 Okay, we're live on YouTube again, and this is Friday, March 12, about 1030 in the morning. So this is the House Health Care Committee, and we are continuing our work on House Bill 210. So because this is, in many ways, this is the first more complex bill that we've really done together, and because we're doing it under the pressure of a crossover deadline today, I've been trying to think, and that's why I've been trying to give us some guidance as to how to work our way together through this bill. And during the break and through some communication, Representative Donahue had some very helpful thoughts about that, and rather than me trying to rearticulate that, I thought maybe I'd turn to Representative Donahue to help us, particularly, and I'll say this honestly, and this is, again, do not take this as anything other than just we need to be providing information to new members, and it's a learning process. We are literally learning and doing at the same time. So Representative Donahue, do you want to talk some about the process that we use when we go through a complex bill like this? And I think that might be helpful then for people to be able to think about when and how to bring up issues that are important to you. Sure, because I think we've kind of mixed elements of this process a lot, which is easy to do when we've, when we've had smaller bills. And, you know, I kind of, I'm more of a lawyer mind, I was telling Bill, you know, we really, we kind of need to follow this when we're trying to focus on a long bill, on a major bill. So, and we've had discussions all the way through on components, maybe even a little more than normal in the sense of, you know, when we hear from witnesses, we're usually just doing that and not commenting in, but we've had some informality in terms of discussion on the way. But there are really three main components. The first one is the walkthrough, which normally we would have finished. We did that early on, but we did just get a pretty significant new version. And Bill said yesterday, we're going to just walk through the big view to see what the structural changes is and then do the walkthrough. So we do need to do that kind of walk through of remembering which what each section is, not just the new sections. And so far, we've done the findings in that way, but not the rest. So that's kind of the next step, but that's also not a time when we discuss it at all. You know, that's not the time for, well, should this say it this way and so forth. This is just to walk through to refresh our memory and to know what each part says. The second phase, which is actually listed usually when we get to it on our agenda this way, and it is for this, is called markup. And that's when we, you know, when we try to identify for each of us, really, I think of it as two different things. One is if somebody feels that having walked through it, there is a there's a section that doesn't really represent the intent that you thought we were trying to achieve. And so you want to suggest, do we need to realign this? Not kind of individual words, or is it the ideal articulation? Because get into longer bills, we really can't do that for every line of a bill. But does does a section, does a, you know, a paragraph in late terms, do you think it really doesn't reflect what the committee's intent was? And so you identify that specific section to look at. Or the other thing is, are there, is there a specific change that you want to propose that would affect whether you would support the bill or not? And I could give an example, you know, if there was a section that, you know, I'm kind of okay with what this is trying to do. But it says it must be done. And I can support this bill if this actually said may. So this isn't about, I'd rather this, but it's, you know, if if this change was made. And then we don't get into a whole discussion back and forth. Well, this is why it sure shouldn't be made. Usually the chair just says, Okay, well, you're proposing this change, we're just going to have a straw poll. Would the committee go along with that or not? And that's how we get through proposals like that. So people may may bring up something they would like to see as as a reason that they could support it. Obviously, you wouldn't be bringing that up as a reason you can't support it. So we should change it this way. So I can't, I mean, I think a little silly guess. But but the point is that this would be a suggestion that would make it something you could be you could support. And then we simply have a straw poll. And then we when we finish that. And hopefully that's a time period Katie can be with us because she would be incorporating any changes that at that point we're agreed on. But then before we get to a vote, but the last phase is really the opportunity to for everyone who wants to fully share why they do or they don't support the end product as it's been after markup. And that's really, you know, an open opportunity. That's the time to to share your views, your perspectives, why you think it's important, why you think maybe it's important, but I can't I can't support it. And here's why any of those things come in that final phase of discussion. And I think it's important to keep those in that order, because, for example, if we start getting into discussion, and somebody saying, I really want to talk about this part, because this is the heart of the bill. And this is what really makes it important to me. If we start doing that during a walkthrough or during markup, we could really spend, you know, days in terms of a discussion done that way. So that discussion aspect is that last segment. And, you know, we make the time for people to be able to really express their thoughts on it at that point. So so what we're doing what we're doing next is is finishing what what we started already with the findings. And that is to go a little more specifically saying, OK, this is what this section says, because we we only looked at the new sections, we don't look at the whole picture in terms of going through each segment of the bill, even though we did those earlier sections earlier. That was a little out of context, and it was a long time ago. So that's kind of the plan of action. We do a walkthrough. We do a markup where individuals say, I'd like to go to this section to suggest this or to address this problem. I see with that. And we agree or disagree on making a suggestion for a change without a lot of discussion. As I said, we do a struggle. We hear the person. We we then vote vote on that proposal and then the discussion about what we think about the end product. And then, of course, about. So thank you. And I think that's helpful. And I think it's helpful for I mean, it's it's too easy sometimes for us to just start doing and not helping folks have a road map and understanding. And I've been, you know, and I think. And I've been informal about the process on some of our other bills and and sometimes we need to be that informal, but given this bill and this bill is actually not the most complex bill we will take on. I mean, that's what it's hard to imagine. But there are bills of greater length and greater complexity than this that will will end up in front of us. So thank you again, and and with that. I think and I'm going to welcome you to help guide us along the way. If I stray too far. Or if we collectively stray too far. I think what this brings us to is to begin looking at the sections beyond the findings in terms of the walk through. And that would bring us to what in my version is a section two. And I what I have in front of me is not the very latest. I don't know if that if there's a way to put it on the screen. Colleen. Oh, Katie's here. Katie, welcome here. Oh, fabulous. Great. Good. We're just I know we're all juggling many things today. So so we were just I don't know if you were here when Anna was explaining that our process of doing a walk through and then a markup and then committee discussion. So what we were wanting to do at this point is maybe turn to section two. And I'm not going to ask you to articulate each section as such. But for us to what we'll find our way through it. But I think starting with section two, the legislative intent and purpose section for us to go through reminding ourselves, Katie, because we we got the new one and we looked at the changes. But we need to kind of walk through the sections just to remind ourselves of all of the pieces of the bill and how it fits together in a sequential way. And again, this is for clarity and understanding. And we're not going to try to. This is not the markup process of going through line by line and making word change suggestions at this point. But people can keep those notes in their heads for the walk for the markup, which we'll do then subsequently. Great. Are you ready for me to share my screen? I am. Yeah, no, I'm I'm totally delighted you're here. And I'm going to need to duck out at 11. But and if you would continue the process with the committee at that point. OK, so this is section two, which the first that's divided into two parts. The first part, subsection A is a legislative intense section. And the second part, subsection B is a purpose section. So just to look at the language, it's the intent of the General Assembly to promote health and achieve health equity by eliminating avoidable and unjust disparities in health through systemic and comprehensive approach that addresses social, economic and environmental factors that influence health. To that end, the General Assembly believes that. And so these are the beliefs of the General Assembly. Equal opportunity is a fundamental principle of American democracy. Equal enjoyment of the highest attainable standard of health is a human right and a priority to the state. Three structural racism defined as the law's policies, institutional practices and cultural representations and other societal norms that often work together to deny equal opportunity has resulted in health disparities among Vermonters and great social costs arise from these inequities, including threats to economic development, democracy and social health of the state of Vermont. The fourth belief, health disparities are a function of not only access to health care, but also social determinants of health, including the environment of physical the physical structure of communities, nutrition and food options, education, educational attainment, the physical structure of communities, employment, race, ethnicity, sex, geography, language, preferences, immigrant or citizen status, sexual orientation, gender identity and socioeconomic status that directly and indirectly affects the health, health care and wellness of individuals and communities. The fifth belief, efforts to improve health in the US have traditionally looked to health care system as the key driver of health and health outcomes. However, there has been an increasing recognition that improving health and achieving health equity will require broader approaches that address factors that influence health. The sixth belief, belief is health equity is the attainment of the highest level of health for all people. Health equity can be achieved only by eliminating the preventable differences of health of one group over another as a result of factors such as race, sexual orientation, gender, disability, age, socioeconomic status or geographic location. So those six items are the belief of the General Assembly, and then we move on to part two of this section, which is the purpose of the act and the purpose is to eliminate disparities in health status based on race, race, ethnicity, disability and LGBTQ status by, and then we have a list first establishing better and more consistent collection and access to data, enhancing a full range of available and accessible culturally appropriate health care and public services across Vermont, ensuring the early and equitable inclusion of remonters who experience health inequities because of race, ethnicity, disability and LGBTQ status and efforts to eliminate such inequities and lastly addressing social determinants of health, particularly social, economic and environmental factors that influence health. So those are the two parts of section two. Would you like me to pause there? Why don't we pause there and take it down? Well, you can leave it. Well, yeah, we're not really going to discuss at this point. We're just getting that overview. And I think it was good that you read each line in this section, but the next ones, I think you can summarize each paragraph. Yeah. OK, I'll keep moving then. So in section three, we move on to creating a new chapter on health equity and there are three sections within. I'm sorry, just for people's for new people's understanding. When you said we establish a new chapter, what does that mean? That previous section doesn't go into law. Oh, thank you for for asking that question. So we put laws into bills in two ways. And it it all it means that it's all law. But we have law that we anticipate we are going to look back on and reference more frequently, so that will go into what we call the green books and it's codified there. And then other law, session law goes into what we call the white books. It's still good law, but it maybe is something that we wouldn't refer back to quite as frequently. And we don't have the same kind of ease of finding it necessarily in a distinction on how we divide up those sections. A lot of times it has to do with short term and long term focus. So, for example, a one time report would be in session law because after the report comes in, it's not likely that we're going to need to refer to that language very frequently or a one year appropriation often is in session law because after that appropriation has gone out. It's not often that we would be be looking for that appropriation. Again, similarly, it's the practice when we're drafting bills that findings legislative intent and purpose sections are session law, meaning that they're they're still good law. They go into what we call the white books because they're literally bound white books that contain each act that's passed. But when I say here in section three that we're moving into creating a new chapter, what I'm saying is that in title 18 that governs all of health. It's broken into chapters and we're creating within that chapter. Sorry, within that title, a new chapter on health equity and we're anticipating that this is something that will be long lasting and referred back to frequently. Did I did I address that concern representative Donahue? Thank you very much. So in this new chapter that's being created, there are three different parts that you've created here. There's a definition part that governs each of the following sections. There is language about the Health Equity Advisory Commission and there's language about data collection. So those are the next three parts of the bill within this chapter. So I won't spend a whole lot of time on the definitions unless I hear otherwise. I think we have gone through them. OK, in detail in the past, so great. We ask a question and I'm understanding we're not so close to go into the weeds. And I'm not sure when to raise this question. It seems to be a conflict of the definition of health equity. So I just want to throw that out to talk about it at some point. Great. Let's bookmark that. OK. So the second section of this new chapter that's being created is the Commission. There is introductory language that's setting out the idea that this commission is to be in effect and have kind of broad responsibilities at looking at health equity and health disparities, amplifying voices of impacted communities. And it also recognizes that this committee will be doing work in the short term, which is providing strategic guidance on setting up an office of health equity. The next subsection of the bill is the membership. And the thing worth noting here is that the Executive Director of Racial Equity is the chair and I'll skip through the membership of the commission for the moment. We have language about appointments and how long members holds their seats on the commission. And then we get into language on powers and duties. So this, again, is recognizing kind of the short term responsibility of the commission in setting up and providing guidance about what a new office would look like and then the longer term responsibilities of the commission. So subdivision A looks at setting up the office. Subdivision two looks at providing advice and recommendations to the office once it's been established. And then subdivision three looks at or charges the commission with reviewing, monitoring and advising all state agencies regarding the impact of policies, procedures, practices and laws on the populations that we've been focusing on, also identifying and examining the limitations and problems associated with existing laws, rules and programs for the identified populations. And lastly, advising the general assembly on efforts to improve cultural competency and anti-racism in the health care system through training and continuing education of members of the health care professions. In terms of assistance, you have the agency of administration giving assistance to this commission, because that is the office where the executive director of racial equity is. There's an annual report coming from the commission. This language in subsection F sets out how often the committee is to meet that the executive director of racial equity is calling the first meeting and then what constitutes a quorum. Also language at the advisory commission is open to the public and there will be opportunities for public comment on a regular basis. The commission could accept grants and other contributions. And then in subsection H, we have our standard language about compensation and reimbursement. And here you'll know online 19. This is for not more than six meetings annually. So that's a policy decision. But because we're asking them to meet every other month, that's the the number that's there for the moment. And we have this appropriation coming out of the agency of administration. So that's the second section within the new chapter and the third section within this new chapter has to do with data. So in subsection A, we're saying that each state entity that collects health-related individual data is to include in its data collection health equity data desegregated by race, ethnicity, gender identity, age, primary language, socioeconomic status, disability and sexual orientation. And that data related to a to excuse me, data related to race and ethnicity is to use separate collection categories and tabulations. And disaggregate beyond non-white and white categories and in doing that, it's looking to recommendations from the executive director of racial equity and the commission and subsection to the Department of Health is systematically analyzing health equity data using the smallest appropriate unit of analysis feasible to detect any disparities. And then the department on its website, let me see, report the results of this analysis on the department's website periodically, but not less than by annually. And the data shall be made available to the public in accordance with state and federal law. And then in subdivision two, this is an annual report that the department is submitting the results of the analysis to this committee and also to human services and Senate health and welfare. So that is the end of the new chapter that's being created on health equity and title 18. There's another change to codified law and section four. And this, as we noted yesterday, this is existing law about the duties of the executive director of racial equity. What is new in this section is subdivision four, which recognizes the fact that the director of racial equity, so the executive director of racial equity is taking on temporarily the oversight and chairing the Health Equity Advisory Commission under this proposal until the Office of Health Equity has been established. The next section, section five is a report. This will be in session law, not codified, because it's a short term one time report that's coming back. So by October 1, 2022, the commission is to report to the General Assembly and it's going to be giving recommendations on improving cultural competency and anti-racism in Vermont's health care system through initial training, continuing education requirements and investments. Next, we have section six. This is the appropriation in fiscal year 2022. One hundred and eighty thousand is appropriated from the agency of the administration to the agency of the administration from the general fund for use by the executive director of racial equity to carry out the provisions of the act. Subsection B is intent language, recognizing that although you can't make the appropriation for future years now, that the work that's being prescribed by this bill will take more than fiscal year 2022. So this is saying the intent of the General Assembly, that similar appropriations be made in future fiscal years until the Office of Health Equity is established. And at that point, the structure of the of the new chapter and how things are organized will change. And then we have the effective date, July 1, 2021. So I will pull down the document. Thank you. Thank you, Katie. Representative Don here, I'm wondering if I could turn to you, because I need to leave in just a few minutes to go over to. Would you be willing to take the helm and take a begin the walk or the process of doing a markup of the bill? Sure. And since you've outlined it so well for us, I think that I would really appreciate that if you could do that. And I think I'm going to I'm going to I'm going to step away from the screen so the members know I have to go. I've been asked to come to appropriations to actually talk about the financial and aspect of this bill that we're working on. So thank you. Yeah, great. So I got to get used to it's not Leslie, representative Goldman. If you could maybe articulate you reference seeing you know, a potential conflict and if you could try to articulate what that conflict you think is and, you know, what how how we might address it that you might suggest. Yes, ma'am, I'm looking at page 11. It says, yeah, and we can't we probably can't does is everybody able to have it up themselves or do we need to have it on the page on the on the screen. Yeah, everybody's got it up. OK, OK, great. OK, so on page 11, line one, it says health equity is the attainment of the highest level of health for all people. But in the definition. It says that health equity means all people have a fair and just opportunity to be healthy, which I think is a better definition of health equity. So I just thought that those were two different ideas about what health equity is because health equity really is not about the attainment of the highest level of health for all people, although that's what we would like. We're talking about access when we talk about health equity, I think. So again, as as Katie was saying, you know, we we the formal definitions in statute would be what would be considered the statute as opposed to sort of general comments. So depending on on because I didn't have it pulled up when you were saying it, but depending on which part you're suggesting you think is a more accurate definition. If that's not the one in the definitions section, what you could propose is say. Let's make that the definition, but the fact that they're not the same language doesn't matter. I think the definition is more accurate. OK, then then I think probably it's it's fine the way it is, unless anybody has strong feelings that it should be changed. Because that would not normally really be a conflict. To word it differently in different sections. Representative Black. No, I just wanted to really quickly point out page 10. Lines 11 12 physical structure of communities is in there twice. Great, Katie's got that down. I think we should leave a little time for people to think and be looking through what we just read through for things that you might want to make suggestions about. So we're not going to jump too quickly. So so just just to remember this is the time that if you have any suggestions for something that you think should be revised either to reflect the intent that you thought we had more accurately or because it would make a difference if it was revised, you want to propose a change to the committee because that would change what your position was on the bill. So that's this is the. This is the time to think through and make any proposals to the rest of the committee. Yes, Representative Peterson. Yes, Representative Donahue. Page 10. I'm looking at I'm toggling between you and the bill here. Paragraph four health disparities are the function of not only access to health care, but other social determinants. I don't know why that's in there. Why can't that be taken out of this bill? That's other things other than health care. Why are we why are we talking about them, I guess? Just just my opinion. No, that's that's fine. And I know, you know, we don't want to have a whole discussion, but Brian is the lead sponsor. No, it's fine to ask Brian as the lead sponsor to maybe make a statement. OK. And after he's responded. Art, if you would like to make a specific proposal that we have a straw poll on removing it, you could do that. But we'll give Brian a chance to I'm not going to go that far. I just I bring it up. That's all I'm not going to I mean, I like to hear Brian's you know, opinion. I'm happy to take a minute and just explain that that. That health care, the health care system is a response to health care problems. But what causes health care problems? And what we understand is that there are social determinants of health that we may be born with a set of genes, but those genes are activated by the environment, and that includes things like the physical structure, the very layout of our community, the food, nutrition, our diet, our exercise, our education, the jobs we have that also includes our race and ethnicity, our sex, geography, you know, all these things you see listed. All of these factors will affect health outcomes. And there is a massive body of evidence out there proving this. And this has been part of state policy for many years. And in our committee over the last four years that I've been on it, we have heard a lot of testimony about how the social determinants of health affect health outcomes. In fact, even with our approach to the all payer model and accountable care, they're looking at population health, they're talking about spending health care dollars on social determinants of health to lower cost in the health care system, because what we've learned is the old statement that an ounce of prevention is worth more is more. What is an ounce of prevention is a pound of is worth a pound of care. Yeah, something like that. So that's really what this speaks to. So I'll stop there. But that's my explanation. I do think it's important to leave it in because if we don't leave it in, we're not acknowledging that it's not just about getting treatment when you need it. It's how do we address the conditions that lead to health care problems? Because if we address those conditions, we're improving quality of life for everyone and saving money. So. Well, we're not really addressing those conditions in this bill, are we? I mean, they're nice to say, but we're not. We're not. I think so, Representative Peterson, I think that would be one of the issues that the Commission would be taking up saying in order to address health disparities, we we advise the office when when there is an office, but we would recommend this. So yes. And also, I think we're creating by creating a definition of health equity. We can we could consider the impact of our policies across state government on health on health equity. So it may inform that Commission's recommendations may inform other committees of other committees work over time. So I do think it's important to leave it in because we want to recognize that we can't if we can we can address that we can fix the problems in the health care system, but that's only one half. And we actually have to look at the other half, which is what happens before someone comes in the door of a health care facility. So thank you, Brian. So thank you, Representative Gina, Representative Page. Yes, I have a I have a comment on page nine, well, eight and nine talks about housing issues, and I realize these are factors that affect our the health disparities. But you know, when I look at some of this stuff like on page nine item D. where it talks about lack of complete kitchen facilities or plumbing or overcrowded homes, I look at some of these examples. I have to say, I don't believe that's the case for all of Vermont. There may be certain sections of Vermont where it is the case. And then the other issue here is that there's something there's more to this item than just health issues. It's also related to, you know, our inspectors, our city inspectors, our housing inspectors, you know, those individuals that are responsible for the monies that go to provide housing for those that are less fortunate. If those if they're not doing their job, then, of course, you're going to have these issues. And, you know, I guess I'm wandering here, but I don't know whether I'm getting my point across. Yeah, I think I think in the language, in terms of just the example of the, you know, kitchen, so forth, that's coming from the definition. And then the definition ties into the the the aspect of housing being one of the social determinants. Do we have specific examples of that in Vermont? Like, I know it's Vermont Housing Finance Agency. So obviously, obviously, I guess we do have specific examples within the state of Vermont. That's right. It's a Vermont report. May I? Here again, here again, I just I think. Yes, there are probably various areas of the state where you might see this. And yet there are others that are. That this does not. And I don't think the finding is saying it's it's everywhere. It's just saying this is this is a reality. Do you, you know, do you have a thought on that it ought to be taken out? Is it now? No, no, I just it just I read it and I just thought. My own community, I don't see it. Yeah, you know, other areas. Yeah, perhaps understood. OK, you know, it's not it's not it's not statewide. Let's put it that way. So no, I'm just bringing it up. Representative Chino, I don't think there's a need to respond to that. If you have a proposal or a comment. You're so yourself. Oh, I was just going to say that perhaps down the road, the committee could take more testimony on this piece as we look at recommendations of appropriations towards housing because it I was in a I don't know what to call it. Like a webinar with the governor's housing person. I don't commissioner of housing or I can't remember the title exactly. But he was speaking about how this is actually an issue that the governor was looking at around the substance that it may not be every single neighborhood in the state has this issue, but it is in every single area of the state. There are people living in very dangerous and unhealthy conditions in that he was talking about if the state invested money in in improving those conditions, it would actually improve health care for people. So but we need we would need to hear more testimony. I just want to put it out there that there is a big body of evidence behind this. And I'm not able to provide that testimony as a committee member, but maybe someday we could do that. So this was identifying a background piece that the commission might go further to. Yes. Thank you. Also on page 12 item four or a line for a where it talks about cultural competency with health care professionals. It says that awareness and acknowledgement of the health care professionals own culture. That just that sentence just seems kind of odd. I would think health care, and I guess it's mentioned later on, why wouldn't that health care professional be aware of all cultures or other cultures besides his own, you know, at least cognizant of it or something like that. Yeah, I think that's exactly what the point is, is that to to help ensure that everybody is because not everyone is. So I think I think you're exactly right. And that that's what it's pointing to. And you know, I've already said it before, I have a problem with this commission. Right. I do think there are too many people in this commission. I would not call it a commission. I would call it, I don't know, a board or something like that. I think too many. I just think there are too many experts at the table. And I don't think you're going to get very much done when you've got everybody looking in their own little piece of the pie. So so Woody, I mean, this is a really good example, because I've actually felt the same way to some extent. And one of the things I've mulled on in my own mind is why are all these department state commissioners on it rather than, you know, that the the groups that would be, we talked about, you know, nothing about us without us, that the groups that would be affected would be the commission. And all of these, you know, heads of the different departments, you know, hopefully would participate and listen, but not be part of the commission. That's been a question in my mind. And I I decided I was OK with it. But I I really I really share in that. And I'm just wondering, do you think it's worth a suggestion to the committee that that those that state officials not be actual commission members? What one option in statute is to say they're what's the word? Ex parte, which means they show up. They participate, but they're not actually voting members because they're not, you know, directly. If that's a proposal you want to make, this would be the time. It's something to consider. Obviously, if you're a commissioner or a specific department, you're going to be trying to. Look after your or piece of the pie, you're going to try to protect your. Your phyton, so to speak, and maybe. If not protected, maybe try to grow it a little bit, perhaps. But no, I just look. It's just it's just a thought and I've already voiced it before. And you all know about it. I just think there are just too many commission members. I think. You know, what do we have 26 27? I think it's an unruly number. I think it's going to be like herding herding cats some ways. So I'm trying to be a real stickler on how we how we address the process. You know, if that ends up being the factor you want to share as one of the reasons. And I'm not saying that this is your position, but if at the time of discussion, one of the reasons I'm not supportive is because I think the commission is will be too unwieldy. But as opposed to something to think about now's the time, you know, if you wanted to suggest something specific that would be different, like taking some people off specifically, that's that's what this is the time to suggest. And otherwise, will we move on? And I know that representative China has his hand up. If representative Page is not suggesting a change, then there really isn't a need to respond to it, because this is the time for seeking changes and responding and then making a decision about a possible change. No. OK. Representative Cheesan, did you have something on a different subject? No, I was just going to explain why I was going to. Well, I should just say it and it'll be quick. I was going to say that I that I'd be open to some modification along those lines. I do think that the strength of having them present one way or the other, whether it be voting or not, is that it creates a direct connection between impact voices, impacted communities with these pieces of government. So I think that's an important aspect, but I don't think they have to be voting members of the Commission. So if there had been a suggestion to change that, I would have been open to it. But I do think it's important that we keep in mind that we want to be making connection between those voices and the people in the government. And that's why I think they're on the commission to begin with. So. OK, so so I'm going to take the chair prerogative. I see the chairs back, but I'm going to finish my last little bit here. And I'm going to say you're going to do more than that. I'm going to ask you to continue. OK, so if you're willing, if you're willing, this is something that has been on my mind and I know it's not, you know, it's not something we've, you know, took specific testimony on or that our witnesses suggested. But but I think it does make a difference. And I would want to see them there and participating. But I would prefer them to be ex parte members, not voting members. So I am going to make that as a proposal. And again, not something we should be getting into a long discussion on. People can think about it, maybe, you know, a sentence or two on your thoughts on it. And then we'll just have a straw poll. But I am going to put that proposal out there that we divide that that commission and those who are public officials for the state be ex parte members. Representative Goldman, did you want to speak on that or on something different? Well, I'd like to speak on that if I may. If I remember right, we did get some testimony along the way about work groups and that the commission could be divided into work groups. So part of by by being able to do that, we do have a sort of a more manageable number working on a specific topic. And I thought that was important to be able to do that. I think that keeping the government as as Brian, I represented Tina said really well that it does create an equality between the people who are voting from the government and the people on the commission. And I think that equality, it's like one person, one vote seems really important to me. So my preference would be to keep everyone at an equal playing field with an equal vote, keeping in mind that the commission process will evolve likely with work groups that can be more effective and efficient on specific topics. Thank you. Representative Gina, just one other comment. So I want to do want to say I appreciate that we're able to talk through this and and hopefully we can get to a place where people feel comfortable. But just about the concern about the unwieldy group. When I was on the Burlington School Board, we were hiring a new superintendent and we had been under a lot of pressure to be as inclusive as possible. So the school board appointed a superintendent search advisory committee that had like 18 people or something. And then the committee demanded that four more people be appointed to it because they felt like the group wasn't inclusive of certain people. And then there was five school board members on a search committee. And I was like the person, like the chair of all of this. So I had to manage a group of 27 people, which is what this is. And it was unwieldy, but we did it. You know, it was a lot of people, and especially when you're in a room together, it's like, you know, hot and everyone's around on top of each other. But we had we had ground rules. People respected them and we did, you know, we broke into small groups a lot. We the facilitation was done in a way that we were able to use the power of the group. And so I just wanted to share that experience because it is unwieldy, but with good facilitation, it'll work. So. So I'll just say kind of my closing comments. And so I brought it up. This this is not a major issue to me. It's not like some kind of maker break. It's a it's a suggestion and I recognize that it comes out of a personal place of being part of or seeing groups within my disability community where, you know, this restraint seclusion committee is, you know, every hospital has a seat. And then there are like three psychiatric survivor or advocacy seats. So it's it's really not about the people who are a part of it. And so so I'm I'm hypersensitive to that. This this commission is not like that. It's not way out of balance. And I recognize that. So it's not an important issue. But since I've raised it and people are mulling on it, maybe we can just have a quick straw vote. Yeah. Can I just say, and I missed some of the discussion, but I appreciate what you're saying, Representative Dahlia. But it's in an ironic kind of way, I think, and maybe someone else is just articulated this, there's something about actually sitting at a table where everybody does have that vote and you're both an affected community and someone who has power in this state structure, that there's a something there's almost there's in some ways there's an ironic kind of leveling there that I'm sitting with you and we both have a vote. I'm not like put over here. I get to vote and then I don't have I mean there's something there's something ironic about it in a way. So I I think I would my my my initial inclination of appreciating your suggestion is one of thinking I think maybe I'd like everybody to have a vote and then learn how to work together. So yeah, yeah, I mean, you're you're helping to actually convince me on my vote. So, you know, unless people unless people want to have a vote because they want to they want to support it, I I think we can skip. I'm willing to withdraw. So everybody thinks we're good to go ahead. You don't want to. OK, all right, then let's move on. We won't bother with a vote. So others along the same line, issues, issues to raise that might be something to propose to propose a change that the committee would consider. And are we on the Health Advisory Commission section specifically? No, this is any section that a member specifically wants to go to to suggest a change. I've got some more changes. Suggested representative page. Go ahead. Page 20 data. I'm a little concerned with the collection of data and what's going to be done with it, particularly items 10 through 16 with the Department of Health. You know, they collect it, they analyze it. What's the action part of this? What are they going to do with it? You know, it's great to have all this data, but it is just sitting there and they're not doing anything that not acting upon. I'd like to see some sort of action words in this in this portion. Yeah, I want to see action. So I think data, so let's do something with it, folks. So my my response is, you know, it's that chicken and egg sort of thing. If we were suggesting actions in this bill, I think people would really legitimately say, where's the data to support those actions? And I think the bill does include the action component in the sense that the Commission will end up making recommendations once the data is there and there's an analysis in terms of what ought to happen to move towards equity. So that's my reaction. Representative Lippert. I think I share our representative page's interest here and when he first my first, at least what I'm looking at in B1, is if you look at that in the data section, is it B1? There's a B1, right? And the collection is to systematically analyze the data to detect racial and ethnic disparities as well as other disparities. I'm going to summarize there. But I think so there's that action. But I think we could add something to the effect of, which has been part of the testimony to say in order to track over time, in order to measure over time the impact of actions taken to reduce health disparities, because I think that's implied, but maybe it said somewhere and I'm missing it. But I think that's that's the kind of action Woody that I think we're looking for this debt. We don't want the data just to be just to be collected. We want the data to be used. And I think if there's a way to add something to that effect, that would I think that would strengthen the section on data. Again, to use it to track to measure and track positive changes in the reduction of health disparities. Or something. Those are the right words. Right. Well, so maybe maybe Katie, who's listening, could try to put that into some words so that we'd have something specific. And while she works on that right now to try to frame something, if there are other people who want to make comments, because then we can again, have a have a straw poll on whether to add that language to the bill. So other thoughts on that suggestion, Representative Goldman. It's hard because I think at this point, the what we're asking for is the collection of data. And then based on the information that we as a committee and as a body need to respond. So it's really asking if I'm understanding this, right, is to respond to the collection of data because we don't have it. And, you know, I agree, you can't take action on something you don't know yet. And that's sort of part of the problem. You're right. I think it's chicken and egg. So I'm not sure that we can really say or I'd like to hear how we can really say you have to do X because of this data, because we just don't know yet. We don't know, given all these different arenas of data, where the commission is going to make a recommendation. So maybe the issue is based on the data, the commission should make recommendations to us on action or something along those lines that would go that included in the report, let's say, is a recommendation of action or something about that based on the data. Yeah, I could I could see I actually really like that because that's that link back to make it clear that that that the commission should is expected to then make recommendations on data. Other thoughts or reactions? I guess I just don't want, you know, after we have our commission and office set up, we collected all this data and over the years, we have this data and it's sitting there. And yet nothing has moved forward, you know, that we can look back and we we can say, you know, folks, the legislature tried to do this, we collected the data, it's been there for years and we haven't done anything with it, you know. And and I'm sure we there's there's examples in our in our state government where we where we see some of this. And so I'll just I'm just giving out ideas, you know. So, yeah, I put a chicken in front of an egg. I'm sorry, Katie, for having asked you to start drafting something. I think what we need to do is kind of have any additional thoughts on this and actually literally do a straw poll on whether we want to ask Katie to draft some language to incorporate into the final bill. And that would be the better direction. So other thoughts, Representative Houghton. Thank you. I think I liked what Bill was saying after he met and having some short term memory here. And I think one of the words that that is being repeated that makes me say this is years. I I think back to all of the times that are present on who sends us data that she has collected from the Department of Health in the past. That is no longer being collected. And had we had that consistency over the years, we could be making maybe some more thoughtful decisions. I think I come from the data world and I think it's really important that we don't think of data as just a snapshot in time, but we collect it and use it and analyze it year over year over year to provide us what we need. So I don't know if that's important to be in here, but I think that is a good thing for us to remember. Representative Chena and then Representative Lipper. Thank you. I'm open to amending this to if the language was going to say that we want the data to be used better. I think that's what I'm hearing. But one thing I just I did want to say about the data piece is that I have seen some examples in my work in this committee where we do hear representatives of state agencies come in and say here's data and here's what we're doing. So it is it's not like it's not all not being used. One thing we found in our work with the Racial Justice Alliance developing the bill was that it's finding the data and it's how the data is presented. That's actually the greatest problem. And, you know, it says in this bill, the data will be made available to public in accordance with state and federal law. It doesn't get into the details of that too much. But what would be really great is if there was and I'm not saying I want to add this, but I'm just saying if there was a data dashboard or some way that the state in general had a data clearinghouse, because the thing is that in a healthy democracy, we're going to empower the people with as much knowledge as possible. And then like an educated public will lead to better decisions of government because our constituents will have access to the data that the insiders have. And so I just think, you know, collecting data better is important. But so is sharing the data because ultimately by sharing the data, we're engaging the public and creating solutions and we're engaging people more in the decisions that affect their lives. So I just want to say that. So I'm open to anything that's going to strengthen the sharing and collection of data. I don't know the exact proposal is going to be, but I just want to say that. Representative Lipper. Well, I want to say that I was when Representative Goldman made her suggestion. It has it appeals to me and I'm not sure that my suggestion and hers are mutually exclusive, actually. I think they're complementary. And so I think I would I would urge maybe both of them to be incorporated in some manner, because I think it's I think it builds on what Representative Page said. This data should be used, not just collected. And so I think they're both I don't think they're mutually exclusive. And I don't think it's putting the cart before the horse just to say it should be used for recommendations without specifying in what way you can't say until you have it. But sorry, Representative Burrs. I think I think it's important to have decisions be driven by data. And I think that adding in the in order to measure over time the impact of reduction in health care disparities would imply that that is the sole purpose of data collection. And I don't I want the data to be sliced and diced in as many different ways as humanly possible or otherwise possible. Because, you know, I have a role in education and the short term data collection drives the next couple of years of school. And then the long term, you know, you have to look at data in both short term and long term and from all different all different angles. I think it's, you know, data collection should be uniform across. I feel that the data collection should be uniform across the whole state government so that we can all be looking at the same pieces of information. I don't know why that is that is the thing that I I think is important. I'm disappointed that the data will be siloed once again. But I don't think we should put any kind of parameters on how the data is used. I think we should say it should be used. And that's it. It should be used to drive decisions. And and clearly we'll be using it to to, you know, see how far we've come and where we're going. Representative Cortis, I think data collection, the word data collection is not enough. There's data collection and then there's high level professional data analysis. And we can do a really horrible job of analyzing all the data that we've collected. So I'm I'd like to see even just the words a way of describing what what high level scientific data analysis. That if there's a way to shorten that, but I'd like data analysis to be in there, like professional data analysis or. I I thought I thought the analysis is a specific subsection in the report. And I mean, I wouldn't want to see the word professional added because that would be an implication that we we would not do it professionally when we're doing data analysis. OK, so that's just my. So it sounds to me that there's some degree of consensus and we can do a raise hands drop hole. But to to add some non prescriptive type language that would indicate that the purpose of the data is both to monitor but also to drive decisions, recommendations and decisions. And and leave it fairly general, but make it clear that there's an intent to make use of it in order to inform the Commission for its decisions and to try to result in data driven decisions. Is that not that's not necessarily expressed perfectly because Katie's going to express it perfectly and bring it back to us. But but is there a general sense that we'd like to see something drafted to include that in the bill? And we can just do a little show of hand. We don't need to use blue hands. We can just set we don't need a round of black. You're not sure yet or OK. All right. All right. So there's general consensus that we want to see. Katie drafts something to try to capture that. Do you have enough, Katie, to. I do. I've been drafting as you've been talking. I don't know if you'd like to see it or if you want to wait and see it later. Oh, if you have something ready, that's super. I didn't want to put that. Yeah. Let me pull up my screen so we can look at the same thing. OK. So I've added language in two places and it's highlighted in yellow. So this is the data collection section. Mem in subsection B one that is referencing the Department of Health. And this is the sentence that representative. This is systemically analyzed. It's the section on it. The Department of Health shall analyze. OK. Yep. And this is the sentence that Representative Lippert was suggesting to add that the department's analysis shall be used to measure over time the impact of actions taken to reduce health disparities in Vermont. And then I just have a little addition here. The data informing the department's analysis shall be made available to the public in accordance with state and federal law. So that's one addition. And then I'm going to scroll up and bring you to the commission section. The commission has an annual report that's required. And part of the report is findings and recommendations for legislative action. And I've written that all recommendations shall be informed by the data collected and analyses completed pursuant to Section 253, the data collection section of the bill. So I've cross referenced that work. Maybe this should be analysis and not analysis. I would throw in just one brief suggestion that we remove the word all because there could be recommendations that make sense to make that are not tied directly to the analysis. OK. We'll just leave it a little bit more open. Any comments, direct comments, because then we can take a more formal straw poll about adding it to the language since we are going to take out all, shouldn't you take out the shall and make it may? Is there a requirement on that? Because I think we want recommendations shall be. But I just wanted to leave a little window that there could be a recommendation that that that wasn't. Is that an insistent? That I that's what I was thinking is doesn't shall make it that that they now no longer have the option to use. Other information to make recommendations. I know we're not allowed to use should. I think may would be the way to keep it loose. Recommendations may be informed or something like the advisory commission is encouraged to base recommendations on data collected pursuant to that section. That sounds reasonable to me. Can you put that once you finish typing, if you could put that back up for us to be able to see it? You sure I can. I can type and share at the same time. For buy, I think still works what you had there. Yeah, when in the wrong place to. OK. Recommendations. I'm hard to make recommendations. Thoughts. Now I see what shares. OK, we do have a representative page. I'm fine with the changes. I just I have some more. Just call me Johnny jump up because I have some more recommendations. That's fine. I mean, this I think this is proven itself to be a lot of value. So if we could now that we have language, if we could take a blue hands poll representative Goldman, did you want to say something before we? Well, I was just wondering, encourage seems kind of soft to me because it's encouraged is kind of soft. But I was just wondering if we could say expected and encourage and expected or something a little firmer that we expect the commission to use data. I'm not sure if that's appropriate, but could we it is anticipated that recommendations would be based on? Would that be is that considered acceptable statutory language? I had the same thought, Representative Goldman. I just didn't I couldn't think of a way to word it. That's allowable, right? I like the idea of setting the bar higher than encouraged. I guess that's my goal. So that's why I said expected that that's the expectation that we have of the commission. They better use it. I'm just kidding. Yeah. Or it or it is the expectation of the general assembly that recommendations would be based on. Yeah, that's fine with me. It sounds like it's a legislative intent section. Yeah, it's the intent of the general assembly that. Yeah, it is. And I bet you could do that. I don't often see a legislative intent. Yeah, no, embedded in the codified law. No, it's suggest a way, Katie, that we could make it stronger than encourage. That would be awesome. Could we say that we request it? It is requested or that's the I think that's weaker. I don't know. I don't know. What's wrong with expect? I don't know. I'm asking, Katie, is that inappropriate legislative language to say? It is expected that recommendations would be based on. I would say it's unusual, but make a recommendation without it. Then you're like, oh, they didn't meet our expectations. I think that's a mistake. I don't want to set them up for that. I mean, if they make a recommendation that's not based on data, then it's probably not going to be taken very seriously. That's the flip side. The point of it is that we want to be prospective, like we want to set the table for them to be able to do the work so that they know their goals. So that's the only reason, you know, like I think we're talking about this is, you know, what is what are we? What are we? That's my encouraged work. So that's so I think encourage does do that. Yeah. Another thought is I have to flip back to the document. The advisory council shall shall make every reasonable effort to base recommendations on data collected pursuant to two fifty three, something like that. Well, I would say if we went that way, I should make efforts, not every reasonable effort might be a little. Well, we probably should know we're. I mean, we're way in the weeds here. You're right. I think we need to. I think we need to take a proposal from Katie for language and make a decision about it. I just see Nolan has a comment. So if he wants to jump in, please. I guess I would just say that their capacity, that their ability to use data will be based on their capacity to actually analyze it. And so you keep that in mind by I would say going with some kind of intent to her anticipation versus shall gives them that room, because they may not have the capacity. It all depends on what their capacity to do data analysis is. So I just want to I think that we did. That's why we wanted to take out the the the shall. But I think they're not doing the analysis. We're we're referring them to the analysis. The Department of Health is expected to be doing so. But again, the Department of Health in previous times talked about their ability to do this analysis as well. And so just keep that in mind. So I I'm going to suggest at this point that we stay with with encouraged and that we have a straw poll on that. And if there is not enough support for that, somebody can make a specific proposal that we can then take up. But we do need to kind of reach a conclusion on this proposal to be able to move on. So how many people with their little blue hands would support the language that Katie drafted and shared with us? Can I see it really quickly again? Yeah, language is encouraged. That says encourage, yes. If you yes, if you could put it back up, Katie, that would be great and can scroll to the two pieces. This is one of them, as we got. Are we actually doing the straw poll right now? Yes, we're doing the straw poll right now. And Representative Sheena is the only one I think who has not. He is. His hand. Yeah, it is now. Yeah. OK. So on the record, in terms of changing the draft, there is a unanimous of those president of those present support that language change. Great. OK. On to other issues, I know that Representative Page has some other suggestions he wants to bring up, but we'll we'll pause a minute and give a turn if there are other people who have something on their mind and then go back to Representative Page. Whoops, my hand is still up. People might want to check if you intended it to still be up because I. All right, Representative Page, floor is yours. I want to say the end is near. OK. But that's not that's not what I'm going to talk about. I'm going to continue to talk about data. If we look at page 20. Data collection. That whole paragraph from line two through through line nine. I do have a concern. And we've seen a little bit of it where it seems like every state office is now going to be collecting data on on race. And that's that's great. I wish it would be more centralized where there may be this. This is the office that should be responsible for, you know, collecting that data rather than every department doing its own thing. Does that does that make sense? Yeah, yeah, it does. I'm looking at it as you are Representative Page. And I think just to be clear, it's it's only saying those agencies that collect health related data. In other words, that they're already doing it. It shall do it in this way. But you're right, if it just sits in their own department. Well, it's also it's not going to be very useful. It's also a very expensive proposition. If you've got everybody, every department and every agency out there collecting their own thing. And not standardized. Well, right. Well, this is this is things that they're already collecting. It's just the way they're they're doing it. But you're right. Now, I'm looking trying to look at the next sentence. How that's done, how that is done, is supposed to be in accordance with recommendations made by the executive director of racial equity, who is the interim person as this gets started in consultation. And I assume that should be with the. Is that with the commission we mean there? Rather than advisory committee commission. Yeah. So so it isn't it isn't according so it would be creating it in a standardized way. But it doesn't say that that that the Department of Health should then be doing anything. You know, it doesn't go anywhere as I'm reading it. It just sits in each of those agencies, although they're expected to. Follow the direction from the. On on how to collect it. Let me go back to where I can. I don't have any recommendations. I just I'm just bringing it up as a concern. OK, and. Maybe there's a way that we can change that paragraph to make it. Yeah, I'm I'm sorry, I'm there. OK, I'm back to I was trying to find hands again. Representative Gold representative Goldman. I just wanted to understand the role of the Green Mountain care board because my understanding is they're sort of the central repository of all data. If I understand that role correctly, that they're they're the central repository for a whole bunch of data and then the Department of Health, actually. I believe has some of its own data collection. It's. Yeah, and what I remember from that, the Department of Health testimony was they have a ton of data, but they don't have the report or the ability to act on it. So that's what I'm remembering. So I'm just trying to see if there already is a central repository. And maybe Nolan, that's why you have your hand up. Yeah, and he's waving over there. OK, Nolan. Jump jump in here. Sir, let me can I reframe the question? I think what the purpose of this language is that all these different departments are collecting data for their different various purposes. Well, you know, for whatever they're doing in their departments. And what it's doing is just trying to undo some of the systemic problems of leaving out this data by saying, please include the data when you do your analysis for whatever it is you're doing. There's not like there's just like this whole pool of data and everybody's doing their own everybody is doing their own thing, but they're collecting data for different purposes. So I don't know that a central repository is really where you're where you need to be at this moment. I think it's just a matter of, you know, Department of Health is doing a study on this and Department of Vermont Health Acts is doing a study on this. When you do that study, please do not forget to include these populations. That's what I believe this language is trying to achieve and not create some kind of central repository on this data. That makes other words. Not not doing it with data that actually is for very different purposes would not need to all come together. Representative Black and then Representative Lippert. I was just I was just wondering how on earth anyone that collects health related data is supposed to collect all of this data that is laid out that they have to collect. Are we mandating that if you're collecting data, you must include things like socioeconomic status, sexual orientation, because I'm wondering, frankly, where that data is going to come from. That this may be one of those places where we ought to consider injecting the language to the extent possible so that we're not creating an impossible requirement. Representative Lippert and then you had your hand up, right? And then representative. No, that's it. Representative Lippert. Yeah, I was just I was back on the the issue of. It's not clear to me like we actually have made an appropriation to the Green Mountain Care Board to work with the Department of Health around collection of data around around these very issues. But I think part of the goal isn't part of the goal to say like, well, let's not have one hospital say, well, we we're collecting race data. We say white, non-white and the other and we know that that's not useful. And then someone in the next hospital says, well, I'm going to do it. So I'm going to say black, Latino and other. And then and then you end up with nothing comparable and nothing really useful, ultimately. And so I think part of what the goal needs to be and I think is the goal. But it's not clear to me how we get there of having a coordinated. A set of data points that health health entities across the state will use. And I don't know. And I mean, in some ways, I think that the Department of Health and consultation with this commission would be perhaps the. Well, that I mean, that's the second sense there, although it says the the Department of the Director of Health Equity and the commission. But I think that's what the second sense is trying to get to, that they are going to recommend that the common. Common means, well, I think, yeah, I think maybe that's but maybe maybe that needs to be strengthened in some ways. And maybe that should be just a separate bullet point, if you will, so that it's steps out and says that this is this is. I don't know. I think that's part of what I'm sorry. Go ahead. Yeah, represent Burrs thought on this. I do have a thought on this. My thought is that if it should come to pass, so to speak, that the the. Director of Racial Equity, Executive Director of Racial Equity's office is strengthened during this session. Then she's really the I mean, it all fits together really well. She's really the person who will be responsible for deciding what what data is collected in what manner across the whole government, right? And that includes this piece. So that includes that includes the what the recommendations of the commission are going to be long again, not putting the cart before the horse. That is exactly what I mean. So I mean, I don't know if we need to say something specific because she's in the driver's seat and she's also she's in both driver's seats. So that's my thought. So can we get to the point of anyone who wants to make a specific proposal about a change versus leaving it the same and that there's two hands have popped up. So representative Gina and then representative Goldman. Yeah, I did. I just wanted to say that this is a bigger issue that I don't think we're going to address in this bill and it might be better not to not to try. In terms of the idea of the bigger practice of data collection and I and there are other bills out there that talk about strengthening the office of racial equity, that talk about giving funding and support for that office to make to figure it out with, you know, so I would lean towards let's like not overdo it. I appreciate everyone's like attention to detail though. I and I do think it's it's nice that we're talking about this. So I think representative Page makes an important point because there's nothing more frustrating than to do a whole ton of work and have it sit on the shelf uselessly. So I think it's really a good point. I think that the idea, which I think representative Lippard said is the idea is that whatever entity is collecting data, they include these aspects that they disaggregate by race, ethnicity, gender identity, which is in the first sentence of Section 253 A. So I'm going to suggest that we leave it be because it is in fact that language doing what we want, which is that who's ever collecting data is disaggregating in a way so that we can then address the findings. So I'm going to make one last suggestion and and then we can, you know, I think we do need to get to closure and if there's a specific thing to then vote on if there's sort of a general sense, I am going to go back to suggesting to the extent possible. And the reason for that is that we know from even from some testimony on various topics that in some cases this could be extremely expensive and difficult to create to change databases that might even be, you know, peripheral to the main issue. This is a pretty strong requirement, I think, and I think if it if it doesn't happen enough, the legislature can come back to it or the commission can can request legislation to mandate it because people aren't following the intent of to the extent possible, but I would after would have to represent Page brought attention to this section. I would like to see that language added. Can you tell me what line you're referring to when you say to the extent possible? That would be let me open my copy again. That would be it would actually be line to a it would start with to the extent possible. Each state agency department board or commission shall include in its data collection or or maybe it's to the extent feasible is is a better wording because it's it is you know if it's if they're saying this just really isn't feasible. That's more concrete than whether they think it's possible representative boroughs and then court is I would prefer if it it said at the discretion of the commission instead because that would make sure that the data was still a uniform had uniformity to it and was standardized because I'm I'm afraid if it's to the greatest extent possible, it'll it won't be complete. Representative Cordes. I have a similar concern that this is work generational work of which has often been delayed or not done because of understandings of what is feasible or what is possible so I would rather not include language that would say to the extent possible of Goldman. I worry that if we say to the extent feasible that it gives them an out and I rather have it be firm that we want it and then have them come back and say well, we tried and here's the problem and then we could address that problem. So I don't want to mean yet that would be my feeling is I would not like to let to the extent possible language in there. I like the language as it is. I actually find that really compelling if they if they end up thinking it's not feasible then they they come back and say, you know what this would cost five million dollars. We we can't do it and then it gets reconsidered. I I think that's a good point and so at this point I'm going to withdraw that suggestion. I'm also hearing kind of a sense that it's not supported. So All right. Little deep breath here and then anybody else who has another specific issue that they would like to make a suggestion on revision representative Lippert. If you all have already gone here, let me know but I have to say that some of the test of the testimony heard some of it that was most compelling for me and impactful was hearing from Judy Dow from as it was at Godakina the group I don't know if I'm pronouncing the name properly but I was I was impressed with the breath of the work they were doing at the length of time they've been doing it and it raises a question for me as to perhaps it also in terms of the bringing someone to the table who's not necessarily just part of the recognized groups about a necky and I'm I find myself wondering if there's a way to bring someone from that group to the table and also I had the same concern. I think I think you know sorry I recognize it's already large group but I think I found that voice particularly compelling and thinking that it would be good to give them a recognized place at the table. Representative Tina and meanwhile I've asked representative Lippert to be thinking on who would appoint how that would be achieved. So I've given some thought. I've given some thought to this too. Because I think Judy Dow's point was that you know we have five seats that are specifically connected to indigenous groups. There may be an indigenous person appointed by someone else because our identities intersect but five designated seats for those are associated with a state recognized tribe. The other one is appointed by the commission and the commission includes members of the state recognized tribes unaffiliated a Beniki people and other indigenous people. So we're only creating one seat out of five for all these others. So I if I could have my way which probably won't fly. I would say that the commission should have two seats one for an a Beniki person and one for an indigenous person who's not a Beniki and we would have the dock and I have a seat because then we're creating two more a Beniki seats. One could be a person in a tribe but it could not one won't and then we also have a seat for an indigenous person who's not a Beniki so that if I know that's aiming high but that's what I would prefer and it's not a concrete proposal. It's just my preference. I had my hand mentally raised and then representative Goldman again. I don't have the full list in front of me. I think something we have to be aware of and I would ask is I don't want to pit groups against each other and how does that relate to the number of seats for people of color black people with disabilities and LGBTQ does that suddenly give you know seven seats to indigenous people and so representative Goldman. I totally worry that I guess we we we include these this set of groups but we're going to leave out that set of groups and it's going to be really hard to be so perfectly inclusive. So I'm wondering how these seats and I should probably know this but I'm not sure how we were we're assigning members but can the commission appoint a member. We decide that the commission may appoint you know by a majority vote or whatever vote we decide if they feel there's a gap that they have the authority to appoint a member rather than us trying to think of every person that we wish we had thought of I mean that's where I'm a little hung up because it's going to be so easy to leave out you know this particular group or that particular I don't know the right answer to that but how do we fill in that gap. You know going forward so I was just wondering could the commission fill the gap itself. Representative Peterson. Yes, I think we ought to add a physician licensed in the state of Vermont to the group to the commission. I think it would would answer a lot of questions right there and and and solve a lot of running around the group could do in trying to come up with answers. So I I'm having two reactions one is I don't I don't have the list in front of me so I can watch hands and I'm assuming from what you're saying is that the Vermont Medical Society for instance is not currently on the list and it's leading me to think that that what you just said Representative Peterson exactly supports what Representative Goldman just said that there could be a number of voices that are really key to the discussion that we didn't think of and that perhaps there is a way to say that the commission may by majority vote ad members it believes are important and appropriate to being a part of the discussion. I think it's really important to have someone in the trenches actually working on or providing the health to the to the communities involved to have a seat at the table to at least have some input. And might bring a lot of issues that would otherwise be churned over worked over and amount to nothing. That individual might have the answer that would make things flow a lot more smoothly. Just a suggestion. Yeah, no, I hear a representative China and then Representative quarters. I hear that I hear and respect the concern around wanting to have like health care provider input. One can one concern I have about the idea of a doctor is that in our health care system. There's a hierarchy that exists where doctors have more power than other kinds of health care providers. So I'm not opposed to adding a doctor but I would just say that like we might want to consider that we're kind of reinforcing some of the systemic power issues if we put a doctor like if we say it has to be a doctor it could be a health care provider though. Right and and and one way around this for what it's worth I you know I as some of you may know I I've written a lot of bills you know and like a lot of them have had boards and commissions and things like that and one one approach we've used in some of these other bills is we have a clause saying that the commission should reflect a mix of and then we say things without saying exactly which seat is what in hopes that when people are pointing someone to the commission they look at it and they say oh there's no doctor well we're going to put a doctor in the in the seat that we appoint or there's no nurse. So one way around it is instead of saying like there must be a doctor and there must be a nurse and there must be this and that we could say we could add a clause to this part of the bill saying the commission should be a mix of patients health health care providers policymakers etc and in making appointments we ask organizations to take that into account or some and that's probably not the right legislative language but it's just a thought I'm not attached to any of that it was really just I wanted to highlight the issue of sort of doctor supremacy that goes on and and also just there's different ways we might approach this but I agree with the underlying issue which is we want to make sure that this in that discussion there are there is contact with providers. So thank you representative Cordes. I agree with representative China about the the doctor issue and I have very close relationships with many doctors but there is still even in 2021 a power imbalance and there are many health care workers that are actually more in the trenches so to speak. So I'm and then thinking about the the at-risk communities I'm wondering I can't remember who said this but I'd like the idea of language that would say something like in order to ensure adequate representation from adequate representation or excuse me equitable representation of at-risk communities the commission shall be empowered to appoint something like that. Okay, thanks we do have two trains going on that right now and I think they're both important. So representative Cordes is back you're going back to that equitable which I also like that kind of an approach but we also have the second issue and without without the in the weeds of what kind of providers you know doctor versus others is there a way people think that we should incorporate some language that that the health provider voice is a part of this critical health decision. Represent sorry I think I think I meant to also include the health care provider part of that to as part of what that would be miss the commission was empowered to ensure that voices were. I do that goes back to what representative Goldman said and I do think there's a lot of sense to you know not trying to include every possible voice and yet have a mechanism to ensure they can be included. Yeah, can I just say I would I would withdraw my specific suggestion and support represent Goldman's and what I think represent Cordes is saying in terms of giving the commission the ability to address I mean to address unanticipated or unacknowledged representation and I think that can include what represent Peterson is said as well that too and to include. That there is a table from the medical community medical and patient community I mean everyone's going to be a patient but not everyone's going to be a provider. Right. So you're right to ensure distribute right well Katie I know has been listening to all this and maybe out of those last several comments there's an evolving potential language. Yes and I'm going to great keep my camera off my Internet is spotty and I keep getting kicked off so we'll see if this makes the difference. But I have I added a catch all. That would be any other person the advisory commission deems necessary to carry out the functions of this section based on a majority vote of the members. I think that's good. I think that there was some other input that suggested that maybe it needs to be a little more detail than just carry out the functions that it it's necessary to carry out its functions and inclusive of you know inclusive of equal representation comma and addressing inclusion of the health care provider community something like that work for people. We say something like a balance of health care provider and patient perspectives or something like that. Or affected community. Yeah, yeah patients because you don't want to if you open it up to any patients then you're yeah yeah yeah that's fine. I did I think I was what I was getting at is I don't want to imply that we only want them to prioritize health care providers and then it's like no right right equitable representation of the affected communities and inclusion of and inclusion of health provider. Voices or perspectives. Okay, I have my hand raised can I speak the thing I was going to say so I am going to be critical for a second. Okay and ask a question that I can hear somebody else asking maybe maybe if this goes through gov ops because it's a commission. What if they just don't stop what if they keep deciding they need another person and they need another person and they need another person and they need another person. I'm not saying we need to do anything but I can hear that already because someone's going to say that along and and and my response to that would be they're the ones who have to function and do their duty and if they think they can function as a 50 member commission versus you know the reality that they would become dysfunctional I'm not sure I would want to press prescribe. But what about the cost. What is the fiscal note for this how can we have a fiscal note if we don't have a limit. I mean this could we could say the fiscal note could say 100 grand that could be 500 grand if they quadruple in size. Can we leave that for gov ops. We could I'm just being I'm just thinking critically of what we're doing and like yeah, let's let let's let a probes raise it if they have a good idea that it might be that it might be overutilized. Okay. Can I ask can I ask sorry I didn't raise my hand but could we say with an upper limit of 30. I mean or whatever we have I don't know what and just you know give some open seats that they could work with add four blanks. So maybe a separate right a separate line that said the commission shall have no no more than X members. Yeah, which implicitly puts a number under clause bb because we've appointed everybody else. Yes. This is something good. Um, the tricky part here is that you have this subdivision to and it's a rolling appointment. So like the some of the members appointed only have a one year term initially and some only have a two year term initially. Um, so we're you know we're saying how many people have a one year term how many members have a two year term. So if we have this kind of open-ended function then we would need a different way of looking at this subdivision to put the member could we call them I'm sorry I just jumped in in bb. Could we say any other members at large that the advisory commission beams and then we can say in part in number two that the members at large only have one year terms. So the commission would have to just keep reappointing the person if they wanted to to keep them on past a year or something like that. That's what I was thinking to and grimace though. I don't know what that I don't initially but now I'm maybe that works. Yeah, because for one thing that could help ensure that there were that there were different voices because they could keep being reappointed. But on the other hand, they could be replaced. You know, rotate every year. And it's not as much of a doctor's busy and they get on the commission and they're like, oh Lord, this is like too much work. Like they're not tied in for three years. They could just let the commission know you know what I'm going to do a year and then find another doctor. I feel like in the end, they'll be a good balance of like consistency and fresh voices if we had something like that. And also those are optional. Although I will say in my experience with government and with working with people, people do what you will people will go up to the limit. So if we say they can appoint extra six extra seats, I would be surprised that they didn't quickly decide that they wanted six more voices and that's maybe that's okay. Maybe that's a culture shift is like we're giving a little more power to this commission to to and this has been an issue on other other boards and commissions where they come back and they ask for more seats or more voices. So we're kind of building that in. Can I interrupt here for a minute and say, let's see, I'm trying to because I realized that I have information that others do not that we talk specific to this. No, but just specific to the timeframe we're using. Okay, it was I think we're close to concluding this piece and it would be good. Unless we're not, but if people feel they're close to straw vote, it'd be I think it'd be nice to bring it to closure. Okay. Representative Cortez I just want to acknowledge that this conversation we're having about the size of a commission or the size of a board is the subject of many papers and studies and the I think it's an it's an important conversation on this long the scale of efficiency on one end and representation on the other. So I appreciate that we are being very thoughtful about airing on the side of equitable representation. We'll feel ready for a straw vote on this language. If not, we'll stop and let the chair speak to what he wanted to raise. But if people feel ready, then I think it'd be good to bring it to closure. Okay, not seeing any hands. Can we have a straw poll on those in favor of adding the language that Katie has just shown us by blue hands? It's easier. We did. Yeah, just do blue hands. Okay. Nine. Is somebody missing? It's nine zero. It's nine one. Oh, that's true. We didn't you didn't vote. All right. So, so the hands down. Is there anyone opposed? Adding this language. Everybody's hands have to go down first. I don't know how to clear all so you got to put them all down. All right. Lean can put them all down. Oh, okay. In a straw poll, we're just looking for where the preponderance of the thank you. Yeah, that's right. We're not really measuring a vote and okay record will show that the majority of members had their hand. The majority wanted to add this language. Okay, thank you. All that's needed. That's really all right. Thank you representative Lippert. You wanted to. Yeah, I wanted to actually share two things. One is that I have not yet met with appropriations because I got there and they wanted to reschedule me because they were taking a break. So I'm scheduled to go there at one o'clock now. And my other commitment is getting. Impactive. That's fine. So I think we and we already are doing what we said, which is working into the lunch hour. So thank you. But also yesterday, there was interest in having Susanna Davis actually weigh in and she's available today at 1230, which is nine minutes from now. And that's part of what I wanted to bring to everyone's attention. She's available only between 1230 and one. And so I think as we continue as represent down here is we continue to move through the our process. I think we should anticipate that be prepared to use the time with her to best effect. Now, now you've told her that we are interested in hearing her perspective on her role in this and she's not allowed to come in with a list of suggestions for changes in the bill, right? I joke. I told her that we were interested in hearing from her further about her ability and willingness to participate in this proposal. So we have 10 minutes. Well, we don't we'll have a break after Susanna testifies this. So I don't think we need to break. Does somebody have another issue or proposal? I think I mean, I'm really appreciating. I think this has been great. Exactly the type of things that markups appropriate for identifying issues and coming up with solutions when possible. So are there any other issues someone would like to draw attention to? So if not, and people can keep thinking as I speak, if not, I would suggest that we not in seven minutes begin the phase of discussion of where we stand on the bill and, you know, our response to the bill as a whole and that that open sharing of perspectives that we not start that and then break for for hearing from Susanna. So okay, we now see a hand representative. Yeah, I mean, I agree that we shouldn't do that also because we don't know what she's going to say. And so until we hear from her, I feel like I support what we've done, but if she comes in with concerns, I want to like take those into account. We may need to revise something. So so I like this plan of like, maybe we take a five minute break or something and then like, and then like, you know, we hear from her and then we can digest that overlaunch, no pun intended. And okay. Yeah, no, I think that makes sense. So people shouldn't go offline, but maybe you take a stretch take a stretch right five minutes.