry. Is that a little better. Okay, sorry, thank you. And I remember once every Saturday morning, we would all the neighborhood kids would go out and play and if we couldn't get someone in the summer to take us up to Lake Elmore to swim or to take us up to Mansfield to ski. And my father was a ski instructor, so I didn't even know you had to pay to ski until I was like 17. We couldn't get anyone in the winter we'd go out to Mr. Farr's pasture, which used to be a gravel pit and had a very steep hill, and we'd ski. So we, we decided that that's what we would do because we couldn't get anyone to take us to the mountain so we went out and I, we had made a little jump and I went over it and I fell. I realized I'd hurt my arm more than I thought I had. And mama was used to say, if any of you get hurt, just come home and if I'm not here check with Mrs. Guthman if she's not home check with Mrs. Collette. So I came home and mama wasn't there. And the hospital the old Copley hospital would frame hospital was just down the street from us on Washington highway. Well, maybe Dr. Phil's down there I'll walk down there so I walked down there. And he saw me right away. And he said, well, let's take an x-ray. And we did and he said, you have a broken arm he said but it's not serious he said it's just a, it's, you know, it's cracked and he said, I'm going to set it and we're going to put some plaster on it and send you home. Okay. And I think I was probably 11. And so he said, now this is going to hurt, hang on. And he grabbed my arm and he yanked it out. And then it went like this, and it did hurt. And he said, okay, come on downstairs and I went downstairs and they plastered me up, gave me a sling. And I said, don't move this now. And then I walked home. And dad came home at five o'clock and he said, where's mom and I said, I don't know. And he said, what, why are you wearing a cast. And I said, well, I think I broke my arm. What, so I told him the story. And it wasn't that big a deal. You know, I had access, I was well cared for. You know, the bill probably would have been 35 bucks, which was a lot of money in those days. And that's how it was. It's not that way today. It's much more complicated. Now, I'm going to ask you. While I'm talking at you, I'm going to ask you to think about some questions in your own life and I'll just, I'll just ask you. Well, have your interactions with our current healthcare system been positive or negative? Second, do you have a primary care doctor? Third, do you have a chronic condition that requires ongoing care and medication is the cost appropriate to your budget? How do you decide whether to go to a primary care doc or to the emergency room if you need help? Next, is your healthcare insurance affordable to you? Do you understand its provisions? Have you ever been surprised by unexpected billing? And finally, for better or for worse, 130 countries around the world have national healthcare systems. Their overall costs are considerably lower than ours. And their outcomes are better than our private system. The US ranks 28 in the world for healthcare outcomes. Do you think it's time for a national healthcare system? I'm not advocating. I'm going to ask you that question when I'm done. So these are things to think about while I'm talking. Unlike when I was a kid, as I said, we have a massively complex healthcare system. It is, it's a more large, it's much larger, much, much more complex. And it's harder to access and harder to afford for many people. And I'll talk more about that. Some specific examples. And these are not, these are not just low income people. I know people of middle income. I have family members who make what we would consider a reasonable annual income who can't afford insurance. The other thing that makes the system immensely complex is it has its own language. And this creates immense difficulties, both on the regulatory side and on the policy setting side. And there are words that are standard in the healthcare system that nobody knows what they mean. Like how many of you ever heard of the term up coding? Up coding is one of the terms that adds the greatest expense in healthcare that there is. And any procedure that is done in the system has to be coded to elective. You know, reasonably important, very important or life threatening. There's a tendency to code everything as life threatening, because you get much more money from the insurance company. If you do that, I had a personal example of that. I had a doctor in the system who diagnosed me with carpal tunnel syndrome on both sides. And his nurse said to me, okay, we're going to schedule seven doctors appointments, including the surgeries. And we'll get all this stuff on your calendar because sometimes it's hard to access the system. And so I listened to all this. And finally, I said, well, with all due respect, we're going to schedule three appointments. One is going to be the surgery itself. She said, no, no, no, we never do both hands on the same day. And I said, it's a 15 minute operation. And I have to stay two hours afterwards. We're going to do it on the same day. So she got frustrated and walked out. The doctor came in, Mr. Know it all. And I said, no, it's not a matter of know it all. I said, I'm just a patient. But I do have some voice in this. I said, this is a 15 minute operation. You're going to do them at the both both. Same time. And he said, well, I hope your wife loves you. And I said, why is that. And he said, and I won't use the language. He said, who's going to handle your hygiene. And I said, well, we have a garden hose. I'll figure it out. So he was angry, but he did what I said. So Kate brought me into the hospital. I went in, you know, I talked to the anesthesiologist and I said, I want the minimum. I just want to local because a it's not that big a deal. And two, I want to be able to leave and frankly at our age, the less deep anesthesia we have the better. I said, well, okay. You know, and had that and two hours later, Kate and I left the hospital. And then I get a call from the doctor's office three days later saying, well, you had an appointment tomorrow, you have to come in and I said, what was this one for and she said removing the stitches. And I said, Oh, I already did that. So, so then I knew what was coming. So I said, I want to see what you invoice my health care plan for. Why do you want to see that? I said, I want to see what you send them for an invoice. So it gets sent to me. And I look at it, and it's coded for, which is survival oriented. This is a 15 minute operation with a little tool that you get from 3M, you open it up, you cut something, you cut another part of it and you pull it back together. That's it. And you sew it up. So I sent an email to the doctor and I said, you've up coded this to a four, you've built $9,000. I want this down coded to elective surgery, or I'm going to write an article and digger using your name about what you've done. And, you know, then I get a copy and it's been properly coded and sent back in bill was $2,800. So I tell you that story only to give you a sense of one of the contributing reasons why health care is so expensive. That's one. Another one is how many of you ever heard of denial management? Denial management. Denial management takes a team of pretty bright people in the health care system that if you go in and have open heart surgery, and they build SIGNA $128,000. SIGNA comes back and says, well, we'll pay 78. And it's it's handled like an auction. And it goes back and forth and back and forth and back and forth. And then they finally settle on maybe 88, you know, or some number. But rather than having a fixed, you know, global cost system for what procedures cost, they have this denial management system. The people who work in denial management make a lot of money. They don't contribute to population health. They contribute to population wealth. And that's another example. And I've, you know, talked with the legislators and I talk about up coding or I talk about denial management. What's that? And understandably, I mean, it's like I'm speaking Greek. And it's it's an interesting defensive strategy in the health care system to have your own language, especially when you're talking to regulators. The, I want to say a little bit about regulation. And I have, I have immense respect for the legislative branch, the executive branch and the judicial branch. And I also have a good sense of how unbelievably challenging their work is when you and I were all young. I know some of you are younger, but I mean, you know, back in the early 1800s. No, 19, no. When we were all much younger, the work of the legislature and these branches was pretty straightforward. Are we going to sell booze on Sunday? You know, are we going to have daylight savings time? You know, I mean, these were all pretty, they may have been difficult issues, but they weren't complex. But the issues that are legislators and executive and judicial branches face nowadays are amazingly complex environmental issues, public education and funding. Criminal justice system access to health care homelessness. None of these are simple problems. And in order to create policy, whether it's in the leadership position like the executive branch, you have to understand enough about it to say, here's what I think we should do. And that's really not easy, because there are so many ways of looking at it. And then, you know, I've talked to legislators who say, you know, we throw up our hands on health care. Because, you know, somebody comes in from the health network and they lay it all out, we go, oh yeah, that makes sense. And then someone else comes in and says something totally different and they say, oh, yeah, I can see that point. You know, so it is so difficult. That's all that I think is important to understand the issues that we face the challenges strategically are not simple anymore. And I have a lot of sympathy for legislators I know how hard they work. And I know how hard they try to, you know, understand and resolve problems. But these are not simple problems. The Green Mountain care board. I was very, very close with con Hogan, who was the first chair of the Green Mountain care board. And, frankly, right now I have no idea where it's going. And the governor doesn't have any idea. I don't think I mean last time I talked to him. He said, is the Green Mountain care boards job to sustain the finances of Vermont's 14 nonprofit hospitals, or to redesign a cost efficient system that provides access for population health. Because if so we probably don't need 14 hospitals, we probably need eight or nine. What we need is rural clinics. We need federally qualified health centers. You know, we need small practices. I was appalled when Shelburne wouldn't grant a zoning permit to their, their little I mean these were what we used to call barefoot doctors, people who were passionate about providing health care. I'm sorry, Charlotte, I apologize, Charlotte, and they wanted this used building, you know, in the middle of town, and they were going to fix it up and without going into a lot of detail. They got a no so they moved to Williston or Richmond. I can't remember. Right. They did. Okay, that's really helpful Martha thank you they got a permit but the end result is they made a decision to move out of town. Right, right. So, you know, it's, it's, it's a real challenge, challenge understanding what is the goal. Now, I want to talk about this through a couple of lenses and just bear with me. Is healthcare a mission driven operation or a business in Vermont to get a certificate of need to run a hospital you have to be a nonprofit. But are they then regulated as a nonprofit, because UVM health network now has expanded controls six hospitals through in Vermont three in New York. It's a 1.8 billion dollar enterprise, and they have scooped up home hospice residential facilities. Just primary care, they're moving now into mental health, which is long overdue. And, you know, is that, is it still mission driven, or is it business driven. And that's a question. I'm not here to, to you know render harsh judgments. One of the things that has plagued, you know, my sense of this whole what is population health is the guild mentality of health professionals. Dentists have managed to convince Americans and regulators that they are not part of the healthcare system. They have their own organization. They operate separately. They are not regulated in the same way that a doctor is. But everyone in this room knows that periodontal disease contributes to heart disease. That's a physiological connection. The health center, which I'll talk more about in plain field, which is a model of rural health care delivery, infinitely less expensive and very, very cost efficient and works with the Berlin hospital has eight dental chairs. And it has its own dental lab, right there, because they understand that dental care and physical care are the same. The same is true of mental health. We pay a lot of attention to the parody of physiological health and mental health. But when I was chair of Fletcher Allen, I would meet a couple of times a year with 400 plus docs. And I would mention the issue of parody with mental health and physical health. And the reaction I got was lighter than this was black hole. We don't know what to do there. We can't handle this, you know, and besides, it's a whole different discipline. Well, what science is learning now. It's not a different discipline, anxiety, stress, depression, all of the mental challenges that that are experienced result in inflammation. A friend of mine, the benchmark for testing inflammation, which is the genesis of a lot of chronic disease. The benchmark is called, I think it's called a blood serum sedimentation test where the blood is put in a vial and if the red corpuscles tend to settle to the bottom that indicates a very high level of inflammation. There's a really clear, you know, scientific link between mental well being and physical well being. We can no longer pretend that they're different disciplines and require different hospitals and different protocols. They're one in the same. They need to understand and this is still a problem. Dental, mental and physiological health are all parts of population health, and they need to be understood as an integrated treatment protocol. I want to say a few words about. I want to say one thing. I mean, after I wrote my I have five columns on my website that I've written for Vermont digger on healthcare and it's a shoe bar dot com if you are curious. And I wrote that UVM crossed a real ethical boundary UVM health network, when they started up their own insurance company, UVM health, UVM Medicare Advantage, and they partnered it with MVP, and they own it. And Dr. Bremstead, who used to be on my board when I was chair of Fletcher Allen, called me in and he said, Can we talk and I said of course. So it came in we talked for two hours and 45 minutes. And he said, Well, why do you think that was an, you know, an ethical concern. And I said, John, with all due respect, you have moved from being a provider to a payer. And he said, Well, give me an example of the ethical challenge. Okay, I come in. And I finally get an appointment and I'm diagnosed with late stage prosthetic cancer, and I'm going to come back to that. I don't have it, but I will come back to that issue. So I go to your wholly owned insurance company and I say, Well, I've looked at my coverage plan I don't fully understand it. You know, this is what the hospital recommends this is, you know what it's going to cost how much do you cover. Oh, well we cover this and this and this but we don't cover that. And so I'm now in this conundrum. Okay, the same entity is saying it's going to cost this much to fix me. And the same wholly owned entity is saying, Well, we can cover some of that but not all this. I now have a decision what is the best thing for me to do for myself and for my family. And increasingly I'm here. I'm hearing people say, Just let it be just let nature take its course. I can't afford that. I have a friend who I think many of you probably know who has made that decision. And I'll elaborate on that a little bit I have five friends who have been diagnosed with late stage prosthetic cancer they're all obviously male friends. And the amount of time that elapsed this is about access, the amount of time that elapsed between they presented in the emergency room, or to a primary care doc with low back pain. And the time that they were finally diagnosed with cancer was eight to 13 months across the 15 of them. And the story of one of them was well low back pain will get you into the spine clinic but the spine clinic is you know they're really heavily booked and you know they can get you in in about seven weeks. Go in there $10,000 worth of imaging your spine looks okay, we'll send you the pain clinic. So you go to the pain clinic, two or three more weeks. They give you the steroid shot that they give everybody makes no difference at all. Well, you go back to the emergency room. Well, you can't come in here except through your primary care doc. My primary care doc can't see me for three months. Well, so you finally get an appointment the primary care doc does a PSA, which shows to be elevated and they say what we need to do a biopsy, but that's minor surgery. That's really hard to schedule we can try and get you in the next four or five weeks. Biopsy, we're really sorry you have late stage prosthetic cancer. Now what is the liability there. And this is not, this is not a liability or a tort liability against a medical provider. It's against the institution, because there's no access the access is not timely. And I asked our the chief legal officer who was then chief legal officer of the hospital when I chaired the hospital I said, what is the institutional liability. What would happen if this went to court. And he said it goes to court all the time. And he said, any court is going to use what's called the standard of care. The standard of care for cancer is early diagnosis and early treatment. So if you're looking at eight to 13 months. That's a liability. So, a few words about staffing and compensation. It's very important when you think about health care to differentiate between the providers and I would say to you that if you can afford the system, and you can get access to the system. The provision of health care is terrific. The doctors and the nurses are phenomenal. Once you're in the challenge is getting in. It's, it's from a provider standpoint. It's a terrific institution. And when I say it, I'm talking about UVM health network but in general this is true of the other critical access hospitals to copies terrific. My sister's worked there for 35 years. You know, once you're into the system, it's a good system. They talk constantly and John says this all the time in the press about staffing and nurses employed nurses. They can't get enough of them. They can't get enough docs and yet learner UVM medical, UVM medical school college continues to just train 90 to 105 doctors a year, of which very few are primary care and I asked the head of the school, why aren't you producing more primary care docs because there's a horrendous shortage of primary care docs. And they said, well, we get these doctors coming in barefoot doctors passionate about taking care of people. Really, really, they want to be helping people. They come in. They look at what they've run up in tuition debt in the first or second year. And they realized the only way they're ever going to pay for it is if they become specialists. And before I became chair of Fletcher Allen, I was head of physicians comp. So I knew what every single doctor at that place made. And it was the inverse of need primary care docs back then and this is back in 2005 primary care docs then we're between 180 and 240. The mid level specialists were 300 to 500 high level specialists were 400 to 800 marquee surgeons were as high as a million five. You know, the guy whom some of you know who was doing two or three open hearts a day and billing $20 million. You know, his salary was around a million four. And this is not secret. That's, you know, this is public information. So, you know, that's the doctors come in they want to be caregivers and they realize how much money they're going to have to pay back and the only way they're going to have enough money to do that is become specialists. The thing that I struggle with is nurses, nurses are converting to travelers, you all know what travelers are. When I was chair, we had 35 travelers and it drove us all crazy, because they were so expensive, and we brought them down to almost nothing. Now, the budget this year at UVM Health Network for travelers is $150 million. That's a public figure. If you took that 150 million and increase the salary of employed nurses, you know, who could then make a decision to be employed there, and, you know, cost infinitely less. What would that be? And the nurses that I've talked to tell me all the same thing. I can't afford at anywhere from $35 to $95,000. I can't afford to be a nurse, an employed nurse at the hospital and 95 is like anesthesiology very specialized nursing. I can't afford to pay my nursing school tuition, have a home and have childcare and continue on the salary I make here. I can make three times as much if I become a traveler, even though it means I have to leave my hometown for six months every year, I have no choice if I want to be a nurse. So you have that. Then I told you roughly what the physician compensation is and I'm going to talk to you about leadership too. I negotiated Dr. Estes's salary when she came in. I became chair right after Bill Betcher, who was the CEO of the hospital was taking away and handcuffs to serve a two year sentence. It was not an easy time. I came right after Louise McCarron and Ed Kaladney, who is a friend to this day, was the person who talked me into this. Never forgiven him. Anyway, when Dr. Estes came we did a national search. She had been running three Cleveland Clinic hospitals in Florida. Her husband was a neurologist at Cleveland Clinic. And when she came in, I said, Mindy, I can only pay you $850,000. If that's not enough money, I totally understand. I can't pay you more that more than that. And she said I didn't come here for the money. And by the way, I need all your perks in that you can't say 850 plus a car plus a phone plus a wine cellar, you know, whatever. It's got to all be in there. It has to pass the free press test and I don't have to tell you what that means. And she said fine. Dr. Brumsted today makes $2.2 million and a year, and that's all in. And that's between 2005 or I can't remember the exact date and today. That's quite an escalation. The most troublesome thing and this is on the non non provider side. These people are administrators. There are 19 administrators head of communications head of this head of that who are not providers and their total salary is 16 million that averages to over $800,000 per individual. They do that against a nurse who's actually providing and nurses are not what they were when I was a kid, which is bed pans and bed making. They do as much as doctors do. You know, they are in every sense paraprofessionals. Got to keep moving here because this is so much here on the, the other impacts. It's important to understand. I end up being defensive about blue cross blue shield people come to me and they say oh they've applied to Green Mountain care board they want another raise rocker rocker rocker and say wait a second. The Green Mountain care board just extended UVM health network asked for a 30% they asked for a 10% and then a 20% increase on top of that. And they, they didn't get all 30% they got something like 22% all in. Blue cross blue shield has to pay those bills. They have to get an increase from the regulator to cover those bills for plans that are already set. So, you know, I, and I have to tell you I work both sides of the aisle I have a lot of friends inside blue cross blue shield. And, and inside the hospital. And it is not a comfortable relationship. Blue cross blue shield is constantly testifying against to the hospital to the Green Mountain care board and vice versa. There, there are a lot of other impacts. One of the biggest impacts is the pharmaceutical industry. And I'm going to be very blunt and say that I think there are a large number of pharmaceutical executives who should be in jail. Just that simple. I, I was doing a panel. And I was someone else was speaking and I got this text and I looked at it and it said, you either retract the statement you made about Purdue pharmaceuticals in Vermont Digger, or we're going to sue you out of existence. So, I sent a text back said I'm busy right now but you know I can talk at one. I get a phone number so I call it one o'clock this woman says, my name is Phoebe person such and I'm with the reputation management firm and our team handles the Sackler family. And I said, ooh, that's a shit job. Pardon my language. And, and she kind of chuckled, you know, and I said so what did I get wrong and she said well you said in your Vermont Digger piece that Richard Sackler played guilty in lieu of jail time and paid a two and a half million dollar fine. When he was when he was indicted for the miss marketing of oxy cotton. And I said well that's, I'm really careful about fact checking. That's right out of the New York Times and the Guardian. And I said what's wrong and she said, he wasn't indicted he was charged. And I said okay, that's fair and I checked and she was right. So I had it changed in the quote. But a two and a half million dollar fine for a man worth $8 billion. That's me paying a parking ticket downtown. The, I'm going to skip ahead from for a few things here, but let's talk for a second about what would an ideal system look like. And I'm going to just paint a real simple picture for you. I think that the most cost efficient system is one where you enter the system, as locally as you can, based on the acuity, which is a fancy word for the seriousness of what you're dealing with. If you have a car accident, and you're a mess, you go straight to a tertiary care emergency room. No question. If you have a non specific pain, or some other symptom. And you can go to a federally qualified health center, which they're 11 and Vermont. Bernie's a huge fan of these he's been really remarkably good at seeing to it that they're adequately funded, because they're much more cost efficient. You go in there and they run the test they first of all they can see you within half an hour, you don't have to make an appointment two and a half months later. And they say, Well, you have this we can deal with this here. And by the way, we have whatever pharma you need right here. You go to the health center and in Plainfield, which is a world model. It's a vending machine. There's a woman who sits at a computer, and they can provide pharmaceuticals at about 22% of what you will pay for them at Walgreens or kidneys. And again, if you need to go up, they have a relationship with Berlin, you go there, whatever it is, but you present at the point that is most connected to how serious you are, that is the most cost efficient way to do it. So you have individual doctors. You have small primary care. You know, doctor collaboratives like the one that was in in Charlotte. And you have federally qualified health centers like the one in in Plainfield. You have small critical access hospitals. It's it's most appropriate and I was talking to a doctor about this. In fact, he was the head of a hospital. And he said, Bill, you don't understand. He said, my business model is dependent on a steady stream of broken people presenting in my emergency room, which is my most expensive way in the hospital is to come into the emergency room. And he said, I'm dependent. Those broken people show up. I repair them. I build their insurance companies. You move that investment upstream to prevention and education. I'm out of business. I need broken people to fix them. You prevent that. I'm out of business. Now that was the head of a hospital telling me that. I'm going to just move through a whole lot of stuff and try and finish up. I think the most important thing I would like you to hear today is that whatever investments we're going to make in health care are infinitely more cost efficient. This is true in the criminal justice system. It's true in the education system. If you make those investments upfront, they will pay immense benefits downstream. It costs much more to keep somebody in jail than it does to provide trauma informed counseling when they're five or six years old. And you help them and you help their family through that. The same is true in health care. There's a film being produced, which I'm helping with called care and crisis. And it's going to be a major PBS documentary next year. And its primary thesis is going to be that we have to invest in primary care. We have to have local rural health centers. And they have to integrate trauma informed counseling. You all know what adverse childhood experiences are, one of which is having a parent in prison, but you know what they are, does anyone not know. If you can bring those forward, you know, with a child at an early age, you can then begin to take care of not only that child, but that child's family, even if it's sexual abuse within the family. You know, you can begin to take care of it so that that child doesn't begin the stream that goes, you know, into the school system, and then into special ed, then into criminal justice, then into corrections, or into the emergency room, either with mental or physical health, I would say to finish up my greatest concern. My greatest concern is the mental health of our young people. You've seen it in the Guardian, you've seen it in the New York Times, you've seen it in the Atlantic Monthly. And I asked John Bromstead. I said, John, my brother works in the emergency room. And I said, he tells me that on any given day, you've got five to 10 young people in here wearing paper clothing, sleeping on gurneys. And they're presenting with self harm, self cutting, suicidal ideation, suicidal attempts, eating disorders, depression, whatever. And I said, is that true? And he looked at me and he said, and Bill you can quote me and I'm very careful about not quoting people when they asked me not to. He said, five to 10 kids is a good day. A bad day is 25 to 35. And he said, we have some of these kids who have been here for three weeks, sleeping on a gurney in the emergency room. And you know what the emergency room costs per night. And he said, we have nothing for them. That scares me to death, because our young people are our future. And if we can't figure out how to take care of them. That's a problem. And I'm not saying it's all medical or circumstantial there have been a lot of cultural changes, a lot of, you know, the whole issue of bullying online and, you know, social networks and so on have altered how children grow up and play. But I think that needs to be a major focus of health care going forward. And finally, the whole issue of do we have a national health care system or not. And, you know, as I, I don't think I said I was speaking to a bunch of leaders did I tell you this and, and there was one woman who was extremely upset with me. And I understood that she was very conservative and she said well clearly you don't believe in American exceptionalism. And I said, I said, well, I beg to differ I absolutely believe in it. And she said, well what does it mean to you. And I said well it's very simple. I said there's 131 countries. Have I told you this. No, there are 131 countries in the world that have a national health care system. We don't. There are 92 countries in the world that have paid family leaves. We don't. There are 54 countries in the world that have paid daycare. We don't. That's American exceptionalism. And whoa, was she angry. She walked out. But we need to really rethink these things. I mean, what is population health, the Yale study which I won't go into detail but it's a massive study that a lot of foundations put money into basically said. If we had a national health care system in this country. It would be much, much cheaper. We'd have much better outcomes than the way we're doing it now. And it was just an economic study. So thank you I'm opening it up to questions observations challenges, and somebody's got going to walk around with a mic. Sorry, I hope to leave more time than this but it's a big topic. Could you comment on today's article in Vermont digger regarding the inability any longer to cover home health care 24 seven for those in need of that due to lack of staff at UVM health and hospice. I can't comment on because I haven't read today's digger. But I will I always do. I haven't read it so I, I'm reluctant to comment on it. Yeah. It was very concerning to read. I used to work at the V&A when it was still the V&A. And so that was unheard of to not be able to have personal care attendance and just telling people okay find your own. Yeah, but what I was going to comment on is the children's mental health and I've been an advocate for many years. The children's issue was this was happening not quite so many kids in the eighties but for years before the pandemic and adults and the problem with children's mental health. In this state is that the only hospital for children and adolescents mental health is in Brattleboro. And most of the population is up here. And they, the Department of Mental Health has finally put out a request for someone to build a facility so UVM said, oh yes they talked to them and they said we're going to do that. But they haven't held and the only place that has is in Bennington. Another Southern Vermont. And as someone who's, who's adult has been in Brattleboro. And knowing many parents who have, it's a long drive to go visit your child. That's right. And so now the UVM solution has been we send them over to Plattsburg. But they can't send over anybody that's involuntary. So if you have an adolescent that is not, you know, saying that agreeing to go into the hospital, they will they cannot legally take them. But my other concern about children's health is that I just read in the times that there were many hospital systems that were decreasing their pediatric hospitals and pediatric care because they don't make as much money on it. And now there's a shortage and hospitals get children in and they don't have anywhere to send them or they have to send them miles away. And I just wondered if you comment about that. I can't say any better than you said it. I know that everything you're saying is correct. I've read the same sources you have. I spend way too many waking hours reading, reading the same things. And it's, it's just profoundly troubling. What, what does upset me is UVM Health Network. Every time somebody says there's a problem, they say we're going to fix it and they buy something. And then they don't, I mean, I met the woman I spent two and a half hours with her, but they brought up from Atlanta to run the Vermont Home Health and Hospice, which they they're now saying they can't run. But they started it and hired her. I don't know. You're absolutely right. We have another Zoom call. What are your thoughts around Medicare Advantage? Here's the biggest concern. And this is really important and I'll try and be very concise. Private equity firms are buying into Medicare Advantage programs left, right and center, just as they're buying into residential care facilities. I'm working with some legislators and this passes constitutional muster. And what I want to see us do is pass a law in Vermont that private equity firms cannot buy any equity in nonprofit healthcare facilities or journalistic facilities. Very, very right wing. Private equity groups are buying up radio stations, local newspapers, TV stations, letting people go and then sending all the news in on a syndicated basis. You, you read about what happened to a lot of the residential care facilities that private equity bought into here in Vermont, right here in Chittenden County. All of a sudden the service levels went like this. They're doing the same thing in Medicare Advantage programs and outside of Vermont, they're buying hospital systems. So if we think health care is going to get better, we have to stop that. Would you care to comment on this? I listened to the BBC World News Service. And once while they're talking about the British healthcare system. Yeah. And it's been held as a model that says there are some difficulties with it. There, it's a shambles. And it's very I follow the same thing. And the reason it's a shambles and we actually have a friend who was part of the startup of the NHS is that it always relied on doctors from the subcontinent. And they're terrific doctors. I mean, most of the doctors in the British system are Pakistani, Indonesian, African, and they are excellent doctors. But what's happened is the pressure from British doctors to privatize sections of it has been so strong. And the government has acquiesced to this. So you now have this whole private sector thing competing with the public sector. And once for profit, and one is a government health care system, and it's decimating the NHS. You can't have it both ways. I mean, we have concierge medicine, we have to our great shame concierge prisons out west, where if you're a rich person and you get 10 years in jail for $135 a day, you can have a really nice cell with Wi-Fi and custom cooking. And, you know, it's the same thing in England. And we have one more zoom question. What are your thoughts in single payer health insurance. Single payer is such a loaded term. I mean single payer could be a national health care system, or it could only be one payer. I, I don't think single payer as we understand it is a solution. And it's interesting because I'm getting a lot of emails from former Governor Dean who I've known over the years. You know about this and Governor Shumlin, you know, essentially pulled the mission out of the agency of human services, the health agency brought it into his office trying to make single payer work. And when single payer didn't work, it never got put back. So I would argue right now, there's virtually nobody running the show, but I don't think single payer, unless you're really crystal clear about defining what it is, is any kind of magnetic solution. You've time for one more question anybody. Don't be shy. Right here Martha. One second. Please. Private equity firm is. Can you name a few without comfortably. Yeah, I mean, in the journalism world there's great communications with just bought Channel three from Peter Martin, and they're very conservative, and they're very upfront about it. And, you know, the news has changed. Sinclair is looking at WD EV, and a lot of those small local papers get bought up. Staff gets like, Oh, look at the free press. You know the free press has two reporters doing local stories, all the rest of the stuff is just syndicated stuff being pumped in private equity firms that they're not intrinsically evil they're designed to make money. But I'm fine with them making money in the business sector. I just don't want them in the nonprofit sector. And frankly, the reason they're so interested in healthcare is because then they can suckle the teat of Medicare and Medicaid. Wow. Thank you so much bill this has been great. Thank you. Thank you.