 This is the Friday morning committee meeting for house appropriations. We are going, our committee has received H611. It is an act relating to older Vermonters. And we have today with us representative Wood and representative Noyes to walk through the bill with us. And we also have Nolan Langwell from the Joint Fiscal Office and Jen Carvey from Legislative Council. Welcome everybody this morning. It's a beautiful morning. So let's just jump right into this bill and understand the pieces of it. Teresa, can you put the bill up for committee members to follow if they have not had the chance to print it off or have it on another device? Okay, we'll do a quick walkthrough of the entire bill. I believe it's section five that is of particular interest to this committee. That's where the appropriation is. And so who is walking through the bill out of the four of you that are here? Jen, are you walking through the bill or is one of the committee members? I'm happy to or I'm happy to let one of the committee members if they'd prefer. Why don't you go for it? Why don't you go for it, Jen? Okay, great. Jennifer Carvey, Legislative Council. So you may remember a couple of years ago the legislature passed a bill that created an Older Vermonters Act working group and it set up a group of people to design an Older Vermonters Act kind of modeled on the Federal Older Americans Act. And so they came back with a number of recommendations and this bill really grew out of that. So it starts out in section one by creating the Older Vermonters Act. And I don't know how much detail you wanna get into on this part or if you want me to kind of give a high level and then get you down to the money parts. A high level, please. Okay, so it sets up this Older Vermonters Act. It starts with principles of a system of services, supports and protections for Older Vermonters and it talks about different principles for a comprehensive and coordinated system of services and supports for Older Vermonters. And maybe we'll just go through the numbers there. So the first one is self-determination and it talks about that. I'll just really redo the numbers there. Self-determination, safety and protection, a coordinated and efficient system of services. And I'll just flag on this part. This is the first of a few places where this amendment differs from what was originally voted out of the committee because this amendment from representatives Wood noise and the rest of the House Human Services Committee adds in some additional language that recognizes the issues that we've been going through recently in this public health crisis in the state of emergency. So making sure that there's some references to the particular needs and concerns of Older Vermonters and their families when there is an emergency. So that's coordinated and efficient system of services. We have financial security, optimal health and wellness, social connection and engagement, housing, transportation and community design, family care and family caregiver support. And so those are the different principles for the framework for this Older Vermonters Act. Then we get into a number of definitions that are used in the chapter. So I don't know that we need to go through those in any detail. And then we have, but they do inform a lot of what the terms that are used in it. And then we get to section 6204 on page seven, great. And that is laying out the duties of the Department of Disabilities, Aging and Independent Living with respect to Older Vermonters in particular. It says that they are the state's designated state unit on aging and makes them specify that they're the subject matter expert to guide decision making across state government on matters affecting older Vermonters. On the next page, we get into section 6205, The Area Agencies on Aging. There you go, and talking about the duties of the Area Agencies on Aging, also known as the AAAs. And a lot of this reflects things that both Dale and the AAAs do, but it really puts them in statute and creates a greater sense of coordination. Then we have section 6206, Plan for Comprehensive and Coordinated System of Services, Supports and Protections. This really recognizes that at least once every four years, Dale adopts a state plan on aging, which is required by the Federal Older Americans Act. This puts in some particular parameters about what has to be included and what has to be considered when Dale is adopting the state plan on aging and also consultation with various parties. So on page 13, we get to the end of the chapter on the Older Vermonters Act, used to saying Older Americans Act, and we get into section two, which is an annual report on the Adult Protective Services Program. This really reflects the current reporting that they are doing, much of which is in response to past legislation. But this is the Adult Protective Services Program within Dale, and their job is to protect and prevent abuse, neglect, or exploitation of vulnerable adults. So this is on for a few pages, on through page 17, with the details of what needs to be in this annual report on Adult Protective Services. Then section three is on a, creates the concept of a Vermont Action Plan for Aging Well, and it directs the Secretary of Administration in collaboration with Dale and others, Dale and Department of Health to propose a process for developing this Vermont Action Plan for Aging Well. So it's contemplated as a very stakeholder-involved process, but coming up with just the development process and reporting on what that would look like. And then in section on page 18, we get into the money parts, or close. So this is introducing a few sections, the purpose of which is to increase the Medicaid rates for home and community-based service providers. So the first thing we have is just a definition section and adding a definition of home and community-based services. So this is defined as long-term services and supports received in a home or community setting other than a nursing home under choices for care. And it includes home health and hospice services, assistive community care services, and enhanced residential care services. So it's broader than just choices for care providers, I believe. Section five is the inflation factor. So this is really the part that I think you'll be focusing on today. This would have the director of rate setting, which is now in Diva, established by rule procedures for determining an annual inflation factor to be applied to the Medicaid rates for providers of home and community-based services authorized by Diva or Dale or both. And the division being the division of rate setting in collaboration with Dale, would calculate the inflation factor for home and community-based services annually according to the procedure adopted by rule and report it to Dale and Diva for application to home and community-based service provider Medicaid reimbursement rates around to the next page. Thank you, beginning on July 1st. So rate setting comes up by rule with a process for determining an annual inflation factor for the Medicaid rates and then reports it annually to Diva and Dale so that it can be applied to Medicaid reimbursement rates for those providers beginning on July 1st. And determination of the Medicaid reimbursement rates for each fiscal year would be based on applying that inflation factor to the sum of the prior fiscal year's payment rates, which is usually how you would use an inflation factor, but also any additional payment amounts available to providers of home and community-based services as a result of policies enacted by the General Assembly that apply to the fiscal year for which the rates are being calculated. So if the legislature takes action that would increase home and community-based provider rates other than the inflation factor, the inflation factor gets applied to gets applied after that additional payment amount is already applied. And then section six has the departments of Diva and Dale conduct a rate study of the Medicaid reimbursement rates paid to providers of home and community-based services and look at their adequacy and the methodologies that underlie those rates. And then the departments would establish a predictable schedule for Medicaid rates and rate updates, identify ways to align the Medicaid reimbursement methodologies and rates for providers of home and community-based services with those of other payers to the extent those methodologies and rates exist. Limit the number of methodological exceptions and communicate the proposed changes to these providers of home and community-based services prior to implementing any proposed changes. And by April 15th, 2021, Diva and Dale would report to the Human Services Committee, to this committee and to the Senate counterparts with the results of their rate study. Then section seven creates a self-neglect working group that would provide recommendations around adults who because of physical or mental impairment or diminished capacity are unable to perform essential self-care tasks. And there was a definition in that Older Vermonters Act section. And this working group would be headed by the commissioner of Dale and it specifies a number of members of that task force. It does not provide any per diem. So most of them are either state employees or they're people acting in their official, largely acting in official capacity. So it does not specify any per diem. And then finally, we have the effective dates. And so the Older Vermonters Act part, most of the act takes effect on passage with some minor exception relating to the state plan on aging. For your purposes, sections four and five, which are really the ones with the Medicaid rates for home and community-based service providers and that inflation factor would take effect on passage and apply to home and community-based service provider rates beginning July 1st, 2021. So the beginning of the FY22 fiscal year. Thanks, Bill. I just have one quick question about the study group. Do we have to provide the language for per diems even though the entire group may not be eligible for them? I'm just wondering if we have to put in the language for per diems. I don't believe so. If you don't put in any language for per diems, there are no per diems. Well, but what I'm saying is, is there anyone who could be swapped out or all of these they would never require a per diem? That's my question. So, I mean, I can go through the membership is Dale employees, Vermont Attorney General or Designee, State Long-Term Care Ombudsman or Designee, Executive Director of the Vermont Association of Area Agencies on Aging. These all have it with Designee. Executive Director of Cove, the community of Vermont elders. Sorry, page 22. Perfect. Executive Director of the V&As of Vermont, Executive Director of Disability Rights, Vermont. There is an elder care clinician, so that person is not employed by an entity that would be performing in its official capacity. The Director of the Center on Aging at UVM College of Medicine. So, I mean, I think it's a policy choice for you, whether you choose to put in per diem language or not, there is not a requirement that you pay per diems. And my other question is when it's a designee, the designee could absolutely be any person they chose to put it. If it doesn't have to be related to the group, it could be a person of knowledge that the group has. So, there could be people who would need per diem. So, I'd like to, we can open that up for discussion later with the committee, but are there questions for Jen or Teresa or Dan or Nolan? Actually, before we do that, let's have Nolan walk through the fiscal note and then we'll open it. Dave, is that okay if we walk through the fiscal note quickly? Absolutely. Hello, good morning. For the record, Nolan Langwell, the Joint Fiscal Office, may hear my dog growling in the UPS guy. He used to marry his growling, bud. He's a good-watched dog like that. So, the fiscal note focuses on section five, and that's the one where the department of rate setting or the division of rate setting at Diva establishes the procedures for determining an annual inflation factor if you apply it to the Medicaid rates for the providers of home and community-based services. And then it has it applied once the effective date goes in. This language, it would not increase spending in fiscal year 21 because of the timing of it, but there would be an increase in the base spending starting in fiscal year 22. That said, we can't determine at this time what that inflation factor would be because the department of rate setting hasn't actually done the work because it's in the law for them to do the work. So, Dale had no way of estimating what that could be, but I did look at what had been done previously, and there had been a 2% Medicaid increase for fiscal years 2018, 2019, and 2020, and by calculation, every 1% increase in the rate is roughly $900,000 gross. So, although in 2022, we don't know what the fiscal impact would be, it can be assumed it's probably gonna be more than 1%, and as a result, the fiscal impact would likely exceed $1 million gross to the extent that the increase is greater than 1%. So, again, in summary, no fiscal year 21 impact, but unknown at this time. And it's a traditional Medicaid split. It would be an additional Medicaid split. Thank you, Nolan. So, are there questions we can jump back and forth between Nolan with the fiscal note and the bill? Dick, do you have a question? Yes, thank you. Jen, we're in section five and section six. Does it actually say that the rate, the inflation increase shall be granted? I understand it says the division of Medicaid shall develop rules for calculating one, and it talks about a study in section six. But can you just point that out to me, please? Well, I think it's implied in the, I mean, you're right, it doesn't specify that Dale and Diva then apply the inflation factor. I'm just looking at the language. Well, no, it does, actually. So, in C on page 20, so on page 19, the director comes up with rules for coming up with the inflation factor, and then on page 20 in subsection C, determination of Medicaid reimbursement rates for each fiscal year shall be based on the application of the inflation factor to the sum of the prior fiscal year's payment rates and anything else that the legislature had provided. So that explains how it should be applied, but it doesn't say in statute or in the green books that it shall be applied. I don't see where it says that, says it shall be calculated, but it doesn't say the state of Vermont shall, on an annual basis, grant an inflation factor to these providers, does it? No, but I don't think that's the way we do it in nursing home rate setting either. So I think to me in saying determining the rate, the reimbursement rate shall be based on applying the inflation factor to last year's payments and anything else that was appropriated comes up with this year's Medicaid reimbursement rates. I mean, it can't require the state to actually appropriate that money. You have to do that through the annual appropriation process. So is it really saying that if through the appropriation process one shall decide to grant an increase, this is how it shall be done? I think it's saying this is what the Medicaid reimbursement rates will be, but it's always dependent on the legislature actually appropriating the funds for that purpose. Okay, so I don't read it as compelling us to do anything, but I guess you're saying it does, even though it doesn't say that, you're saying... Well, you can't compel... You can't compel a future legislature to do it. I mean, that's always the issue. You can create the framework for it, but each year's budget has to actually appropriate the money to fulfill that requirement or not withstand that requirement. Madam Chair? Well, I'm sorry. Go ahead, Teresa. I still have a question for you. Okay, I just wanted to... I don't know how things work in your committee. That's why I put up my... No, I see the hands. I was just waiting for Jen and Dave to finish, but if you can help clarify this, Teresa, that would be great. I think... Thank you, Madam Chair. I think that Dave is getting at one of the original reasons why there was some deliberation about whether this was going to come to appropriations or not. And because it doesn't compel an appropriation, it compels a process and then leaves the appropriation up to the normal appropriation process. So that was the original deliberation about this back in March. And so it went back and forth. And I think the speaker decided to err on the side of caution and send it to appropriations. If it creates an expectation and it's done exactly the way the nursing home inflator is done, I'm wondering if a precedent has been set and then that expectation would be expected to be realized, that's my concern. Yes, and we were not expecting in section five for that to be similar to the nursing home rate study. That is actually more in section six to devise a process to establish a methodology for establishing rates, which frankly, there isn't any right now. It's just historical and it's really not based on cost. It's not based upon anything other than history. And so section six seeks to establish a process that would really look at the costs associated with providing home and community-based services and establish a procedure for that. So the section five is not intended to be like the nursing homes. That's just, I just wanted to clarify that. Okay, section six is very clear that it's a report, a study and a report back. Section five gives, I don't have a comfort level with the exact intention, but Dave, did you want to finish please? I'm sorry. Thank you. No, don't be so, gosh, no. Yes, just to follow up on that. So if I were working in the agency of human services, I don't think I would turn to my budget people and say, gee, we've got to put in the budget and increase here because it says so. I think what I would say is if we're required to do one, here's the procedure and the process that needs to be abided by. That's what I hear, I think I hear Teresa saying. So that to me is less onerous than you shall be compelled and I'm not sure. I should know what the nursing home language says, but I don't, we'd have to do a side by side. I don't see a precedent there too. I just wanted to shift to another area if I may quickly, Madam Chair. Dan and Teresa and anybody else on your committee who's there. I don't see in this bill anywhere, and I may have missed it, some kind of acknowledgement that given we're one of the, we are the most rapidly aging state in the country that some type of sustainable funding will need to be created to help the entire aging network. Is that, is that in the bill anywhere? Do you address that? That is, that specifically Representative Yacoboni is not in the bill. We did focus on Medicaid services in this bill, not on the full array of supports and services that are available to Vermonters. We've focused on those things that we currently have a direct appropriation to. But yes, and even that one would think would be very streamed as more and more people age just the Medicaid portion, but that's just my observation. I'm, Dan, did you? Yeah, I think some of that will be addressed in section three when we do the Vermont action plan for aging well. So we tried to think about a long-term plan for aging in Vermont and what services will be important as the population demographics change. So I think a lot of that will come out of this Vermont action plan for aging well. And in future legislation, you may see some additional needs that have to be met. So was it intentional on the committee not to talk about the design possibly of a long-term care trust fund? Was that discussed and was decided that wasn't something that's needed or is it just an omission? No, I'll address that. I don't believe the committee had any in-depth conversation about it. I did talk to, I talked to our chair about it and I think we did not include anything about that in the bill, although I think it would be a good thing at some point to think about. Thank you, Madam Chair. Thank you, Dave. And I see we have another member from human services. Kelly, I don't know when we started, but welcome and just join in, either raise your hand or use your flush hand or your blue electronic hand if you have anything to add. Nice to see you. I have Bob and then I thought Marty was up. I have Bob, Mary, Peter. How's that? Perfect, Bob, it's good. So yeah, all right. I don't want to sound like I'm down on seniors. Just take a good look at me and you'll understand why I am not even though I will never be on a program like this. However, I just want to bring to mind everybody's attention to our financial situation at this time, which isn't expected to be any better next year. And I don't know why you would think it would be better in 2022. As a matter of fact, I almost think it's going to be as bad as it is. It's not going to be any better. But anyways, I'm going to be supportive of this. But I need somebody to be aware of. We just can't spend 10 cents right now. Even though by doing this, we are setting ourselves up for that. And that's all I'm saying. Be careful. Thank you. And I'm all done. Thank you, Bob. Teresa, did you have a response to that or something to add at this point? I actually did. I think what Representative Helm brings up is an important, very important factor. And I just want to give you, I guess a real life example of how this plays out in real life every day. So there's a retired physician in my community who took care of her mom for many years with the assistance of activities at the Waterbury Senior Center. And then she also attended Project Independence. Her mom had advancing Alzheimer's and for five to six years of that advancement, this physician was able to take care of her on her own with the very small assistance, like I said, from adult day. And did that for five or six years at home. She finally was admitted to the Woodridge Memory Care Unit for the last year or year and a half of her life. But we saved literally hundreds of thousands of dollars by having her be in the community, being cared for at home when she was eligible six to seven years prior to that for nursing home level of care. And this is very real in terms of its impact on our economy in Vermont and the strain that it could put on our economy not to do this. And I can give you another real life example. Project Independence has not survived the pandemic. Project Independence is an adult day service that has served hundreds of people in the Washington Orange County area. And those are individuals, many of whom have significant memory issues. They have significant adult care issues they are cared for at home by families, except when families need to work or need a break. And that adult day center has been a victim of COVID-19. And we do not yet know what that impact is going to mean on the nursing home population in central Vermont. And I just want to caution the committee about being, you know, what I would really call is Pennywise and Pound Foolish. The administration has not put, and it doesn't matter if it's democratic or Republican, the administration has not put the support of these private nonprofit providers, many of whom are very small. Adult day providers are really small, triple A's are really small, has not been on the priority list to address the financial situation of those providers. And if they fall apart, if you think you've got budget problems now, the cost of serving somebody in a nursing home is significantly higher. And I know you know all the numbers than it is to have that person stay at home where they are much happier. And I might add, not isolated like they are right now, you know, the people in nursing homes, residential care facilities have not been able to save loved ones for three months now, going on three months. And they're gonna be the last ones to do that. And if they were at home receiving that support, they would have been among their family members. So I'm just, I, sorry, I got a little passionate about it. Thank you, Teresa. Can I make one statement? Yes, Bob. The only point I wanted to make is, I believe, and I get it, this is government, you cannot compare government to business in a situation like this. However, I believe we are sliding to a point of possible insolvency. And government can massage that a little bit better than business can, but it's still there. And when it's there, it's hard to get rid of. So I'm just, that's all I'm saying. Bear in mind that's all, thank you. Thank you, Bob. Here you go. Mary? Thank you. One of the real liabilities of being on the Appropriations Committee is, you see great bills like this. And I really think this is important, significant work that is helping us understand and support the community that we have to support. And that the liability is, you go, how damn, how do we pay for this? How do we balance that? And that's our job and we'll figure it out. But I just, I think all of our thoughts are going to them. Hear my dog? How do we do the balancing act? Sorry, guys. And as I said, we'll sort that out. The specific question that I had was around the issue of how the rates are set. And I think it was in section five where Dave was asking about the, not Dave. Jen reflected that this was similar to what we were doing for nursing homes. I was wondering if Jen or Nolan could tell us, one, is it the same language? And two, what has been our historic approach to, if it is the same language, what has been our historic behavior around that? So it is not the same language. There's quite an extensive process, both in statute and in rule for nursing home rate setting. And I, are you asking, have you appropriated the money to meet the nursing home rates that were identified? Is that the historical question? Yes. And let me just try to flush that a little bit more. Dave was suggesting, it doesn't say you will appropriate it. And I get the point about, we can't compel future legislatures. But I think we have historically appropriated money to nursing homes, regardless of, we have felt an obligation. And I am wondering if this is creating the same sense of obligation. So I think in my understanding, and I'm not well versed in the fiscal stuff, so I would look at Nolan or Maria if they have been more involved in that. I haven't heard the same kind of concerns raised by stakeholders about nursing home rates in the sense that there's a process. And it's my understanding that the process is, it seems to be followed. I'm not sure I know much more than that. I don't know from the nursing home side, whether they view the rates that are created through the statutes, through the statute and rules as sufficient. I think you may hear different things from different folks on that, but there is quite an extensive set of statutes and talks about the factors to be taken into consideration. And there is an inflation factor. It's a very extensive system. And so what is set up in the bill does not mirror the extensiveness of that system, but it does create the idea of an inflation factor. And address Medicaid reimbursement rates as incorporating that inflation factor. Again, always subject to the authority of the legislature to appropriate the funds or not. Nolan, do you have additional thoughts? I believe Nolan had to leave. Oh, no, you're there, I'm sorry. I have to sign off like in like 30 seconds, but I don't really have much more to add. I think it just comes down to how is it going to be interpreted in 22 in terms of spending? And I don't know the answer to that. And I think it's important that it's very clear, whichever way we go that it doesn't leave any vagueness that when it leaves this committee, it's clear with the intention that the committee chooses for it to have. I have Peter, Diane and Marty. Thank you. Thank you for coming in. This is important work. Dave posited a good idea early on that I think would be very helpful to us if we did have a side-by-side comparing this to what we do for the nursing homes. And I know that there's a lot more, Jen is alluding to the robust nature of statute as it pertains to nursing homes and their rates, and there's rules behind it. But just to give us a sense of how this could develop, I think that would be very helpful to me. And I would really, really wanna see that. Number one, number two is just a question and that I have about the bill itself. And I scanned it, I'm sorry, I didn't read the bill. I was unfortunately involved in a situation where elder abuse occurred. This was about five years ago, so it may have changed by then. We contacted Dale and asked for assistance and got exactly nowhere because there wasn't enough, there wasn't enough, even though the individual who was doing it actually had a record. There wasn't enough linkage there or something like that. So is there anything in this bill that will actually work with the Attorney General's office to strengthen our laws, to ensure that situations are thoroughly investigated for appropriate adjudication? So Dan chime in, or Kelly too. There's a couple of different areas that would apply to that Representative Fagan. The first is the broad plan for aging well in the state. Now, we use positive terms because that's what we want to do. But the reason that that sits in the responsibility of the Secretary of Administration is that that is intended to be broad across government. So it's intended to encompass emergency management, the state's attorneys, any public transportation, all of those kinds of things that we all would want in our communities as we hope to age well here in Vermont. So that would be something that would be included in that area. The other area that we specifically are codifying in this bill is around adult abuse protection reporting. You may recall a few years ago, Dale was being sued by Legal Aid and the disability rights Vermont around their, well, it was a whole bunch of things, but their reversal of substantiations, their rate of investigation, the number of vacancies they had. And so they had a significant reporting requirement for a period of time that expired, frankly. And we felt in our committee that it was, this is a significant enough and an important enough issue that that should be a permanent requirement for adult abuse. And so it would give us as legislators not on that sort of individual granular level, but as a systemic way to look and see, are we making progress in this area? And then if not, then we can work on fine-tuning the laws. Gotcha. That's correct. Thank you. And do you want to weigh in? Yeah, just quickly, we did change some of the laws around financial exploitation of older Vermonters a couple of years ago. And so, those are currently in place right now. Good. I want to say it was probably two years ago that we increased, put some changes in there. Good, because that's what it mainly surrounded. Thank you. Yeah, there was some instances where someone, it wasn't a felony or it wasn't criminal if you sold somebody stuff. Correct. So that's been changed. Thanks. I have Diane, Marty, your hand was up and then it's down. I'll come back to you the chip and back to Dave. Diane, Diane, for some reason we're not hearing you. Sorry, sorry, I pushed the wrong button, Madam Chair. Thank you. So this is an area that I have had just a little bit but I'm nowhere near an expert in this field but on the budget line items we see in our committee when yearly the nursing home rate is right there every year for us to consider. It could be anywhere from two to $3 million increase a year. However, in their defense they'll say but the nursing home days that they're not getting paid for now pretty much almost balances that out. So you'll see their rate being increased and then you'll see the next very next line is a reduction because of the wonderful work in the community services over the years of having the placement there. So it might be up $2 million by law and then down a million and a half because of reduced nursing home days which is unfortunate for their business plan but very good for our seniors because they're shifting to the choices for care. What used to be, you know, a little bit of a loss used to be, you know, a very large amount in nursing home and we have not kept meaning the big way we have not been able to figure out a way to create balance and equity among all those systems. And I'll just, this is really my question is we're talking about a Medicaid population. We're not talking about providing something. This is a Medicaid population that goes to Bob's point that we have to by law provide these services. This isn't an option of doing something nice, you know but it's about a Medicaid population and we have in Vermont particularly figured out a way to be able to provide that mandated service much more efficiently and economically and then we have not been able to keep up with being able to figure out how do we fund it equitably and that's basically so I just can somebody Nolan or so we are talking about Medicaid population, correct? Yes, you're talking about Medicaid rates. Right, so this isn't something not optional. We're either paying for it in a nursing home or we're gonna pay for it in a different way. We should examine the most effective and economical way and equitably funded. Just saying. Okay, I'm done. Thank you, Diane. Marty, your hand was up and then down. Do you have a question or a comment? Okay, I think we're going to chip. Thank you. I have a question for Jen, I think and then maybe a brief comment. So Jen, the bill requires rulemaking to determine how the inflation rate will be determined. But that's as far as it goes. And then, but the fiscal note is created, must be assuming some, I don't know, standard way of arriving at a inflation rate. So I'm just, I guess my question is even though we're kind of leaving it to be determined, is there sort of a pretty standard way of going about that, that we could actually have a create a fiscal note for 2022 in this case that's somewhat accurate? So is your question, is there kind of a standard way of coming up with an inflation factor? So it's not a, that narrows the universe a little bit of what kind of numbers you might be talking about? Yes. It's a good question. Let me check, I know Nolan had to get off the call. So let me, let me check in with our fiscal folks and see if they have a, and maybe Representative Wood has take on that. Theresa? Nolan, I believe from our conversations calculated what he did in the current fiscal note based on essentially a simple percentage of what we have for long-term care, home and community-based services and not his knowledge of what we have previously done. What rate setting, the reason that we have this or are proposing this with rate setting is that we don't know if they would do something based upon a medical consumer price index, whether it be a regular consumer price index, whether it would be some combination. We didn't want to mandate a certain procedure in law because frankly, we're not the experts on it. We felt that it would be more appropriate for rate setting to do that deeper dive to determine what method would be most appropriate for this with of course, public input as you have in the rulemaking process. So that makes sense to me that we would leave it up to people who have a better more knowledge about what the proper way to go about it is. I just wonder what that means in terms of the possibility, the range of possibility for inflation rate that might be determined, but. I would expect there to be public comment on that, including from legislators. So for instance, we don't know what the economy is gonna do. If we have inflation that tops out at six or 7% or something like that, I would imagine that we'd be seeking as legislators some sort of cap on what the inflation could be. But I think Nolan's sort of rough cut at it in terms of what each percentage does is roughly a million in gross dollars. I mean, that's probably as accurate as we could get in terms of what we know now. If we were just using the same method as what has been used in the previous three fiscal years when the legislature said, okay, we need to do something here. Let's do 2% and then they calculated that based on total cost essentially. Thank you. So I just have a, I guess it's a comment and kind of the reason I was asking about the inflation rate is, and I should say, you know, my history on that appropriations committee is short and so I don't know how these things generally go, but I was reading this language in section five kind of over and over again, sort of in response to Dave's looking at it. And I think it is best I can tell he's right. It doesn't require anything to happen, but it certainly seems like it is very clear that the rate will be calculated and it will be applied and that we will have a reimbursement rate for Medicaid that will I assume be presented to us that this is the Medicaid reimbursement rate. What we do with it after that, you know, is always our determination to do, but I guess I'm just saying it will set, it certainly feels like it would set an expectation that that will be the rate going forward. And if we decide not to do that, we're gonna have to decide that every time we appropriate money to say, no, we're not going to do that, or yes, we are going to do it. So anyway, that's my comment. So when and if this bill leaves the committee, there has to be complete clarity what the expectation is. Either we're setting in motion a rate increase or we're setting in motion policy and study work. We cannot put a bill out that is not clear on what the impact will be. And I just wanna bring to the committee's attention that there is some confusion, obviously around section five, but to bring to your attention the second paragraph of the fiscal note, which our committee will be working off from and we would use when we go to the floor, it is written that there would not be an increase in 21, there would be an increase in base spending in 22. So on the fiscal note that we are working with, either this has to be corrected or the language needs to be fixed, but there's not clarity here and before a bill can move out, our committee needs to know if we're putting pressure, financial pressure on a future budget. And granted, a future legislature can not withstand, but our intention needs to be very clear when we get to the floor that either yes, we agree to increase an amount for the base funding or no, we're not voting for an increase in any amount to base funding, we're supporting the policy and the study work because the information before us is in conflict a bit. Dave and Teresa, Teresa, did you wanna respond to that before I go to Dave? Okay, Dave. Thanks, thank you. I'll be brief, I know the clock's ticking here. I was director of rate setting for a number of years, albeit it was the number of years ago, but a brief history on this, what drove the requirement to give nursing homes an annual increase was something called the BORN, E-O-R-E-N, very BORN, the BORN amendment in Congress that was established in 1981. It was established in hopes to be a cost containment mechanism, but the courts interpreted it broadly that all nursing home rates at the time should pay what were deemed reasonable and adequate rates to operate an efficiently run facility, something to that effect. Vermont in 1990, I think 1997 and Vermont's law essentially paralleled what the Fed said. So that's why the nursing homes got their annual increases for at that time with the passage of Act 160, which started significantly the home-based movement. An effort was made to amend the so-called Vermont BORN amendment statute to sufficiently weaken it to give more latitude on that reimbursement. Having said that, however, the commitment to provide the annual nursing home increase is in statute and the few times that I recall that we did not withstandings, if Jen were to, and she may have already done this, if you were to go back and look at what they not would stood, you would see in the nursing home law what built that annual inflation increase. And that would help us, I think, do the side-by-side that I think is necessary in order to determine whether Nolan needs to amend the fiscal note, not being critical of him, he always says great work, but he said he made a determination based on somebody that this compelled the rate increase. Now I wanna be clear, I'm all for the rate increases. I just don't think this language compels it, but I think there's more to be done to help us come to a conclusion. And I agree with what you were saying, Kitty. Thank you, Dave. Theresa, your blue hand is up. I just wanted to mention, and I think Dan's gonna chime in here. I just wanted to mention that we took this bill back to committee and developed the amendment. And we naturally wanted to include, it seemed like a glaring oversight to us about not addressing emergency and health crisis, but it seemed very obvious now. But we put specific language in there. And then we obviously talked about this appropriations process and what that meant and considered whether our amendment should remove section five or not. And I think Dan wants to share some of the comments from our colleagues. Thank you, Theresa. Dan? Yeah, thank you. So we did have quite a discussion about section five and the intent and this is once we heard that there was a fiscal note being required and that it was gonna come to the Appropriations Committee. And we did have some discussion about just removing section five. And one thing our committee unanimously supported leaving this section in and having it come to this committee because we felt strongly that we need to support the agencies that are providing these services to these individuals, especially when we look at the impact that the current emergency is having on them. Because if they weren't there, it would be hard. And as Theresa stated earlier about project independence, these home and community-based providers, we just wanted to make sure that they were adequately funded so that during time of crisis, they're gonna be able to provide those services to the individuals. So, you know, our committee really did have a discussion about just removing section five and sending it to the floor. And everybody on the committee felt strongly and that's why all their names are on this amendment. So it was actually fairly comical because Dan and I were just gonna present the amendment and some of our most, what we might call our most conservative members of our committee said, you know, wait, wait, this is so important. I want my name on this bill, on this amendment. And, you know, to a person, you know, they all said we want our names on this. That's how strongly we feel about it. So thank you. So I just need to be clear. They all felt strongly that the policy and the study and the report all need to move forward or they also feel strongly that the inflator be put in place. They also feel very strongly that the inflator be put in place. They were very clear about that because we, like Dan said, we had a serious discussion about just taking section five out and leaving it with the study. And it was actually some of our more conservative members said that we can't do that, you know, and we have to bring this forward because if we don't bring it forward, nobody is going to. So just, I want to remove the conversation from the bill at hand and just give a brief explanation of the landscape that we're in so that we're not, it doesn't sound like we're targeting older Vermonters in this important part of work. And so between the time we get out the quarter year bill and we come back in August or September to report out a fiscal year 21 bill, at this time there's a $265 million gap. And so any bill that has spending that is not, that is ongoing dollars because that's important, there, you know, there's always some overage somewhere to address, you know, a one time need. But these would definitely be ongoing dollars that would build annually year after year. And I'm just talking generally now and I don't want to target any specific bill, but there's a $265 gap that we need to close. And so anything that we pass that is ongoing in nature would be a priority above any other spending at this time in state government. It would not be considered against any other, well it would be, it would be considered against anything else that we would have to reduce or systems reform and changing things to get to balance that an appropriation would be the top priority. And that's what I have to make sure of that with having to find $265 million and that number could change once we get the consensus forecast in August that this or any other bill is the top priority for state government. And that's what we have to reconcile. And, you know, there's a very many important things, but between now and putting out a 12 year budget in the late summer and fall, you know, it's likely we're going to have systems reform and I am wondering if there's work that can be done between now and that bill coming out that would find things that are less of a priority and substitute this in for the ongoing dollars. If this is the top priority, one lesser priority that could come out, knowing that you may have to find $20 million in savings, you know, and I'm just throwing a number out there, but when the number is 265 and human services spending is 50% of our state budget, a lot of attention is going to be in that area. And so I just wanna make sure before any decisions are made that we fully understand the priorities of the legislature and of our committees and of this committee. And so that's the dilemma that we're facing. And so, you know, it puts us in a quandary for many things. There's so many good pieces of legislation that need to be passed, but now we have to start prioritizing, okay, if this is where we need to go, what are we doing that is less of a priority that we can substitute it out with? And also, what is a lesser priority that doesn't get substituted out is we have to get to zero by September. Thank you, Madam Chair. I think we certainly definitely appreciate the huge amount of work and the enormity of the task in front of your committee. That is definitely something that weighs on all of us. And I think, you know, the thing that I would say, I guess maybe in parting words about this bill is that I think that this actually assists with that problem because if we don't do it, we will have increased nursing home expenditures that will add to your problem. And I think that this will help your problem, our problem. I mean, our appropriations are all of our problems. So, but I realize you have to set the priorities. And no, no, no, the policy committees are going to help us with our priorities. Yeah, it's true. We very much appreciate the partnership. I think that the thing that we find ourselves in is the situation that Representative Lamper spoke of earlier in that the major systems reform for this population has already occurred when we shifted from an institutional bias to a choice bias that and we're more and more and most people now, the vast majority of people are choosing home-based services. So that big systemic change to shift the tide of how we would allocate resources into the future in Vermont has really occurred for this long-term care system. Thank you, Teresa. Are there any other final questions from the committee? The committee will have discussion and I have no idea where the committee is going to go on this. I certainly understand the importance. If we agree that the inflator needs to be there, we need to make sure that the language reflects that. If we feel the language does not reflect requiring an inflator to happen, then the fiscal note needs to be corrected so that the information jives on both sides. If we choose that the money is not available to be committed at this time, it does not mean it's a dead issue. It means between now and August to look at the revenues of the state and reprioritize other things that are being funded and remove those and put a new plan forward to do a systems reform based on what are the most important items within budget areas to be implemented and go forward for Vermonters because they're going to help the most and they're the most critical appropriation that we can make to Vermonters at the time. And I just do have to reiterate, it's not just substituting out, we also need to find $265 million at this time in reductions, knowing that number can change and the outlook for 22 has not looked that rosy we may learn something differently in August. I don't mean to be a downer, but I just need all the cards on the table. So we know how they can be moved around to make a set that does what we wanted to do for state government. Thank you, we appreciate the realism. I'm tired of the realism. I know, I know. Are there any other questions? Thank you so much for coming in. All on the house floor in 25 minutes and let's just have a mini discussion and I need to go grab a Kleenex quickly. Thank you. Thank you so much for coming in. Thanks for having us. So let's just wait for Kiddie to come back. I'm sorry. Yeah, no worries. I apologize for that. And so as we continue, I think that's going to have to be the theme and I don't want us to be the bearer of bad news but there is still a substantial amount of money in state government that we are appropriating with all funds, around $6 billion. I don't know if this brings it down to 5.9 something with whatever the gap is going to be. There's a significant amount of money that still will be appropriated. And I think it's important that this is the time that we work with policy committees and really identify priorities and what system reforms can happen to take the best advantage of the money that we do have. We can't focus on the amount we're losing. We have to focus on what do we have and what's the best way to spend it. That's a, I think a much more positive approach than what are we going to cut? What are we going to cut? What are we going to do to support Vermonters in the best way we can? Diane, and then Dave. So thank you. So I would put this in the, when we talk about our different vehicles, this goes in the system reform but the system has been reformed. This goes in the system reform payment reform. This is about payment reform in section five versus the system. So I could see where that goes in that bucket. Yep. And in order to pay for it, what comes out? You know, that's the other piece. You know, where does the money come from? Or what balances it? What comes out on the other side that it's in balance of? There's an inequity now. And I don't know if the answer is taking the sandbox away from others so that everybody's equitable or making the, you know what I mean? If we have this money to work with, that's all the money we have to work with. And so do we fix it? You know, it really has to go back to priorities and spending most important first. I agree. And that's where all the committees and everybody and if there's a consensus in this state and in our legislature body, that this is something that makes sense than much like what Dave said. That doesn't happen in our room. We have to stay within the box that we have to spend. But if there is a desire to make this system work in a payment reform, that may make the money look differently for this particular system payment change. Do you see what I mean? Yes. That's not necessarily our room's decision. It's the bigger body's decision. Well, it is our room's decision, what is appropriate in the end that gets to the body for the bigger decision and they can vote that down. Yes, they can vote that down. Okay. Dave and Mary. You know, in the end, it may all be budget neutral, but do we want to come to agreement to ask Jen, it may be implied and she may have already done it while listening, but if she could do some type of side-by-side and come back to us and say something to the effect of committee, I've looked at this and I am 101% positive, it is a commitment to increase funding in the future. I don't see how the administration could ignore it unless they're proposed and not withstanding. Or she might say, you're right, it's not a commitment. And if you'd like me to revise the language, I can do that for you. I'm just wondering, if we don't do that, the bill will be on the wall and that may be the committee's choice, but it won't come to an end one way or the other. I think you're right about Dave. I want to put out like a few options on the table so that I get a sense of where the committee wants to go so that would drive the work that Jen would do. But we have to have some clear, we need clarification on the language depending on the direction that we choose to take as a committee. Mary, Dave, were you finished? I don't mean to do it. Yes, yes, thank you. Mary, Mary, you need to unmute. Sorry guys, that way you didn't have to listen to my dogs try to, you know, they were awful. I'm back on the systems question and the dilemma that I believe the human services committee has is that this system floats between them and the healthcare committee. And honestly, I think we need to be also looking on the healthcare side about what are the opportunities and the changes and how we have to behave in this new regime. And I just wanted to say that while I can see that Teresa and Dan are still here, maybe Kelly is too, but I think we have to make fundamentally hard questions about our healthcare spending and are we doing our healthcare spending in the right place? And could we be spraying up some money over there to bring into the community, which I totally agree is the right place to go. The second kind of systems question I have is just wondering what has this whole pandemic revealed to us about both the nursing home or congregate-based provision of care versus the more community-based provision of care? And do we need to be standing that on its head? And I really hope that the human services and the healthcare committees will pick up those questions and see what the opportunities are there. Doesn't help us with this bill right now, but I think it's the fundamental question we have to solve. Thanks. Chip? A couple of thoughts. One, I mean, I trust Dave implicitly to know kind of what this kind of statutory language might or might not require of the administration, but to me, the plain reading of it just leaves no doubt about at least the first step, which is when you get the letter C, it says determination of Medicaid reimbursement rates for each fiscal year shall be based upon on application of the inflation factor. So whatever the administration takes that to mean, I think the public advocates, whoever, well, there will be an expectation that that's what's going to happen and whether or not we follow through and apply those rates, they will have been established. They will have been determined what they should be. And I'm not taking a stand either way about whether we should go ahead and do that or not. I'm just saying to me, the language is pretty clear about at least up to the point of the administration's actions what's gonna happen. The other thing, and this is really, really stating the obvious, but if one option is to think about systems reform, is there any, and to Diane's point, that much of this has probably has been done over the years and even recently, but could if we set the effective date back on this section, can Dale come back to us with at least an argument for why increasing this rate would help drive down the spending on nursing homes. And to say that we may be budget neutral in a way that's actually sort of more just, to increase these rates. I mean, I guess I'm just looking for it to your point, Madam Chair, about not having any money to spend right now but trying to figure out where we go in the future, maybe we can ask for an analysis of whether or not that would likely be budget neutral if we were to do this going forward. Even if it's budget neutral, there is still a big gap that we need to fill. And so when we put all the pieces together of all of state government, whether you're talking about ANR or any human services or public safety, all the pieces have to fit together to get zero. And so I see we have like four choices here. We can leave the bill as it is and accept it or not accept it. Section five, we can write it to determine yes, there will be an increase so there's no ambiguity or section five can be written as it's informational only or we can remove section five from the bill. And then if it goes back to the second option where we want the increase no matter what, that's a top priority, we have to figure out how we're going to adjust that to all other spending and we really can't do that until August because we don't have the ability to know ongoing money at this time. And I do not believe that we have sufficient information to pass a substantial bill like, I mean, this is up to the committee without the information, without a consensus forecast to know where it's going to fall unless we determine this is the top priority for state government. And then it's our job to make it happen. Stuart Marty. Based upon those last comments, I agree, we need to, I would see section five, I would like to clarify what the language of section five means, whether it's compulsory or informational and my preference would certainly be that number five, setting in motion the calculation of an inflator factor would be informational only and then leave that up to the legislature and the administration to determine whether it actually goes into a proposed budget or not. I think it's valid to look and see if the rates should be increased and whatever those factors are they use to compare them for other things to say, yes, we need a 1% increase on these particular rates but I do not want that to be compulsory. I think that should be information then that the administration would use and ultimately the legislature would use to determine whether to increase those rates or not in any given year depending upon what the fiscal requirements are for that year. So I would like clarification on that point on number five. As it stands right now, which way it means whether it's compulsory or just informational based. Thank you, Marty. Can I get a sense of what other committees or members are thinking? We have 11 minutes until we need to be on the floor and we also need to put together a schedule for next week, a Zoom schedule. And we also have to remember to wish Linda best wishes on her subject that is coming and we expect her right back as soon as possible. And we need a little bit of a break. Yeah. No, I neglected to lay out my shirt and tie this morning so it was not gonna go in and disturb my lovely bride. So what I would like to do then is I, the bill has been clearly laid out. We have our fiscal note. I'd like committee members to think about the direction that they would like to take and then we'll see where the majority of members want to end up with this bill. For the schedule next week, if we keep it kind of in the lanes that we have been keeping, does anyone have a conflict that they know of next week other than Linda? Linda, you will be out. Your surgery is, we're not meeting Monday, it's Memorial Day. Linda, you're out Tuesday and Wednesday. Yeah, that's what I'm thinking. Hopefully the surgery is Tuesday and I don't get out of the hospital till Wednesday. So I don't think I'll just run back from the hospital and sit down here with you guys. I don't think so. And you may meet Thursday and Friday too. Yeah, Thursday and Friday for me. My best wishes with your surgery, Linda. Thank you very much. I appreciate that. Thank you. Does anybody else have a comment? Yes. Kitty, yeah, I have a, Tuesday I have a 11 o'clock Zoom appointment. Not here. Okay, 11 to 12. Well, yeah, 11 until it's over. Probably 11 third ish. Okay. Does anyone else have a conflict next week? And Teresa put together a schedule. Okay, then we'll work between house floors and other committee meetings. Again, Teresa, Dan, thank you for coming in. I think Kelly's jumped off, Jen, thank you. We don't have time before the floor and Peter needs to get his hands on. I believe we are planning on coming back this afternoon with the committee like to continue this discussion on Tuesday, or would you like to come back this afternoon and clear it out? Tuesday's good with me. And I have, that's one for Tuesday. Two for Tuesday. If you agree with Bob on Tuesday, could I have a raise of hands for Tuesday? One, two, three, okay. And put those hands down. Is there anyone who would like to come back this afternoon? And, okay, this gives you the weekend to look over the language. And we'll speak where we're going. But again, thank you for this thoughtful work and sort of, see you on the floor. Thank you. Hey, I'm going to stop the live. Okay, Theresa, you want to help me?