 Okay Good morning, this is the house health care committee. It's Friday March 12 just about 8 a.m. and We are convening earlier than normal because today is the day before crossover and we have a lot of Work on our plate still although I think we can achieve it And I want to just I'm going to turn to represent Cordis to I think wants to help us remember the significance of this day as well. So representative Cordis March Friday March 13th 2020 was the last day that the Vermont legislature worked together in the state house. It's been a full year And much like a natural disaster where the glass of milk and the cup of coffee were left in place As people fled. It has the same feel. I don't remember what I left in our committee room and it's been a year full of Loss and stress and angst, but also a year of incredible open-heartedness and generosity and Solidarity of all of us here in this zoom room and all of our communities pulling together In this brave little state to help one another out and I'm profoundly grateful Thank you and I too express my Deep gratitude for all that we have we have a lot to be grateful for being in Vermont and Being amongst the safest states in the country But we also have to acknowledge that the deep losses that many people in Vermont and elsewhere Can we just take a moment of silence just to Just to acknowledge the losses that we have had. Thank you And I think it's entirely particularly appropriate for us as the health care committee to be Noting both the significance of today and and the changes that we've Kind of the resilience in a sense The changes that we've found how to how to accommodate What has truly been a life-changing experience for for everyone? Okay Thank you represent quarters for helping us remember the significance of today So we have in front of us today My goal is for us to achieve closure on the Work we've been doing around Expanding Dr. Dinosaur and that's what we'll turn our attention to first and then we'll turn our attention to As to 10 to continue our work through that you should be receiving if you haven't received it already You should be receiving any time now a revision of to 10 Katie did a terrific job last night of Doing as we as as was suggested and what do you want to thank you for that for initiate helping to initiate that That I think is was very very thoughtful and helpful and Katie has incorporated all of the Documentation and references to the parts of the findings will be going over that later in the morning But you should have it and if you get a chance you can be looking at that as well First of but first one Yes, it is in the inbox is Okay, right just so great. It may not have gone through editing yet But I had I decided to send it prior to editing if because I don't think that will change it in a substantive way So to bring us back to our Work on Expanding Dr. Dinosaur I'm going to ask Jen I asked I've had Jen draft several several dirt versions of a proposal and I want to Ask Jen to walk us through it and I want to give a little commentary as we walk through it If that's okay because I think it'll help put some context on why why it's structured the way it is And And then we can then we can you know have further committee discussion and See where we go from there So Jen good morning again. Thank you for being here Welcome. Good morning Jennifer Carvey Legislative Council. I will put up this draft so we can all Be looking at it. It is also posted on the committee page And if you can yes, if you increase the font for those of us who are challenged I'll clue myself Yes, is that good I can make it bigger Just a touch bigger. I think that's good Good for folks Yeah great So at this is a committee bill So it Has a statement of purpose in it that I've been changing to reflect what's in the bill But it would be entitled at least for now an act relating to expanding eligibility for Dr. Dinosaur to all income eligible children and pregnant individuals regardless of immigration status It would add a new section in title 33 in chapter 19, which is the medical assistance chapter It's the Medicaid and other similar programs chapter And I put it in where there was an empty number So there's Dr. Dinosaur coverage for undocumented immigrants And it would require the agency of human services to provide coverage under the Dr. Dinosaur program to children and pregnant individuals who are Undocumented immigrants, but who would otherwise be eligible for medical assistance from the state under the applicable provision of the Social Security Act which is the the children and pregnant women coverage option for states under Medicaid law I have sent this language to the diva folks to Confirm that the reference is right. So I'm still waiting to make sure that that is the right federal reference Section 2 would appropriate funds to the agency of human services It would appropriate one million dollars in one time funds to the agency of human services in fiscal year 2022 to begin Implementation of the diet Dr. Dinosaur expansion set forth in that first section I don't know if there's anything you want to say on that. Well, I think I think I'll have you walk through the But I want to explain that section in particular Section 3 would direct the agency of human services to include the full costs of expanding Dr. Dinosaur eligibility to undocumented immigrants pursuant to that section new section 33 BSA section 1901 C in the agency's fiscal year 2023 budget proposal And then finally we have effective dates section 2 that one time funding appropriation would take effect on July 1 of this year Which is the beginning of FY 22 The remainder would take effect on passage with the agency making coverage available to eligible undocumented immigrants under Dr. Dinosaur in accordance with section one not later than July 1 2022 And that is it So let me make a couple comments in terms of explaining the content there Excuse me So there's really two parts one is to direct the agency human services and diva in particular to expand Dr. Dinosaur to Pregnant women and children who are just regardless of immigration status effective not the year that's coming up that we're right now building a budget for The numbers are confusing still for me sometimes but we're talking about fiscal year 2022 22 right So if you think of it is starting this July and ending next June that's always the way I think of it is This year is going to end next June 30 of 22 so it's FY 22 So what we're what we're saying in this is that they shall propose in their budget that it would be implemented Not in this coming fiscal year that we're working on in the appropriations to me right now but in the following year And I think I think that's what diva testified that that was I mean that in order to achieve it that was that was achievable It would take some additional funds to actually put it in place. I think a hundred thousand dollars was the amount that they talked about And that there would be indeed some additional cost but that we're saying please put it in your budget proposal for that year And of course then it will get considered as part of a budget proposal I've also added a section that says and I Picked an arbitrary number of a million dollars of one-time funds To be appropriated to the agency human services rather than to diva specifically now you remember diva isn't Is a department under the agency of human services And I asked Jen to have it be appropriated to the agency human services to give the greatest range of flexibility For how they might find a way to begin implementing this in this Year prior to proposing it for their budget In my mind that gives them flexibility. I mean there's a level of There's a level of Specificity that we will not we can't and shouldn't try to take the time to sort out here today But if there's a way to do it and if we can use one-time funds They may be doing they may be able to do it through a series of grants to organizations They may be able to do it through some early implementation that they discover they actually can do so I I think sending the money to AHS gives them the broadest flexibility It also and the dollar amount is frankly Something that the Appropriations Committee would have to determine what an appropriate amount was Whether one-time funds were truly available etc and But the key is that this will then Trigger sending this bill to the Appropriations Committee Which is where in fact we want it to go So that they can consider the possibility of something with one-time funds and or To consider something with with one-time funds or to see if there's some Something that emerges beyond the point in time that we have today to try to set this in motion So that's that's the explanation I wanted to give for For that section in particular I see represent are you a question I have a question for Jen Because we sometimes use the term Migrant workers for example, and we're saying here Undocumented immigrants and I was just like double-checking the definition immigrant does normally mean a person with the intent to Reside permanently and I think we want to make sure we're not excluding Migrant workers who don't have the intent to reside permanently. I'm wondering if we want to use people who reside in Vermont But are undocumented whether that would make sense or not I'm not sure that term helps either because resident reside or Vermont resident is typically somebody who has is domiciled here with the intent to remain here Let's not try to get into it then I think I think the meeting will be clear. I don't think this was this You know, I've worked on a few things for introduction this year that related to individuals who are in our Undocumented workers and working with a colleague to try to figure out what the right terminology is. This is what we had come to at the time So I you know, I think some of that is why I was trying to use regardless of immigration status We can use that throughout if you would prefer That it might be a little bit less clear No, I think that explanation is fine and I don't think there's any Question about intent. I don't think diva would be going and saying oh, we got to separate out, you know Based on intent to stay so okay And throughout our statutes, we do tend to use the agency of human services in a lot of places for the Medicaid program Just to explain why it says now says agency of human services throughout instead of diva even though you're hearing from diva diva does a lot of the implementation work But just just to explain where that came from Okay So represent Peterson Yes, thank you. Um I'm not familiar with Dr. Dinosaur I'm not familiar with the program and what it entails the individual to have what requirements there are Of the individual or family if any Um, and if someone could just What I'm wondering is is there a like a copay for a visit? Is there any sort of a premium or piece of this that that they pay? Uh, if someone could just just so I know So the the short answer is yes actually for dr. Dinosaur for certain income for income levels above I think 195 of poverty There it is Under statute permissible to charge a premium and I believe there is an income sensitized sliding scale premium that goes up from income levels above that Um, I also believe in nolence here. So he may be able to weigh in as well, but I think the same Um prescription drug copays likely apply In dr. Dinosaur the one two and three Dollars at least for the part that's Medicaid funded But I termed it nolan for that the way I would Look at it is that dr. Dinosaur is the umbrella name We use for Medicaid coverage for children and there's multiple programs So regular kids and we have our children's health insurance program, which is does have a small family premium But otherwise it's just it's a blanket name umbrella name for kids under the Medicaid program. I see I see now It is it's available to those who are living in vermont not to I mean there's there's an eligibility That they go through as there is for Medicaid generally And we will we will require these Families and children to follow all those guidelines of income Um, um, so forth and so on correct. I mean yes As far as eligibility. Yes, it requires so the language requires the agency to provide coverage to those people who would Uh, otherwise For medical assistance from the state under the program that allows us to run dr. Dinosaur Now when and I don't know if anybody here can answer this and I'm sorry for nitpicking, but I I need to know this When a family An immigrant fan undocumented family worked for a farm They paid How were they paid? Do we know? I mean is there pay? Um Can you find it out? I mean, is it able to be quantified? Um Do we know that I don't I hate to ask that I'm trying to find out if it's if it's uh, if they get a check and it goes in the account and there's uh, You know an irs. Doc that goes somewhere. I don't know So to be honest my knowledge of this is fairly limited but comes mainly from working on a bill with representative cordis this year um for introduction this year that dealt With hospital finance and healthcare facility financial assistance policies and through that I think we identified some of the ways with the office of healthcare advocate that people who are not US citizens are not lawfully lawfully residing would be able to Prove their financial eligibility and so I can look at that I mean I guys that's what i'm getting at you can't can financial eligibility be proven. Um based on how they're paid I believe so and I think there's references been made over time to the fact that uh, in fact numbers of folks working in that status Are actually paying taxes, uh having having deductions taken from their pay As a product in the same way that uh an employer would otherwise So I think yeah, yeah, I maybe there may be some exceptions, but I don't think it's the rule Right, right. I know there's exceptions. I'm sure there are but I I just wonder how When these folks come to a farm, I wonder if there's anything set up with a farmer has to You know follow certain rules and paying an undocumented person. I guess I don't know just a food for thought Yeah um Did you have something? Just that it does put the honest on on diva They're all that they have to They have to do this in accordance with the rules for determining income eligibility So they will have to having mechanism for Doing that. Yeah, good point. Good point. Okay, and the terminology I was looking for was the profit and loss statement so under this other This other bill That creates its own process for things Um that talks about an income tax return and then it would allow someone to to provide a profit and loss statement in lieu of an income tax return. So that may be the kind of thing that could be used in this instance Okay, uh Representative golden there's something you need you're looking to weigh in on this particular point I am I would like to directly committee towards the romant health connect website Um, which has the really excellent grid of a description of the premium payments and family size and income levels For eligibility for dr. Dinosaur So anyone I could forward it to the committee if that would be helpful um You don't pay any premium just as an example of your one person household and your income is $2,000 So those kind that kind of information is available on their website for those that might be interested. Thank you Our representative page Yes, a couple of things. I wonder how easy it would be for a um undocumented family members to To get that information from their employer to present it show How much they are making or not making? Um, I think in some ways that may be a hindrance And this is just me thinking that it might be a hindrance in uh improving how much you're making or not making I I don't know. Okay Yep Go ahead chair Well, I think I think I go again. I think the point that Representative donahue made is I think well taken that it would it really puts the onus on diva to I mean, I don't think we want to have no eligibility requirement But it puts the onus on diva to think about how to do this in a way that's most appropriate The other issue is the million dollar sum Yesterday when we took testimony from diva We mentioned I thought it was 1.4 million dollars was coverage of children and and pregnant women So I'd be happy I'd be happy to have that number changed that because it's a reference number and and maybe 1.4 Would be the appropriate number for us to use because we've heard that in testimony as what it would require for a full year So I'd be happy to have that Adjusted, uh, it's a point of reference. I would suggest it's a point of reference It's not something our committee can determine in any case, but it would it would allow then for Uh communication with the appropriations committee to say that in our testimony We heard that that was the dollar amount that a full year would it the best estimate at this point Would that be That that seemed to make sense uh represent page. Oh, that's fine. I'm just I'm just bringing it to your attention. Yeah I'd initially had something closer to that and then just Through various iterations ended up at this number, but I would suggest using the 1.4 as you suggest And uh, and that then then that becomes a an actual point of reference based on testimony So I think that and knowing that there's a lot of variations that the appropriations committee will actually need to take into consideration So can you make that change Jen? That's for just changing one point 1 million to 1.4. Yes, very easy and Nolan just pointed out a technical correction in the Statement of purpose, uh, and I had to take out an earlier line. So I'm already working on I have a new draft going here Okay, great Uh representative black I just wanted to um, hopefully provide some clarification to representative page I'm being advised by the office of health care advocate who obviously works with eligibility and diva all the time that diva already does this with mixed status households in determining income and that They already have they already determine family income for this population and that they have procedures to be able to do that Okay, great. Thank you. Excuse me. I was just checking Checking a notice from the speaker trying to see that I also did want to answer a question from yesterday about the employer assessment and whether the farmers who employ these individuals pay the employer assessment. I think the The clear answer is maybe and I think it depends based on the definitions in the employer assessment chapter Definition of employer is someone who's required to pay unemployment insurance under the labor chapter um or labor statutes and then that can depend on On the employer And then in addition it depends on the size of the employer and whether they do or don't offer coverage to some or all of their employees and how much they would pay and there's a There's the first four full-time equivalents They wouldn't pay on so it's possible that some do and it's possible that some don't so I'm sorry for the clear as mud answer but I wanted to at least follow up Bill you're muted Probably just as well. It was a little bit snarky. I was thanking Jen for her clarity I mean that in a positive way Jen not not a criticism I gotta tell you it's Friday Uh Are there other questions about what we have in front of us at this point? So I'd like to suggest that oh, yeah represent golden My only comment is I just read this again and I just feel you know the sense of Gladness that we can do this small thing for this population. So I just want to Thank those who brought it forward and did the work on it. It's going to change lives in an important way So thank you for that Yes, uh represent Peterson You're you're muted. Yeah Jen would you put up the first page of that again, please? for me And the reason I ask is uh representative donahue asked about I just want to see the language around the Um undocumented what what it says just my own stupidity. I guess Wherever sure. So it's actually that probably the top of the second page okay, uh Undocumented immigrants who would otherwise After immigrants could we say who reside in Vermont? I think that again the residents issue gets complicated. Um, partly because you would need to Define it. I think but it does talk about people who would otherwise be eligible for medical assistance from the state Okay, so that would be people who would otherwise so that so that it piggybacks on the same eligibility criteria We currently have around people who are physically present in the state. Okay. I I certainly would You're the legal expert. I just want to make sure that you know My my biggest headache is that any of this is folks coming from out of the states to take advantage of it That's the biggest thing, but if you feel this is proper, then I'm I'm all with it What I'd say is that I think it aligns with the the Vermont presence requirement on our for existing eligibility um, and so So the same ways they verify that people are really here in Vermont in order to be able to enroll in our programs would apply here as well Residents gets complicated because it's usually about having a permanent intent to stay here and to return here if temporarily absent And for someone who goes back and forth to another country that may not always be the case. Got you. Okay. Thank you um Representative donahue and then representative page Uh, yeah with apologies to the chair. I I do want to make a slightly broader statement about About our healthcare financing Um, and I think there's a totally separate reason Why it's a good thing that we would be doing this um, and that has to do with an issue that this year we haven't even touched on um, but that Hangs over our entire system. We haven't looked at it in depth in years actually and that's something called the cost shift um that um Things get paid for one way or another whether it's uh in the chair mentioned this yesterday whether it's through the hospital Bad debt Accounting that shifts the cost to ultimately insurance rate payers But but the way we do it as a whole um, creates a very inaccurate picture Of our health resources and in terms of who pays We significantly under pay as taxpayers for health care that we make a policy decision That we think uh, we should make available to Very poor people in Medicaid. We don't pay for what we buy and as a result those costs are paid Through insurance rates, which means it's incredibly Inequitable because different people pay Very different amounts when they purchase insurance Based on where they work or who they work for or what their income levels are In contrast to if we are as a state buying something And we pay for it Through our taxes Then we have a more equitable system of taxation um So the the cost shift and the fact that it has been growing Um Anytime we're not keeping our eyes on it which we haven't done because we've had a lot of other issues We've had to deal with in the past several years It keeps growing and it keeps increasing that inequity and that hidden cost Um, and actually, you know right now is even significantly impacting our all-payer model Which was supposed to include Building Medicaid's fair share of the cost of the system And is not at all in fact Medicaid is Sharing less because when we hear it's level funded That actually means more cost is shifting So, you know, this is this is really good and important for a totally different policy reason um That in this case is a very very tiny piece but We got a book market That's an issue Do we have to at some point try to get back to and dig into more gateplay because it's it's a very serious systemic problem Thank you Uh, representative page Yes, I don't want to belabor this but maybe somebody could explain Get your woody. It's hard. You're hard to hear. Okay. I'll move up um I don't want to belabor this but I was wondering whether somebody could explain How we get the word out to these these families that The state of Vermont dr. Dinosaur Is going to look after reimposed natal pregnant women as well as Children Is that just should we just assume that that's part of the program of of of of advertising and and No, well, can I can I make a suggestion because I think your point again is very well taken and at the risk of because I We have a lot on our plate today, but the risk of For the delay. I think your point is very well taken And that perhaps is it is it conceivable Jane that we could just add a line to the section that says appropriate 1.4 million dollars and include something to to to include outreach To to include outreach to the affected communities that the agency of human services should Make a particular effort to do outreach to the affected communities. Uh, it particularly in this Next period of time in anticipation I think I think that might that might address some of the concern woody and I think it's a it's a what point very well taken So I can just add on To the end of that sentence. So after as set forth in section one of this act comment including outreach to the affected communities is that Mm-hmm What you're looking for great done great good I appreciate it. No, we and I remember that issue had come up and we even thought about whether we should have a particular section That spoke to that but I think that hopefully that That does that well, uh, what do you Oh represent boroughs Thank you. Um, I was just going to say that maybe we should have something that that a component that um Puts word out to the medical community as well since Part of the problem is that there was already a program in place that wasn't being used Okay, that's um Just just a suggestion And you're you're muted. I can't hear if you're saying something The affected and the provider community Yep outreach to the affected and the provider community Sounds good. Thank you Representative goldman I think yeah, I'm going to defer to represent black for a second if you're willing to come back Yes Should we have something that says language appropriate outreach? We're going to keep building this sentence, but I think these are all good suggestions Yes, I think it is important for us to be noting this uh I'm yes Representative goldman Um, I just want to say that we I think we should have some faith in our sort of public health community To do the job that they do so I do feel a sense of that that we can like I'm hoping and it's hard work But I do think that's work. They take seriously Um, I just wanted to respond for a moment with what representative donahue said about our overall system Um, I think It's quick and we're not going to spend any time on it I just want to throw out representative donahue was taking us down a whole another road and I'm I'm the chair I'm going to direct us to focus our attention on what is in front of us now You draw me back from the hole I just hope All I wanted to say was I hope she puts together a bill or if she wants to work on something Please speak to her offline Let's do it. That's all I'm saying I'm I'm gonna have to I can see now right now. I'm gonna have to kind of get us get us focused Okay, representative black. Did you have something in mind? Uh, thank you chairman leopard. I move that draft number 21 0936 a committee bill relating to expanding eligibility for dr. Dinosaur To all income eligible children and pregnant individuals regardless of immigration status pass favorably Okay, well that got the clerk's attention It'll be draft one point marie. Do you have your papers ready? It'll be draft 1.4 I think is what we had yesterday too. Yeah, we want to reference the draft. Yeah draft 1.4. Thank you Okay, is there a second second Okay, we have a second from representative goldman Uh, is there any further Comment or question before asking the clerk to call the roll Representative chena. I've been listening, but I do want to read the final version before I vote on it Like I don't see it in my email. I've been like listening and watching but No, I've been making changes as you've been talking. I can certainly send it out Okay, and I can read it quickly and please I'm probably gonna vote yes Well, he's reading do I think I know who the reporter is going to be but is that officially decided yet? Well, oh, it's got to go to a probes It's it's it will go to a great. It's a committee bill introduced And then it will I assume they refer to approach They will automatically refer to approach because it has dollars in it. Yep All right, I'll talk offline. I'm just gonna say in the meantime While I haven't made this an explicit inquiry, but I will publicly I was thinking that perhaps representative black would Be the reporter of the bill having taken the lead on work For our committee early on before we even knew that would come to a committee bill status Well, was that about freshman legislators always get an easy bill on their first one And and this is the other piece of that is this legislator will get full support from this committee On the floor and through the process and we will Stand strong with you I'm frankly honored that this would be my first bill. Yes. I'm pleased that you're willing to take it on Representative houghton Thanks chair. I just um I think we all know how important this bill is but I want to put a personal touch on it So last night my husband came into my office as I was on a zoom call and said my blood pressure is racing I'm anxious. I'm really concerned. I want to go to the ER I Ended my call without saying a word. I got my son to my mother-in-law's and I took him to the ER I never once did it cross my mind That there would be a problem with insurance never once Did it cross my mind that someone might ask like some questions of why Sorry, no I am there And I might drive home because I had to leave him He's home. He's fine I thought to myself. I can't imagine If I was pregnant Or had a child that wasn't considered To be eligible to receive care And I'm really thankful we are doing this and I'm really sorry Let me go up video No, you do not need to you're you're are completely appropriate in your emotion. There is nothing wrong with it And I appreciate your willingness to share such a personal story. I feel like every year I cry in this committee. I'm sorry There is there's we need to move committees No, there is room for tears in this committee because there are times such as now when they are completely Appropriate and I do want to say my husband's home any sign We're very glad to hear that I think it's important to recognize that the things that we do and the decisions we make Have this direct impact on the lives of people and that's really what I just heard from you is this this recognition of the The problem that this bill will seek to fix and I did read it in I was listening to you, but I did also read multitasking read this and I I am fine with it at this point So if you are waiting for me, you don't have to wait any longer Thank you. Thank you represent Gina Are we ready? All right. Is there anyone else who wishes to speak before we have I asked the clerk to call the roll Representative black, would you be so kind as to restate the title of Our committee bill So draft request 21 0 9 3 6 draft 1.4 A committee bill I'm sorry Relating to expanding eligibility for dr. Dinosaur to all income eligible children and pregnant individuals Regardless of immigration status Black Yes boroughs Yes Gina I Yes Cordis. Yes Donahue Goldman Yes Houghton Yes Lippert Yes Long Page Yes Peterson Yes And the motion is approved by a vote of 10 0 1 Thank you all I do think this is an important piece of work and One which we can all stand behind and be proud to move forward And we will When it will be assigned a number There will then be A reporter assigned officially and represented black. We will work together to support This presentation on the house floor and I think It's clear that this committee feels unanimously and very strongly in support of this bill So We'll we'll all we'll all be there together It's great Okay, um I'm gonna suggest we take a five minute break No, I see it's 847 So let me let me share something The speaker Earlier, I was distracted. The speaker has sent a notice out to all chairs that One of the bills on the calendar today is going to be postponed In order to create more committee time today, and I think there are many chairs that are pleased to hear that So but we will be going to the floor at 9 30. I believe is our custom on friday What I'd like to do is if we could just if we could go off video or let's let's take a break and Let me check in with legislative council Both gen carby and katie mclin to see When katie is available to us and we may Depending Anyway, I need to check in just to see where we are. So let's let's take Let's see. It's 848 50 Well, let's say that we'll be back here just just before nine