 All right, good morning. It is January 12th, and this is the Senate Health and Welfare Committee meeting. This morning we're going to get an update from our joint fiscal on our senior fiscal analyst on health care and health care overview, and that'll be helpful. And then later in the morning we're going to move on to try to understand some of the basic funding for childcare and families, because next week we're going to hear a little bit more about childcare. So, Dolan's welcome. Good to have you here. Thank you. And why don't you just take us through your presentation? Right. And Dolan, do you want us to stop you? Okay. For the record, Dolan will join fiscal office. The purpose of today's presentation is to give you a very high-level health care system 101. There are a lot of slides on this slide deck. I'm not going to go through each of them. It's partially designed to be a reference document as well, something that you can refer back to later on when you're like, oh, I remember the guy from JFO said something about these numbers and other chart. So, I'm going to blow through a lot of these, stop on the slides that are important. There's a lot of information here, and we're going to be actually doing this over two days. So, do half today and half tomorrow. A lot of what's in here is really me just trying to tell you a story, kind of the story of the health system. Sometimes it might be a little progressive, not progressive, but piece by piece to build up to what I'm trying to, the point that I'm trying to get to. Feel free to stop me at any point if you have questions. And another thing I'm going to say, and I'm going to say this again when I do my Medicaid overview, is that particularly we get to do more complicated stuff. With health care, if you don't get it the first time, it's not you. If you don't get it the second time, it's still not you. However, if you don't get it the third time, it's still not you. The stuff is really complicated. Medicaid, it gets very weedy, very fast, human services in general. I know people are coming from various levels of personal experience and professional understanding about this. So my job, I feel like, is to help build that foundation and try to get everybody on a level playing fields that when a budget adjustment comes in or as a Medicaid director, you start having a little bit more foundation to get there. As I said in orientation, I feel like my job is to help give you guys the tools to make informed decisions the best that you can. So I have a tool, a resource, use me. Chair, could I ask a quick question? And I should have asked this yesterday, but what's the difference between the filming that's happening here and the filming that's happening there? Oh, okay. Thank you. That's a very good question. That is Peg, public television. Orca in this part of the world, and our part of the world is called Channel 17. CCDB. So there, are you sending it directly out or recording? You're recording. So that will go out at some point in this area, perhaps other parts of the screen. Great, thank you. That's a good question. Well, I'm live here anyway, so I guess there's no difference. I didn't mean to give you an answer. So I'll just start with the basic caveat of that. I've moved through a lot of different numbers at you throughout this presentation. I generally tried to flag what year it is, 2019 or 2022. But just with the understanding that a lot changed during COVID, COVID really shook up a lot of our consistent trends and made things very inconsistent. So it's just more of me just caveatting things. So you might see some things and also there's a drop. I'll probably try to explain when those happen, but this is that sort of new reality in the world that we live in sort of post-COVID. And also finally, I try to break this presentation into four pieces, patients, providers, payers, regulators. If I am talking too fast, let me know. I'll try to slow down. I'm just going to try to cover as much information as possible. And also I feel like with the chair's blessing, just I think ask questions as we go. If you have a question, just ask. So we'll start with patients. This is really just a population slide. Again, just high, high, high, high level. You can see our population really didn't change much until about 2020. I won't get into the population demographics, but we've all heard the stories. But again, this is sort of our tradition. We've heard a lot about, you know, Vermont has an aging population. Well, this slide shows that you can see that our 1824s have pretty remain flat as the red line. Our 0 to 17s have gone down, our 65 plus have gone up. So this is a consistent problem. And this is a theme within the healthcare system, too. And you'll see that later on as we see some of the shifting of who's being into what payer source and where are our expenditures. I'll skip over this. So healthcare expenditures, this is just meant to give you a picture comparison to the United States. In Vermont, our overall health expenditures in the state of Vermont were 6.37 billion in 2020. We have a two-year lag on some of our data. This is from the agreement on care board. I always try to give the most up-to-date number on 10. If it's an older number, that's because that data isn't available. Or like with this particular stuff, there tends to be a two-year lag in that data. The equivalent spending in the U.S. was $1 trillion. You can see that our spending from 2019 to 2020 went down. The U.S. still went up. This is a pandemic type thing. I don't know why ours went down and theirs went up. But it could have been because the federal spending offset a lot of that. I don't know what the story is there yet. But our per capita spending is still lower than the United States. It's $900 per capita, almost $12,000 per capita at the state level. Again, at the nation level. Again, you can see ours is dropping and the federal government has gone up. But our state growth product is a little bit higher, roughly equivalent to the United States. This is really a pandemic slide because you can see this is our overall spending growth and spending from 2020 to 2020. It has traditionally gone up. You can see 2019 actually dropped 2.5%, almost 2.5%. That's the first time that there's ever been a drop that I can remember in health spending since we've been recording this stuff. Again, that's a pandemic effect. But nonetheless, I wanted to show you that when we talk about healthcare costs are going up, this is one of those things that shows this is overall health spending. When we talk about health spending, there's two ways of thinking about it. One is how much we spend on behalf of, how much is spent on behalf of Vermont residents. So that would include I go skiing out of Colorado, I break my leg. This would count as well. And then we have our provider perspective, which is I go to Colorado, I break my leg if it doesn't count. But someone from Colorado is skiing instead of breaks their leg if that's counted. So there's two ways of looking at it. What I am giving numbers, I'm generally coming at it from the cost on the resident side because that's off in our perspective. We're thinking about things in terms of the residents of our state. So this is the resident spending. So we spent $6.3 billion total across the whole healthcare system. This is just another slide, just sort of comparing national to the federal. We'll go through this. We'll move on to the provider's hospitals. We're going to talk about the different providers in the system. Hospitals are our biggest. There are 14 hospitals in Vermont, all of which are not for profit. I don't know of any other state that has a full, not-for-profit health system. We have one level one trauma center. It's the University of Vermont Medical Center. There's also the Dartmouth Hitchcock, which is not in our state. We don't regulate it, but it's part of the Vermont health system. Our numbers, so when I talk about the resident expenditures, it would count for monitors who go to Dartmouth Hitchcock. We also have the VA, which is the conjunction, and then it's the psychiatric care hospital, which is the psychiatric care hospital of Berlin, which is run by the state. And then there's Browell Borough, which you'll be hearing a lot about both of those in the coming days. So what a question about the hospitals. We also have the UVM Health Network that affiliates with Plattsburg, and then a number of folks in the Bennington area access Albany. But they are not... How do we... We regulate health facilities. We don't regulate them at all, but our Medicaid dollars might, and Medicare dollars might flow. Yeah, I mean, if you have a Vermont resident who's covered by the Vermont Medicaid, and they provide a service, and they go out of state, Medicaid's going to pay, because that Medicaid is there providing, or they're paying. And by scripture, we have people who come to Vermont and they might be on Medicaid, and that Medicaid will pay as long as there's no rules. Spending on hospital care was $2.2 billion. This is a 7% increase. This is 34% of all health spending in Vermont is hospitals. So that's 6.4, 34% of that is hospitals. There are total 214,000 visits to emergency rooms in Vermont. The University of Vermont Medical Center accounted for 23% of those, followed by Rutland, which was 12%. 12.5, Rutland UDM also accounted for about 12.5... Sorry, 12.5 of these emergency room visits resulted in an admission into the hospital. And then roughly 1.3 of these visits were paid for by private insurance. There were 41,000 inpatient discharges. Those who were 65 are older accounted for half of all those inpatient discharges. Medicare was the principal payer of 50% of those times. The average length of this day was 5.3 days. And again, University of Vermont Medical Center was the biggest priority accounted for 45% of all inpatient discharges. And then there was 114,000 outpatient visits. Again, University of Vermont Medical Center accounted for 45% of those. And Medicare paid for 50% of those times. So you're starting to see the trends. This kind of gets into an immigration, non-migration question you were talking about a moment ago. This shows you sort of where patients are coming from in the state. So statewide, 13% of total is on discharges. 13% of inpatient discharges were for half-state residents. Of course, that varied depending on where you were. So if you look on the chart on the left, you can see that in Bennington, 30% of their inpatient discharges were for half-state residents. Nor is North Country half-state discharges accounted for a much smaller piece of there. What this doesn't count, again, is that flip side of how many Vermonters are going to darken the pitch time. Quite a few. Years ago, the number was close to 20% or something. It was a Vermont resident accounted for a very noticeable margin of revenue for the university for the Dartmouth-Hishcock system. So you said it's 20% of Dartmouth? It used to be somewhere in that range. I couldn't tell you what it is now, but I'm vaguely remembering that it's not as significant a number of Dartmouth-Hishcock business and vice versa. They cover a big chunk of Vermonters in which try to the lens you're looking at. I threw out 20% but don't hold me to it. That's a number I remember reading years and years and years ago somewhere in that range. But I shouldn't sit down now. Oops. So another important piece of our health system or we're known as Federally Qualified Health Centers FQHCs. We'll be hearing a lot about them. They're an important part of our primary care network. You'll be hearing, I assume, at some point from an organization called Bi-State Primary Care. They're the trade organization for the FQHCs and the ones who represent the interests of the FQHCs in the State House and throughout the state. Actually, throughout the English. It's a reimbursement destination from the federal government. They're reimbursed differently than regular providers. They have a largely regulatory burden in order to get those special reimbursements through the federal government. That could include about 90 requirements or some more to keep that FQHC status in return. They get a better reimbursement schedule from Medicare than regular other providers. But they have to meet standards in order to maintain that. Some of the defining components would include the offer of comprehensive services, including primary medical care, dental, oral, other mental health services. They generally need to be located in an area of high needs, so a place that might not normally get health care services. That's why you'd often see them in more rural areas. They have to have a patient majority governing board. And then they accept all patients who are this payer or ability to pay and have to offer a sliding fee schedule. So you'll hear more about them in the future. Chair, can we just ask questions? Yeah, go right ahead. Would, for example, in Burlington, would the Community Health Center be an example of FQHC? I think so. This is just a list that shows you kind of where they're at with the people that they serve. 2020, it's 170,000 for Rogers. So they're not an insignificant part of the system. And they provide critically critical services, for the needs of services. Another part of your jurisdiction you're going to hear a lot about is long-term care. We have 37 nursing homes, 34 of which participate in Medicaid. As of October 2022, that was about 2800, almost 2,900 beds. I say that because the numbers of beds often fluctuate. Sometimes it's, sometimes the beds fluctuate because of licensing, sometimes they fluctuate because of nursing and goes out of business. Sometimes they fluctuate because of staffing. They might not have enough staff to staff those beds. So there's a lot of factors that go into those numbers, but they fluctuate. We have 10 home health agencies, 17 assisted living residences, 100 residential care homes, 10 hospice programs, and then what is known as an SCFID, which is any Medicaid care facility for individuals with intellectual disabilities. It's a group of people with special needs. Mental health, you're going to be hearing a lot about whether, if you haven't already, I know that you had Commissioner Hawes in the other day, so I imagine she talked about our designated agencies. So we have nine designated agencies. Again, they're an important piece of, they're a criminal piece of our governmental health and developmental disability network. I won't go too much into these because I think I would defer to them to tell you more about it, but it's just in here as a reference and again, and they are critical and part of our mental health system. We do have, I did mention, we have 193 adult psychiatric inpatient beds across the system. These were numbers I got back in October again. They might have fluctuated. Some of the beds, again, might be closed because of staffing, but these are the amount for which they're, I believe, licensed for. So we have 25 of them. Vermont psychiatric care hospital. We have 24 at Rutland, 80 at the Brownville Retreat, 14 at Central Vermont Medical Center, 12 at the VA, 28 at the University of Vermont Medical Center. So I understand we're early in your presentation. I don't want to jump too far ahead, but this is all about capacity and I'm wondering if you're, it sounds like we're going to touch on need. Is that part of this analysis or not? It's 193, okay? I don't know that I'm going to get to need in a direct way. It's probably going to be more in an indirect way. I think we'll show you when I get into services and payers and uninsured rates and those kind of things. So it's a little more indirect. I mean... Yeah, so we'll be bringing folks in so we can understand where the gaps are. Yeah, so that right now, long-term care and mental health have significant gaps and problems. So we'll hear from the different providers. And the budget? Yeah, everyone is implicated in what you're asking about. So this just gives you the... I think this is important to understand what we do have because then as you hear about the gaps, it could be workforce gaps, it could be a bed gap, it could be a whole facility gap or all the different elements. I think the different constituencies will be coming in to tell you what their needs are. And I'd rather them be the ones to tell you what they need. They want you to tell them. Well, if I could just piggyback on what Senator Lee said, this is so great. And it'll be even more powerful when it's put into a context that is real-world lived experience. Thanks. Yeah, this is just meant to lay the groundwork so when people come in, they're like, oh, yeah, there was a slide on that. And you guys are in the system? Yeah, so when somebody says, Broward, we're over a tree, you say, oh, let's see, I'm not there. Yeah. In previous, I've been doing this presentation for a decade or more. And I recently added the workforce slide in here because this is a really critical piece. During the pandemic, there was a lot of conversation about workforce. Workforces, as you know, it's something that's one of the biggest needs in our system. And so, these are some data. They're from varying pieces, but again, this slide is going to start telling you to start. So this 2018 data for physicians, but you can see there was about 2,473 physicians or roughly 1,400 FTEs that were providing care. Quarter of those were primary care and 75% of those were specialty care. You can see the trends were, in primary care, we had fewer and fewer, 21 less FTEs, 21 less physicians or 33 less FTEs in 2016. And in the prior survey in 2008 or 19 less, there seems to be a trend of less and less. If you look in specialty care, there was 312 more. So you can see that we're getting physicians, but they're often going into specialty care. I won't tell you the reasons why, but we have heard those and we will hear those again. But that sort of highlights. There's need across all. We need specialists in primary care, but this sort of helps show where people are kind of going based on this. That's the story that this survey is telling. Got two questions here. Nurse practitioners. So does that... Next slide. Okay. This slide. In my world, FTE is full time equivalent. Same set. I should have said that. Another piece is that when we've talked about workforce, we've talked about our different programs that we offer in the state. So 33% of physicians attended medical school, ran a residency in Vermont. And then 30% are under 40 or 30% or over 60. So again, just taking a sense of the workforce. Physicians assistants are becoming more and more an important part of filling that gap. We have 355 physicians assistants in 2019. 111. 31% of those were in primary care. 70% of those were in specialty. Mainly. Again, you can see that the trend unfortunately for PAs is that it's going up. We tend to have a little bit more than we did in the previous years. It seems to be moving in the right direction for both specialty and primary care. However, there are no position... There's no PA program, training programs in the state of Vermont. So all of our physician assistants that come to Vermont are coming from out of state in terms of training. They're coming from out of state. Most are under the age of 44. There's a kind of demographic in that population. So it kind of shows that they're helping to sort of fill in some of that important gap. Nurses. This is various years of data. We have our advanced practicing registered nurses our RNs, our LPNs and our LNAs. So I will walk you through the slide of each particular one. But again, the story is showing you that the number we have licensed in Vermont the percentage that are actually practicing in Vermont, the average age you can see is between 40 and 50. How many are under 44? How many are over 65? How many are sort of looking to further their education? What percentage are full-time? What percentage are traveling nurses? So this again is helping you to tell the story of what our emergency workforce looks like. Dentists. We don't actually talk a lot about dentists in the legislature. Yes. Except for Senator Hart. There are 389 dentists. Most of those provide main primary care. Again, I break out the age break so you can get a sense of where our workforce is. And then this has sort of been staying the same. The net number of dentists stayed the same between 2017 and 2019. However more were providing 30 hours or more per week. So that increased the full-time equivalence by 3.3 because they increased their hours. The percentage of dentists accepting new patients was 97%. So that was good. But only 55% of dentists were accepting new Medicaid patients. And that's a problem. Particularly because reimbursement rates for Medicaid is extremely low. So now we're going to move into the fun stuff. We're going to be a little bit more meatier. Not meatier shower, but we need to hear. So this is a high level. This is what our insurance coverage looks like. I tend to think about things in terms of private and government. So in terms of private insurance we have our employer base. We have our individual market. We'll get into a little more detail on the future slide. But what's also important here is to see that we get 49% of Vermonters of private insurance. 24% of Medicaid. 21% of Medicare. 33% of military. And then we have a 3% uninsured rate. Yes. Do you know how that 3% uninsured compares to the nationwide? Yes, it's much lower. I don't know what the national rate is. It's probably at least double that. Vermont and Massachusetts traditionally have the lowest uninsured rates in the country. No one has really gotten below three. Can you characterize the group that's uninsured in different groups within that category? I have a slide later on. So there's a document called the Vermont Household Health Insurance Survey. And I can send folks a link to get a lot of this information from that. They have a whole section on uninsured and underinsured. And they ask, well, why do you have an insurance? There's various reasons. The whole reason is cost. There's also a tron in people as they switch health plans. There are also a number of people who don't have it are undocumented migrant farm workers. A lot of it is just switching between things and walling through the cap of grant crafts and eligibility for Medicaid as well. Yeah. So if you could send that link, that'd be great. Yeah. We could get it to Alps and he'll get it on our page. But a 3% rate is really, really low compared to most states. And I don't know getting from 3 to 2 is probably more work than getting from 10 to 3. Yeah. Right. There's reasons. And this slide is another way of looking at it over time. And again, I like this slide tells a story. If you look at 2008 the number of private insured was 60%. If you look at the government, and that's the Medicare and Medicaid combined, it was 30%. It was 30-60 split. If you fast forward to 2021 the number of folks on private insurance decreased to 49%. The number of folks on Medicare and Medicaid increased to 45%. So we're seeing a shift of folks from private insurance as their primary to some form of government. Now, there are a lot of reasons for that. We have an aging population so we have folks that are going to Medicare between 2018 to 2021. We had the Fourth Care Act. We've had a lot of initiatives in Vermont to educate expansions to try to move more people into to get more people covered. Because the uninsured rate was 8%. And that was 3%. So a lot of those folks went to Medicaid. So we had expansions. We had policies that have tried to encourage folks to enroll in Medicaid. There's another small piece that's not represented here. You're going to hear about this. I'm going to go a little off script for a second. But we are in the middle of the corona I have this presentation I'll give to you tomorrow. But I'm going to give it to you now too. I need to tell you the story. There was the Coronavirus Relief Act one of the federal bills that passed. And what it did basically was it gave states an additional federal match for their federal matching. I'll get into federal matching rates later. But part of the in order to receive that money one of the things one of the requirements is this thing called maintenance of effort. Maintenance of eligibility. And in short, normally Medicaid has what we call churn Senator Harding when we think of this churn. You have people come into the program people come off the program. And that's because there's this thing called re-determination. Annually, people run Medicaid the system that looks at their eligibility are they still eligible? But they're in can go up they're in can come down to get insurance elsewhere. And so we tend to have this churn of people coming out and people coming off the trend's still going up because we have more people traditionally coming down and coming off. But it's a steady trend when the maintenance of effort goes into in the place we can't do re-determinations while we're getting this additional match. Because there's this requirement that says you can't change the eligibility rules you can't do re-determinations etc. So what happens now is people are coming out but they're not coming up. So we're seeing this spike in enrollments that's going up. And you're going to hear about that in budget adjustment it's going to be a piece of that and you're going to hear about that in the budget. Now yes, spending is going up but it's not commissary. Just because people are staying on it doesn't mean we're seeing the same spike in the annualization. We are seeing increased utilization for short. But just because people aren't being disner old doesn't necessarily mean they're using services. Many are. And there's definitely an increase across but that's part of what that additional federal matches is doing is providing that fiscal relief to the state. So without getting too much into the lease that's a piece that's going to skew the numbers in the future. But there is this piece and I want to be a little bit of a foundation when Diva comes in does our budget adjustment and talks about our caseloads of change or the caseloads increase, the realization increase. Redetermination is part of that story. And that's the thing I asked the secretary about yesterday was their pre-determination because once the public health emergency ends, redeterminations are supposed to restart and then there'll be more people coming on and off of Medicaid because of it. But there's some complicated time happening with the redetermination restart and the public health emergency ending. And that's going to cause some complications with the numbers. And that's what I was asking the secretary about yesterday when she was in. I shared the stage with Ashley Berliner yesterday and she had a little bit more information on that and she talked about some recent federal legislation that was addressing that. We're going to get you and Ashley in so we can come back and take next week. So we'll talk again if you can ask her about it. She knows more about it. Yes, we can get everybody here and next week we'll go with everybody here. Yeah. Just to make sure I'm understanding the jargon or elm enclosure. I was going to say say it all over. One more time. So, yeah, is redetermination the same as churn? Are they sort of the same thing? Sort of, I mean yes, redetermination is an element that controls churn or is a factor in determining the level of churn? Because we have churn in all types of things. We have private churns as well. But redetermination is a factor. It's one of the major elements in the Mediterranean churn. Doctor, thanks. Okay, so you told us that we didn't understand it the first time. So the difference between churn and redetermination? Redetermination is a policy. It's a technology. They go in and every year they look at eligibility. People have to submit a documentation and they say, okay, you're eligible and you're not eligible. So churn is the normal flow of things. I'm new to the program. I come in. You've been on the program and you've got a big wage increase and you've got your job and you've got private insurance and now you come off. That natural flow of things and the levels of it. And now with redetermination not being there, you've got a new job, we don't know. You're still technically on the Medicaid books. So there's no churning because redetermination is on pause. Thank you. So you go back on screen now. I like this slide. This is an agreement on care work. It kind of shows you where spending is. So for instance, the government spending that's Medicare and Medicaid combined and then the red is private insurance. So you see for things like home health and nursing homes the large part of those is government spending. But when you look at like you start getting into physicians and hospitals it's about either. Then you start getting into like dentists and other stuff that's being more private insurance. So that's just, I like this because it kind of tells a little bit of a story. We'll start getting into a little bit of the weeds now of the breakdown of private insurance. Again, remember 49% of the monitors are covered by private insurance. I'm going to Well, I'll talk about this first. So the majority of private insurance is employer based. Meaning that folks who have private insurance are usually getting it. The majority of those folks are getting it through their employer. So those would include folks who are self-insured or insured. And I have a slide down the road that tells the difference between a self-insured and insured. So I won't pause that for a second. But you'll hear the term large group, small group, individual market. And that has to do with the group and the type of insurance and the size of the employer. So if you're an employer over 100 and you're not self-insuring, you're usually a large group. This particular population is a smaller group. A self-insured group is a larger group of people better than that. And then there's a small group which is 100 or less. So if you're an employer who offers insurance and you're 100 or less you're considered a small group. And then the individual market is folks who do not have insurance that they're employer. They might be on the exchange. You can buy a small group and individual group plans through the Vermont Exchange and the Vermont Health Connect. And I'll get into a little bit more of these on that in a moment. But this is a slide that I wanted that actually Representative Houghton asked me to put in there. It was basically an important piece. This is sort of like when we talk about who are segments of the market for which the legislature has some regulatory control of some sort. We have as I don't say influenced by the state. So we regulate individual market group, a small group and a large group. We regulate them through the Vermont Care Board who insurance companies have to file rates with them and they look at the see if the rates are reasonable and there's a role for the healthcare advocate in that process. Also the Department of Financial Regulations looks at the rates for solvency to make sure there's enough reserves and that they're insolvent. The other piece that we regulate is Medicaid. But we as the state are the care, we are the provider. So we review, regulate them through the state budget process and then we review other pieces in terms of we want Medicaid to cover this, we want Medicaid to cover that and that's what we're going to get into next week when we start talking about the global commitment. Global commitment just to sort of put it out there now is the name of the agreement that between the state and the federal government for how we administer our Medicaid program. That includes what we cover, who we cover, so that we'll get into a little bit later on as well. What we don't regulate is all the white. So obviously we don't regulate the Medicare, that's full federal. We don't regulate military insurance, that's the military. We don't regulate getting insured because they're not regulated. And then there's the self-insured and you can see that's a pretty big chuck. The self-insured group, I'll get into it in a later slide. It's actually the next slide so let me segment into that. In terms of the uninsured and those folks we do have we do have clinics that provide services for them and so that includes some of the non-residents who are undocumented and it also includes people who don't have insurance so there's one where they're being buried. I know there's one in Addison County so there are clinics around that do support people that don't have the coverage that many do. Real quick I just want to let you know the reason I'm coughing is I've had that respiratory thing over Christmas and now I've got that cough that never goes away. I promise you I've taken a lot of COVID tests I'm not sick, I just have a very very dry throat so I'm just letting you know I do not have that. I don't have RCD, I did I think I don't know but anyway I had that respiratory thing over Christmas and I'm still coughing. I have asthma too so that's the trick. This is a good committee to be in. This is a good committee to be in. I'm not contagious I usually wear a mask anyway and I don't have COVID. I have it too and it lingers a long time. I have a question about the slide. I'm confused. The title of the slide is Private Commercial Insurance. That was because when I made the slide I cut the pace of the virus and said have all the backgrounds and I didn't change the title. I should have called it. What should the title be? Title should be not private. The title, thank you, thank you. What do you want to think when you start a new student? Regulated influence by the state. Got you, okay. Thank you for that. There are a lot of slides and I upgrade them and you spend so much time on something you start losing sight of. Thank you for that. No thank you. And also was kind of in that section of things. Real quick insured versus self insured. For instance the large group in the small group market. In that case it's like I'm a small employer or I'm a large employer. I decide I want to offer insurance to my employees and so I go to Blue Cross for a shielder and I buy a plan for all my employees and I pay 20% of their premium and I just pay premium every month. Self insured is where the employer basically assumes all the things they're not paying. Instead of like paying for an insurance plan where they insure I'm paying the premium and then they insure I'm paying for them to have the risk. Self insured is where I'm saying you know what I want to I think that I can assume the risk. I think it's cheaper for me to pay for those claims when people get sick than for me to pay a premium every month which is why a lot of time you see large companies doing this and they have wellness programs these things in place I make sure they have their musicians and I give them bonuses for walking 100 miles and those kind of things. What they still do is they'll they're still their card might still say Blue Cross Blue Shield on it though because what they're doing is they're hiring an insurance company to be what's called a third party administrator or TPA and the insurers offer products for companies like that well they'll still they have all these different benefit packages to register the claims but the employer bears the risk they'll pay the cost someone gets sick and goes to the hospital the employer will pay it but it's still they're balancing they're looking at as a risk benefit analysis in terms of like I think I have a thousand employees and if I have two people that I would say it's a business decision and usually if a company is self insured they've done the numbers and say you know what I think this is a better risk for me to do it that way there are also the differences is regular insured products like small group and large group they're subject to state regulations so for instance you know several years ago we started to require we put an mandate that they have to do insurers have to cover colorectal screenings or have to cover mammograms so insurers have to cover those but self insured do not because they are not regulated by the state they're regulated by and I don't want to get down this road I'm going to let this thing call ERISA and it's got some what I meant retirement I don't know what it stands for yeah something and basically it's a federal law that it covers a lot of things but I don't think we need to get deep into it but you'll hear people call it ERISA plans or self insured plans it's the same thing when people are using those two interchangeably but in short if it's an ERISA plan or a self insured plan like we have no regulatory authority over those plans so and I just will say and then when the federal law was passed there was a huge discussion about self insurance which states could regulate at that level and Hawaii does not have Hawaii was excluded from that so they now have that authority to regulate insurance over all including ERISA plans and then there was a period of time in my history in this building when we had some legal analysis of to what extent can we regulate ERISA and there's a difference of opinion about that we won't talk about it it's a very easy round of call to go down some yes some no so it was legal debate about that and then so we continue to look at how we can provide oversight for self insured plans to ensure that that people are covered effectively so that we will come back to this at different stages we may see something so if we were to today which we can't really do because there's a whole lot of other implications but if we were to do another mandate saying we want to cover hearing needs we just have to throw that out we would only be affecting that small blue sliver of the population in terms of being required of course then we'd say well we're going to do it for that we want to do it ourselves and cover it and medicate but that's a separate decision if you're going to mandate commercial habit then then it's a question of whether we should make Medicaid do it as well but that said it doesn't mean that those private insurance with this ERISA plans are already covered in many cases we found when we were covering when we said we were demand grams and other things a lot of times like IBM and other large suppliers were like we're covering that already so it's not like some of the mandates we've done I don't know if they were between that and specifically but a lot of times these bigger self-insured plans often cover a lot of what we're covering anyway but we can't tell them to do it I think Senator we'll have time for questions thank you chair yes I do next one please yeah could you just for clarity give us an example of an organization that would fall into that self-insured category Middlebury College University of Vermont State of Vermont sort of we're self-insured but we're public self-insured it's a lot of different rules theoretically the state of Vermont is self-insured can we do the same for the insured yeah small lawyer practice a lot of small businesses nonprofits it's too late thank you no thank you one question what I understood before I came to this door was Medicaid, state, Medicare and federal how many insurance companies are actually allowed to operate in the state so it's a great question there are a lot they don't have the list but there were somewhere between this parliament's 50 so I've seen this report that the Department of Financial Regulation puts out and they have every insurance company that has somebody covered some of Vermont during the state so you might have some small something mutual it might have three people from Vermont but that's because those three people work remotely and they work for a large company based in Oklahoma but they are I think that they are I believe, I'm not a lawyer they may be subject to some federal state regulations but the bigger question is the vast majority of Vermonters are covered by either Blue Cross, Blue Shield of Vermont or MVP the two of those combined are somewhere between 80 and 90% of Vermonters and that includes self-insured who have them through a TPA is that the case with Medicaid? no, Medicaid Medicaid is its own insurance company Medicaid is not self-insured Medicaid administers the product processes its own claims it's technically is an insurance company but it's not really an insurance company yes so we've got federal rules and guidelines and then we have state rules and it's within DEVA the Department of Vermont Health Access in AHS so yesterday we heard about DEVA and that's where Medicaid is but then there are other there are two issues that Medicaid in different parts of the AHS it can get complicated quickly right I'm sure we'll get more you'll get more comfortable and to clarify I'm at 80-90% of privately insured so 80-90% of that 40-90% there it is so here is sort of that breaks out that private insurance group so you can see of that private insurance of that 49% 74% are self-insured 15% are small group and 7% are large group so 3 quarters of that 49% are employer sponsored plans which includes the military because the military is technically an employer and they have their own but you know more about than I would I'm not sure so the 3% military or roughly with the overall population is that active duty or retirees I believe it's active duty I don't know about retirees it's about 16 howl folks I'm not sure how they're calculated in that particular in the health insurance survey I'm not sure I believe it's tricare I believe it's tricare that's what the military is good question I don't know the answer 16,600 remoters have military so primarily so health benefits exchange this is something you'll hear a bunch about health benefits exchanges were created by the informed care act and they were designed to be online marketplaces for the individual and a small group marketer small business again, employers under or lust is a place for people to be able to buy health insurance it is administered by the remoters Department of Health Access so technically it's administered that the online marketplaces are administered by Medicaid and the reason that is is because they administer subsidies for folks but it's one stop shopping this is the breakdown of the folks who run either so of the small employers again we define them up to 100 employers there's 40,000 people who are in a small group and then on the individual plans as just the blue and the yellow it's approximately 30,000 folks who have individual plans 3 fourths of them receive financial assistance and that's both state and for federal so the federal the different assistance programs that are out there is what's called the federal advanced premium tax credits or APTC those are for folks up to 400% federal poverty and before you're asking what 400% federal poverty is if you go to the very very last page of this printout I have a field chart you can look it up but essentially 400% federal poverty for individual is $54,000 a year for a family for it's $111 I usually have an FDL chart but I gave one to this group probably put one back up there I usually give them to my committees it's going to come up with a lot it's going to come up with child care conversations then you can folks also can get additional state tax credits available up to 300% why 300% that's because prior to the Affordable Care Act the state had a program called Catamount Health we had negotiated with the federal government to allow us to subsidize those Catamount Health products for folks up to 300% so when Affordable Care Act passed and Catamount and BHAP had to go away we were able to negotiate with the feds for us to be able to have state matched dollars on subsidies up to 300 we wanted to do 400 if they said no 300 is where you have to catamount that's where you're after this so the tax credits essentially are through the tax system but they help lower folks monthly maybe at some point I don't want to interrupt you talk about the value of having a higher risk pool a higher number of covered logs and how that helps to lower the costs that's a whole insurance conversation by the way I have a whole presentation on insurance coverage we can do that you can put me on agenda for that I'm doing it for house health care next week but I do talk about risk pools and again the weeds are deductible so yes we can go down to saline Alex is taking note that we want to have you do that so in addition to tax credits which help reduce folks monthly premiums there's also what's called cost sharing reductions there's federal and there's state cost sharing reductions again you know the state we cover them up to 300% of federal poverty and what that does and this is the premiums it also essentially increases decreases out of pocket costs essentially helps folks so their out of pocket cost liability is reduced because the state is subsidized for that as well but in order to get those you have to buy your insurance through the exchange now if you're someone who's over 400% of federal poverty or doesn't not eligible for premiums you don't have to in kind of a subsidy you don't have to buy through the exchange you can buy directly through the insurance and in many cases it might be better for you to do so we have done things with the markets to try to help folks who don't have exchange to bring down their payments a little bit and I won't give it a week on that because that goes out of a really dark and grab a hold real fast like those of us but in short if you're over 400% of federal poverty and you don't have to pull your response to insurance and you have to buy it, you can just go to the insurance directly as a matter of fact I'd recommend asking you to do it but you still could, Mike wants to say something can I phone a friend, Fred wants to say something absolutely introduce yourself this is Mike Fisher, healthcare advocate at least for the next three years through the enhanced premium tax credits there is in effect not a 400% cap on premium tax credit cap on the percent of so the temporary for the federal premium tax credits it's above 100 now temporarily for one of the current buyers we did a lot of temporary things during I should let it be I think it was in the inflation reduction act actually yes it is see this is why I'm here I don't think there's a view we were right so real quick I was mentioning 16,000 3% of folks that military coverage covered on current previous military service and I couldn't tell you if it's a retiree or not that's a good question yet in short you can see that from 2012 to 2021 the number of uninsured dropped so in 2012 we were at 20% and in 2021 we were at 3.1% I give this information again from the Vermont hospital health insurance survey up those uninsured 20% were actually eligible for Medicaid this gets into how do you get below 3% a lot of folks were eligible for Medicaid and for whatever reasons they didn't apply if they were sick sometimes they don't want to stigma there's multiple reasons why folks were 52% of those uninsured were eligible for state or federal tax credits or any kind of subsidy and another 33% of those had access to some form of people-responsive insurance the most common reason cited why they did not take their employer sponsored insurance was that it cost too much cost was the primary reason so we're starting to get into some of the reasons why folks may or may not have insurance so as long as those folks have access to insurance but they do not take it for whatever reason usually cost obviously I threw this in here because of the pandemic but this is what needs to be surveyed and of those who were unemployed or furloughed during the COVID-19 pandemic 84% and 18% coverage so this is important because even though people had lost their jobs with furloughed a lot of companies kept people on their roles and kept them insured or people paid for Cobra or Medicaid or whatever but a lot of them stayed on and you can see a quarter of those it's because they were on Medicaid or Green Mountain Care which is Medicaid where they had two spouse and they paid Cobra so in short COVID-19 did increase the amount of sugar in a little bit but not as much as you think because people maintained their coverage due to the pandemic what I like about this slide is on the left is the same chart I showed you before 49% of private insurance 24% Medicaid this is total population however if you look on the right side this is just kids this is just kids under 17 and under you can see that we only had 1% on insured rate for kids it's only 1200 kids in the state of Vermont on insured but 52% of the kids in Vermont were on Medicaid so you can see a slightly different looking chart so I wanted to just sort of show like wow like power covering kids now we're going to get into Medicare and Medicaid I think probably when we come back to this when we get you in the next time tomorrow I'm not good we're going to take like 3 minutes alright well we're back this is senate health and welfare continuing on January 12th and we have folks from DCF here with us we have Melinda Gray welcome and you will introduce yourself for the record and we hazard will also do that so we have our deputy commissioner why don't you start first thank you so much for the record my name is Melinda Gray and I'm deputy commissioner for the child's health and education and I'm a hazard I'm a child care benefits administrator for the child care financial assistance program good excellent and so Katie are you going to give us a background on the bill when we're at 11 o'clock we'll touch on let's do that and all to say that as we catch up on the work that we have done with regard to child care and then knowing that we're getting a very important report this next week on the 17th from the grand corporation on financial on the finances for child care so I thought it might be a good idea before we start reading a report that we understand the baseline for child care investment and oversight so that's the goal today and I'm very happy that you could be here at this time thank you alright thank you we appreciate the opportunity to come and talk about this and certainly there are additional questions if I didn't quite get what you were hoping to learn today then let me know if you want to come back with further information do you want to share a screen I didn't bring that ability Alex can put it up if you'd like that because we have your information here so we could put that up if you want us to is it on our website yeah I think we did print out copies I'm sorry this is for somebody in person for the senate oh my gosh we've been on zoom yes I think I'm all about that I know still there are certain rules that only bring paper at least so now it's like those are changed we've modded on we're in the 21st century now that's why I have my paper in my life yes we're going to put it up okay you will thank you and that helps that's good terrific yeah I forgot we've all been remote it's been a nice week it is it is very nice and now but thank you for your kindness and my learning about what we're all learning we have the best technology okay so we are in the child development division and we're going to talk to you about the child care financial assistance program today I'm sorry it's already got to say next slide please so we are going to share about what the rate structure is as well as what the eligibility criteria are for the child care financial assistance program I believe the request is also to talk about the landscape of the child care scheme including workforce and then also child care resource distribution so that is next slide please so is the child care financial assistance program administered by us and it's our mission it's part of our mission to improve the well-being of amongst children the program provides some or all the costs for early care early education and school age care for eligible families helps ensure that all children ages six weeks up to the age of 13 and for those special circumstances for children up to the age of 19 years old have access to quality care is that cgd contracts with 11 community child care support agencies these specialists help families find child care and they also determine eligibility for the families so we have time is it okay if folks interrupt you with their questions absolutely okay so we'll do that okay the program assists many different types of families whether care-based or students looking for work are retired or working to give you kind of a baseline a family of three with a housing income of $80,000 a year qualifies for some assistance current budget $62.75 million which is a combination of both general fund and federal funds not as our child care development block grant so maybe are you going to talk through each of these like the block grant and the CCPAP so we won't need to yes I'm hoping but let me know next slide we thought we would dive a bit into the child care financial assistance before we move on from the last slide do you have any kind of data on the number of children involved in the program there's a later on it is later on I guess I have a big scope on my part that we should have committee members introduce themselves here because we are we have a newly constituted committee so I'm going to stop here and Senator Dave Wietz from Martin I'd like to interrupt you with the Burlington I represent two groups you two I'm Ruth Hardy from the Addison District Kerry Williams from the Relatives Getty Alliance Chittenden Southeast welcome welcome it's online and we have it here and then Alex so I thought it would be important to start to let you know that our child care financial assistance changed really recently so this summer we implemented the minimum viable product of our first our new IT system of module one so we launched that in July 3rd and that changed what families experienced with the CCPAP program was there was a co-payment for every child in your family and now what we have done with the launch of our new system is that we look at a family's income eligibility and then we determine what their family share is based upon the age of their youngest child so that is what we're going to talk about today because that is the most relevant information about what our system looks like so what we had launched for the rates they were based upon using the 2019 market rate survey and said at the 75th percentile 75th percentile was important for us because that helped us put us in compliance with federal requirements we have set a cap on what our rates are this isn't new we've always had a cap however they were increased last year of the importance here as well is that the state pays the cap rate or the providers rate whichever is less after subtracting what the family would know and so this is a little bit of a change from what it used to be if a family uses more than their provider the family shares the provider that cares for the youngest child first this is fairly common and then the portion the state will pay for an eligible family depending on the family's application the provider's rate of agreement the state's cap rates and the amount the family is obligated to pay which is the family share so it is a number of components put together and we're happy to go in more depth if you would like but we just thought of a level setup what goes into the CC cap rate next slide please this next slide is what our rates are presently so you can see we have a tier rating system it goes from one to five stars and also has our licensed child care homes as well as our registered homes and those rates are very depending on the child's age from infant to school age and then also the stars the state pays more for the family with the more stars that a program has so this is to just give you a sense of what families might be being charged but this is what the state will pay for a slot generally speaking what's the relevance of stars that's going to just ask you yeah so this is this is the quality of a program so what what programming what educational levels have the staff achieved and then there are ways for programs to earn more stars in which we help support them and then and the stars is really to help families understand to have a gauge of what level the program is that they would be potentially having their child so is it the variety of programs available or the quality of the programs quality of the programs and it goes for home-based care and licensed care centers can you just give a thumbnail of the difference between those two yes so the license are typically center based on the family child as well and then you have just have to meet a little more criteria which I don't know if Emily has the top of her head but if not I would be happy to follow up after and then we have our family child their home provider so we typically care for less children in their homes and I want to go with the six children in theirs a bit more for school-aged children that would be joining it then and the day or over vacation we sort of restricted to ten hours a week for the school-aged kids I think you're thinking of universal pre-kindergarten yeah terrible yes there are so many nuances hi okay all right so I'll go to the next slide I realize I'm just saying I needed to step out um she's getting me some water I do have a water bottle we'll use it okay sorry that was not a real time we spoke here for a second yeah go ahead so school-aged children I need to understand the concept is this like after or before school after school you know but school-aged kids yes so um which generally speaking it would be like after school but there are some families that we have with before school care as well some families are at home accessing care during school vacations or summers or school closure days so it's a combination of schedules there's school programs following the report go ahead okay so the next slide is talking a bit about how families or characters are found eligible for the child care financial assistance program so to be eligible a family has to have a reason for child care so it must have a job thank you very much they are self-employed looking for work attending school or training participating in research special health needs for specialized development needs where as an open family service or the family is experiencing significant stress significant stress could be like the lack of shelter substance use within the family the family must also meet income guidelines must be a Vermont resident and the child receiving care must be a legal resident of the United States so those are those main components the next slide please slide into a sense of what those income guidelines are for families so within the chart in the gray section is the gross monthly income so if you have a family size of three or less and they have a monthly income of $2,800 their weekly family share is $0 and then just want to point out the weekly family share is that it's weekly so we talk about monthly but what a family's obligation to pay for child care would actually be able to buy by 4.3 to just give you a sense does the weekly family share per child or per family per family so that was the change that we made this summer I think next we'll just talk a little bit about the child care landscape so how many children are reserving and then how many programs that we have so if you I'm going to the next slide please so this slide is the number of child care programs that we've had over the last six years I thought this would be helpful to just give a sense of how it's going to be during the pandemic I think because we all here a lot of programs have closed I would attribute us being able to not have a huge loss to the fact that we have received a significant amount of American land act funds and we have done a lot of capacity building so trying to increase lots of current providers as well as helping new programs that would like to come online so in the September of 2022 we have 394 registered family child care homes 24 licensed family child care homes center based programs non-recurring for example at a ski lodge so just a family that would like to have some care while they go out skiing the center based programs there are 495 of those and then after school programs there are 150 just out of curiosity is there this is the number of programs does it also reflect the number of children that are accommodated maybe some programs they are larger in size there are fewer programs so this is the number of programs is there the same trend the number of children capable of being provided for by the programs the programs could be declining but the number of seats could be increased they could potentially if we were opening a large center I would say that large centers work in our more populated areas and they do not in our more rural areas it's just not the number of children so the same trend is seen in the number of children for full service by programs of course so is there as we've gone through the pandemic we've seen that decline in the full cost bar have you evaluated why that's happened or what are the reasons for maybe some of the closures we're seeing so we haven't done a strong analysis do programs do let us know and some have to close classrooms or their entire program some of the staff others have decided after the pandemic that they were no longer going to do this professionally the families have their homes etc besides staff what are some of the other reasons for programs it's kind of critical to understand that some of the licensing some of the other reasons but we don't want to doubt there's any doubt I would love the opportunity to give you that data because I know that we had some of that and so I think that would be the most beneficial for you to see what we have gathered rather than the academic that's our you can imagine it was burnout or you can imagine it's just work for us or you can imagine it was a decline in kids but it would be great to have your the data that would be helpful thank you so the next slide Keith this is the as of September also the number of children that we are surveying personally actually I take that back I'm like no that is wrong sorry this is a slide and it's not that this is this is the number of programs that we have and then this is the capacity so this gets to like how many children could we be serving and this is what I would say is reported capacity so we have licensed capacity this is what we've said a program licensed capacity is what we say a program can care for a number of children reported capacity is what programs tell us what we're going to serve so the reported capacity broken down by the different age groups is the 28,000 do you have a comparable slide on the man next I'm going to ask that I should say I have how many children that we have and then there's also I'm happy to follow up we have not done that analysis but let's go kids put out a report each year or I think it's ever two years that will show you what they consider to be the anticipated need so next slide please is actually has on it that might be helpful to see where families were falling within the income guidelines who were serving and then the total number of children that we are presently serving is 6,740 and that's a total of just under 6,000 pounds I'm not sure so you're serving roughly 7,000 capability is 28,000 correct and I would say that's at a given time I think one of the things that we do notice it depends on staffing you can only have their ratios staff to children if you don't have the staff then you can't have the children that doesn't show how many kids are out there in on a waiting list or in need of families in need of childcare services correct that would be you can get staff just to clarify for senator weeks the slide that shows the capacity is showing the number of slots that are available to all children and then the slide the slide is the number of kids served by CCVAP that are getting the subsidy so there are families that aren't eligible or don't apply for and they're still their kids may still be in childcare they're not getting the subsidy but I think that's very yes I should have started that we serve about 20% of the population that is accessing childcare with CCVAP all right and the next slide please our final slide I was not sure what resources you were hoping to or incentives that you were hoping to understand but I put the most recent programs that we have run so that is the coronavirus resettlement supplemental act I believe I don't know if I quite got that right but that is a program that we ran in April of last year and that was $12 million that went out directly to childcare programs we have the ARCO child care American Mercy Plan Act childcare stabilization that's $29 million and we send the last payment out to childcare programs next month and we also have our American Mercy Plan Act discretionary funds these are funds that are more focused on your capacity building those funds we've also have our new business technical assistance to childcare programs with those funds we are putting in quality coaches with those funds and then we also have what are called special accommodation grants which I expect to be similar to what you would have like paying for one-on-ones in public school that's what SAG grants are kind of the equivalent in early childhood that some of what is in the $18 million so it's a bit different than the stabilization funds and then most recently at the childcare workforce retention bonus and that's a $7 million that was passed last year just to make sure I understand this is all one-time learning that can be going away correct so then without this support this was obviously a result of the pandemic and trying to keep these centers alive there were no kids and probably maybe no teachers so now are they stabilized you can't talk about the budget yet but maybe we'll see something in the budget I don't know how are we going to keep these centers alive because they'll be looking for the money that is paid for kids to support them if that were possible things would be great right now there's deficit we did increase what we pay childcare programs on behalf of the family so we have increased that that was one of the previous slides like this is how much we pay for an infinite thing it's like $394 if you're in a five-star program but once again that is only 20% of the population the private pay families and what's their contribution cost increased I think I would say anecdotally I heard from programs they're concerned about not having this funding because this is just a small subset of the funding that they received over the last two plus years throughout the pandemic there was a lot of it was very generous and we received a lot of funds federally as well that we were able to distribute to childcare programs I'm wondering if it would be helpful for you to talk briefly about the overall administration of this because it touches on different programs reach out etc and then CCFAP determination how do you determine across the state all these families and how do you then end up with an appropriation or CCFAP or an individual family how does that all come together I'm looking at eligibility requirements is there a deeper dive on those do you look at the educational experience of the parents how do you look at children with special needs particularly in the infant group so can you talk a little bit about the overall administration and how that's managed within the community and healthcare yeah we mentioned we have contact with 11 agencies 12 regions to administer CCFAP so a demo of an application that indicates their household members, their household size their household income their service need or reason for needing care single parent household we don't look at the household their service need and income it's two parent household we look at both parents income and reason for needing care so the eligibility specialist they get that application they look it over and then they submit or they send out a request to the family for further information so pay subs or documentation of what they're doing for schooling documentation of a special health need whether it's a parent or the child does that come from a physician yes special health needs documentation that's one of the options there are other options you can get verification from a special educator somebody's familiar with the parent or the child's special health needs and their need for accessing care it's beyond just having a special health need it's needing a needed child care to help with developmental resources for the child or for the parents they're not able to care for the child during that time during the day so once the eligibility specialist sends out the request for additional documentation once they receive it back they can finish processing the application and that's when they determine how many hours the family is eligible for whether it's part time full time or extended care this group eligibility into those three names time frames and then what family share they would have if any so looking at their household income their gross household income and figuring out what their family share would be and then from there the specialist creates certificates to the individual programs that says this is how much we're going to pay you for this child so the programs get the information that will be how much they'll be receiving for payments and then the families also receive a summary of how much assistance is being paid so the money actually goes from you to the child care it doesn't go to the parent correctly child care providers on behalf of eligible children on a bi-weekly basis so the determination is made once and every 12 months unless there are some situations where we need to review more within those 12 months but generally there's a 12 month determination of eligibility if a family decreases during that time to change their eligibility so that they're eligible for more assistance if they're income raises as long as they're within our income guidelines they'll actually stay at their original eligibility determination that really helps some families just less of a benefits clip more of a benefits slope gradually changing before at their next redefinition then at what point has the parent applied to the child care historic center and then at what point is that determination and has it all come together yeah I think for the most part families probably have a child care provider identified before they have their financial assistance but there are some times where they may apply just to see what their family share would be before they commit to enrolling a child care program it really depends but I think for the most part families have identified who their child care provider will be if they can find one if they can find one yeah okay any questions there related to that it isn't uncomplicated but you have a system so now you've got your in places across the state district offices yep there's a community child care support agency and there are the 12 HHS regions we also work closely with reach up in every district families working with a retail case manager they can authorize child care for the family so the family can side pass the whole application process we also work with family services in every region they have an open case with a family that they can authorize child care as a support to the family and for their safety planning some other partnerships and then can you talk a little bit about the IT that you've utilized for data collection and the determination so that's our new IT system that launched this summer CDM so that's where the specialists they enter all of the applications are entered into the system income is entered that's also providers access the system to submit their bi-weekly billing and access documents that relate to families eligibility so it has a parent interface and a provider interface and eligibility specialists that's where they do all of the eligibility determination so has that facilitated the process as I've gotten support to do the administration of the new IT you said or not enough experience yeah we're still learning it's a little bit of a change from what we were eating before and some of the processes are very similar and some of them are a little bit different with the IT component but I think over time it will probably be about the same once you pass out on our go ahead thank you Sarah Holbrook Center an example of a provider that would be under the CCFAB partner with CCFAB they sound very I believe they are one of our programs which one are you Sarah Holbrook yeah that's okay thank you and Robert's next the region's listed somewhere so we can see what's available in our county reach out to the district offices yes absolutely and then we could share also where our community child care support agencies because they aren't state agencies they are contracted staff and so we could share who those are as well in Rutland it's the Vermont Achievement Center okay that would be very helpful and any data on numbers of kids you've heard the questions about where are the openings and where are the kids what's the need, what's the demand so that if you have that information that would be extremely helpful to us and then any data that you have on workforce and we will certainly back on workforce at some point to understand what we did what the effect of our legislation last year has been but anything you have would be very helpful but questions committee we're a little bit early this is really good so on the CCFAP we went to the 2019 market 75% of the 2019 market when we passed the bill when when was it last no last session year before last so can you just talk about what that means where it was before we went to the 2019 level that you know because it was a significant increase and can you just talk about the importance of that how we did to so and I don't have the rates but it was increasing what we would pay to providers on behalf of families and also really providing support for families to be able to pay more of their childcare expense and that is a part of also using the 2019 market rate survey is still kind of looking back at what are the costs going into childcare programs but it did raise this up I think prior to that we were using the 2017 market rate survey and the market rate survey we have another one that is due we're doing it this summer so then we will be able to look at what the expenses are for childcare programs and then that's how we look at our rates does that give you yeah it does is it a cost-based system not a cost-based system what would be the difference with a cost-based system probably significantly more expensive yeah yeah so and I think that is something that the I'm trying to remember the brand study was tasked I think so I think they would tell KU to update us on that they had multiple components they were supposed to look out for financing but that is one of the aspects of this not necessarily saying this is the true cost of care just a general question I've seen long signs I'm a childcare voter a governor's initiative for childcare and we're talking about childcare here how do these programs interface everybody has a different idea of what childcare is do that's a big one do they interface? what you do and what what I can say I'm thinking of the signs that you're probably I've seen them too we do work with so the same advocacy partners are also a lot of the times partners that are helping us so I will name the beautiful signs that they put out and they are also one of our partners that help us with capacity building so they are instrumental in us being able to add more slots is what we call them around Vermont but they also have a mission to be able to advocate for what they think childcare should look like in Vermont yeah I could just sort of tack on to what Senator Williams was saying my lived experience with childcare is 25 years old plus or minus so it's not super relevant at this point I don't know if you're comfortable answering this question but our childcare system has certainly been designated as in crisis a word that we heed a lot is it would you agree that that is a correct term for the situation that we're in right now I think that it is we are certainly in a challenging time and it is the mixture of childcare expenses for Vermonters it is a large expense for your monthly budget and then childcare workers are some of the lower lowest paid staff in Vermont so that is a challenge there's a large disconnect there and one has to be very thoughtful about how you approach that I think what we found when we raised our rates in mind you we only support 20% of the population who's accessing the childcare a number of programs raise their rates because that is we pay our rate or their rate whatever is lower but you also have to charge everyone the same amount so there are challenges for those families that aren't eligible for childcare financial assistance is that if the rates have raised they just now have a larger out-of-pocket expense and that is something that the brand study was asked to look at Act 45 is that no Vermont family pays more than 10% of their income on childcare and this is also an issue because cost of living is so different depending on where you live in the state as well just the cost of living is not flat across the state so I was just wondering if that's also plays into this complexity because it sounds like you're dealing with a flat rate across the board yes absolutely and that's why the market raising putting it up to the 2019 market rate was so important because it was I forget where it was well wait I think it was 2017 so maybe before then and now we've got inflation that is hitting everyone so the estimated cost would be higher regardless everything will look yeah go ahead just a specific question about the $7 million payments to provide the retention bonuses you mentioned that the final payments are going to go out next month is that what you said that's what I heard you say sorry there was two items there so the $29 million the stabilization grants that final payment goes out next month okay the retention bonuses we have left open so we have an initial surge of I know that I continue to sign agreements and it really you know what were best for programs or what was their capacity to request the retention bonuses but we have left them open because if they hire new staff and we would like to be able to give them our retention bonus they absolutely can do that so that won't end until it is time to like probably may because we would need to be able to get out the final payments before the end of the state fiscal year so do you know how much you what percentage of the $7 million I don't but I can also add that I do know there are programs that are sort of struggling because it's a little complicated to do as we discussed in the past so yes but complicated what's complicated the operation process what we're specifically talking about is we appropriated $7 million last year to provide retention bonuses to childcare workers and the way that they had to distribute those bonuses is complicated for these really small childcare programs that might not have a lot of administrative capacity or expertise and so there's this money that's available but they might not be able to access it because they're not they don't have the capacity to do so and look that is exactly what we want to get we want to have folks come in a report on this generally but this is one of the areas that we're going to look at receive some emails about this so it's always fun what we can do what we can't do any other questions go ahead I reached out during my campaign to a lot of people that do childcare in my communities a lot of them that used to do childcare they were proud of it because there were too many regulations and stipulations they had to provide so what that did was it took in these communities it took those people that used to do it and how can't do it onto the ones that are doing it according to regulation do you see do you think that there are too many regulations I mean there used to be families used to do childcare I took my kids to my mother because she was retired and then I went from mom because she couldn't do it anymore to Patty down the road who took two or three kids in and provided them exercise a little education on that and she doesn't do it anymore so that's one of the biggest hurdles I've heard from my constituents is that we want more people to come in to work here but they can't find childcare at the regional level so how do we fix that do you think it's a fine balance that we have federal regulations that we need to do and we are tasked with making sure that children are safe and that they are being cared for and educated we opened all of our regulations and did work groups we needed to hear from the providers and by each provider type because there are differences between summer based and family childcare homes and even after school programs to see what is working for you and what really isn't and is this something that we can look at changing or can we absolutely not so but they are very likely regulations I do believe we're in the process of one of our attorneys is now looking through proposed revisions so it's going to take a bit of time but trying to be responsive where we can and then also making sure that we draw those hard lines when there aren't any there isn't room to negotiate and then also factoring in that some of the regulations are tied to other like the division of fire safety the agency of natural resources who is in control of drinkable water yeah I mean there's a number of factors but we tried to make sure that we hear voices and then what can we do and what can we do and if the state is providing resources and money then it becomes an obligation on the part of the center but so are the changes that your your legal counsel looking at are those the rules or also statute is it your licensing guidelines where where's the I think it's the rules the rules that'll be fun it hasn't been thus far I've got the disability right now that actually go ahead I think earlier we agreed that based on the slide showing the radical decrease in the number of programs available in the state that you would come back with some of those factors inhibiting the private sector from developing child care programs or mutating child care programs sometime in the future you'll come back to us with those factors yes so and I had to written down the workforce but you don't mean more of like what might be others don't quote this only on workforce there may be a thousand different factors and I don't want to certainly don't want to contain put boundaries on what those factors might be because frankly I don't know what they are certainly staffing could well be what but there could be many many others salaries it's critical so my perspective is from a private business perspective is what's inhibiting private industry from changing that trend that downward trend of programs available to an upward trend of programs available to solve this issue such that we have the child care programs necessary for the population of children and parents who need the program that's the fundamental issue that actually brings to mind you mentioned business and businesses that really have pulled out from this a lot of them closed them so what role if any of our businesses playing in this is an excellent question I know economic development committee is going to be looking at that a little bit but if you have any information that would help Saturday week that would be great I don't know if we have formal information but I do know on occasion there are programs that will reach out to me to share and I find a building that will meet off the the required codes or the sewer isn't large enough I mean there's a number of factors that certainly are we are aware of but aren't necessarily under our governance but I do see what we have for information to share we need more infrastructure knowledge from the sewers any other this is a very good beginning conversation we're starting to get our feet on the ground with us so it's very helpful I appreciate your time thank you so much if you have additional information you heard the questions and there are questions we haven't asked that you know we should be asking inform us educate us absolutely about thank you thank you just recently we're going to take like a five minute break and then we're going to come back and Katie's going to talk to us about some legislation that was passed that we have wanted to do we'll go off to YouTube hope yes