 All right, we're back. This is Senate Health and Welfare. It is January 18th, 2023. We're now have invited Chris, Chris Doss of the RAND Foundation to come in with us and to answer questions and to carry through our dialogue on the early care and education financing studies. So, thank you for being here. I really appreciate it. And we'll go around the room and sort of introduce ourselves so you know who we're working with. Thank you. Oh, go ahead. I'm Ruth Hardy. It's nice to meet you in person. My question. Terry Williams? Robyn? Jenny Lions. David Weeks. Robyn County. And Elaine Gulick has taken a trip over to meet with a treasurer, but she'll be back. It's Martine. Martine Gulick. Martine Gulick. What did I say? Elaine. Well, it was a mistake. So, Martine will be back. I don't know where Elaine is. Okay, this is great. So after your presentation, there were some questions that I think we each have. And so I don't know where to begin because there's going to take us all over the place. And you touched on a lot of the questions that we might want to look at. You know, one of the assumptions that you made was that this is or that you identified that this, the changes that we would be making to fill the gap would have a low effect on the, on our income and our economy or on workers' economy. I don't know exactly how you said that. Can you talk about that a little bit? Because if we're at a place where we're trying to raise money to fill a gap, whatever that gap may be, how do you determine that it's going to have little effect on one's income or ability to survive economically? Right, no, that's a great question. I'll start and then I'll throw it to Erin. We got into the weeds with the modeling of that part. But when we say it would have a small effect on workers, we kind of look at total economic low B. So if you think about their income, which almost you're part of the ECE system wouldn't be affected by this, right? If you think about the average package of that a person spends their income on throughout the state throughout the year, the taxes that would be levied as part of our proposals, for example, would have, would it be a small portion of their average expenditures? And so we wouldn't expect that the additional expenditure on a per family basis would be so owner-assessed that perhaps changed their standard of living in any appreciable way. Erin, did you want to talk a little more specifics about how the model kind of talks about that? Yeah, sure. So there's two things that we want to think about. The first is. And would you mind, Erin, not wanting to interrupt the flow, but our tradition here is that you introduce yourself by name before you testify. So thank you. Erin Strong, yeah. Thanks. So there's two ways to think about this. The first day, or there's two portions that we want to think about this. The first is when we think about increasing revenue to the state through or being able to pay for those subsidies to the early childhood sector, what we're thinking is that would either come from increases in taxes in some sector, whether that's a payroll tax, a sale, increasing the sales and use tax, or any of that, or a decrease in expenditures in other areas. So if I think about that on net, what are we doing? We're changing around the composition of income that's coming to the state, which if I increase taxes, what does that do to consumers that lowers their ability to buy goods? So that we will in some sense see a change in the composition of the economy because of this change in subsidies, change in family contributions and changes in taxes. That in essence has a very minimal effect on the economy as a whole. It doesn't have an expansionary effect. It really just has a compositional effect. The second portion to that is as we have less costly from a family's perspective, early childhood education, that can induce participants to participate in the early childhoods education, put their children in child care, which allows them to participate in the workforce. That second aspect is where that expansion is likely to come from. As those workers during the labor force and as new employment opportunities arise, we will get this expansion of the Vermont economy that not only will there be additional workers, there'll be additional machines and capital that will cause this increase in income. Our estimates suggest that that expansion of the Vermont economy due to that increase in labor force participation is likely to be on the order of 60 to 200 million dollars. So that's where the expansion is taking place. The expansion is taking place because of those that increase labor force participation. There is really no expansion taking place caused by the subsidy and financing system. That's really just a shuffling of the economy. Okay, thank you. And so your determination, the modeling that you use was based on Vermont data. Can you talk a little bit about how you have the data that you used for that piece? Yeah, so what we've done is there's a company out there called Implan. What Implan does is they take the Bureau of Economic Analysis data on 536 sectors and makes it specific to Vermont or any county in Vermont. And so what we've done is we've used 2019 data developed out of data from the US Bureau, sorry, BEA to calibrate the model that allows us to view these scenarios in terms of financing scenarios, in terms of labor force participation impacts. All of that is done with Vermont specific data calibrated to 2019. And then the issue, so it leaves alone the issue of the current inflationary pressures that we're feeling as well as the changes and interest rates and so on. Although I know Chris, you think we're talking about that. I think this is an area that is going to be filled with discussion going forward, but it's good for us to have an understanding in here. I would say we do reflect those numbers to $20.22 based on Northeast specific consumer prices. So we've taken into account the inflationary pressures from 2020, 2021, 2022 to account for that. The most recent data that you have access to when we did the study was 2020, and we didn't think that 2020 was representative of what a well-informed, stable situation in Vermont. And so we felt it cost you free-banding of data rather than use pandemic data, which we thought might be solid in terms of both the composition of the economy as well as the level of economy. Do you want to go more? Yes. Hello, everyone. I'm Carolee. I'll be part of the grant team. Pleasure to be with you today. I just wanted to clarify because I think I heard the question as referring to overall impacts when small. And I just wanted to clarify that we do have the statement. I think it's on slide three. But it's specifically referring to our estimates of household economic well-being, which in some ways is sort of a concept that economists use to assess the impact of household consumers because of the changes in things like taxes and economic changes. And to do that across the distribution, to be able to see how well-being changes at the lower end of the distribution and the higher end of the distribution. So that's just one of the economic impact measures that we look at where we have that relatively small. But I don't want to necessarily attach that to our findings with respect to the fact that we would expect some changes and increases in the labor force, increases in the overall size of the economy, and increases in tax revenues of the magnitudes that are referenced on the next slide. So I just want to be clear that we're looking at different metrics of fiscal and economic impacts of the policy changes and being clear about their magnitudes and how you might characterize them in terms of small or large. Well, thank you for that clarification. It's really helpful. And I know that this is an area that at least our finance committee will be looking at. But as again, I just want to say it's important for us to have some grounding here. So I'm going to hold my next questions for a minute. I know Senator Hardy has questions. I know that Senator Weitz has questions. We each have questions. Senator Hardy, why don't you go ahead and ask those? Let's limit ourselves to one question and then we'll try to get the conversation. Everyone going. Okay. Might be a follow-up. I'm not. How much time do we have? A lot of time. We're good. We have tomorrow. Okay. Tomorrow as well, yeah. Okay. Well then I'll take, the first question is sort of an extension of what we were just talking about a little bit. In our earlier sort of briefing that we had with you guys in I think early December, maybe, I asked the question about whether you were going to try to model any kind of other impacts of the increase in access to early childhood education or the increase or the decrease in cost. Something like you, I appreciate that you mentioned the household economic well-being but other sort of well-being metrics. And I know it's not quite in an economist's role but the sort of long-term benefits of early childhood education on children and society but also the benefits on families for less stress, more access to the workforce, et cetera. And I didn't see that. Was that something you were not able to get to? Well so I'll take, there's two parts of your question. The long-term effects and then other effects. So we do have in the limitations section that there is a lot of evidence that early childhood, high quality early childhood education programs have a lot of long-term benefits for children and society. So talking about in K-12 it can reduce special education services. It can lead to longer total accumulation of education, better employment in the long-term. The charge of the study to us look at a five-year time period. So modeling those effects that would show up beyond those five years would be quite difficult considering, you know, the specifics of the data that we have within also kind of beyond the scope of the study. So we do acknowledge in the report that there are these long-term benefits. So you can kind of see this as a short-term investment that will pay off later. And that's going to be a decision for Vermont to make. But there are long-term benefits that we couldn't just for the kind of the scope of the study look at. It is true also that, you know, having care could help families in other ways. It's just very hard to measure those ways, especially on an individual level and then at scale and then to somehow put that into like the economic model. So that's part of the reason why that's also not in the report. But Lynn, I don't know if you have other thoughts you want to add? Yeah, I'll just quickly add. Chris is right that, you know, there's a broader research base that shows those benefits from participating. And especially I want to emphasize it's in high-quality programs. So just expanding access without attention to quality does not necessarily generate the kinds of returns that are talked about. And second of all, that those benefits tend to be concentrated among children in lower income or lower resource situations. And so that's not to say that there aren't benefits as you move up the income ladder. But you know, it's an argument for why if you couldn't afford all of this at once, you would definitely want to start, you know, with lower income families and making sure that they have access to high quality and that the cost is not a barrier for them to have their children in these high quality early learning opportunities. So I just think those are important aspects that potentially shape how you think about, you know, where you would make the investments, especially if it's not possible to do all of the investments at once. Okay, I appreciate that. And I know that you Lynn actually have done some of those studies. So I was, I was hoping they would be more referenced in this report so that I understand that any, a lot of people are going to be reading this report which I know a lot of people already have that those would be embedded more in the argument for, you know, beyond the sort of pure economic arguments there are a lot more long term and short term benefits to investing in early childhood education, but I appreciate that you had a scope to stick to. I will say we didn't give as much attention to it in the presentation partly because of time, but there is a discussion in the concluding chapter around these issues pointing to some of that research and what those findings are. My own reading and contributions of that literature is to be somewhat cautious that there are some estimates that I think overstate those potential benefits. And so, for example, we're reference returns on the order of two to $4 for every dollar invested. But those are typically benefits when we look at making these investments relative to know early learning, you know, high quality child care early learning experiences. And so it's important to put some of that evidence into the context of today's investments and where we think those, you know, those estimated returns really are. Yeah, what's the game, you know, the game is going to be made as a start higher and higher. You okay for now? Yeah, I have more questions. Yeah, I'll take my turn. Go ahead. Yeah. Senator Wheat. Good morning. Excellent study. I just had one question about in the assumptions as trying to follow the thread through the presentation. Does the study assume that given the demographic block of children, you know, certain ages and such, you know, as immature, does it assume to develop the costs and what have you that 100% of children between age 0 and 5 would be are covered in the study or is there an assumption that some families will raise their own children and such? I just wondered. Yeah, I didn't hear it. So maybe I missed it. That's a great question. So it assumes that 100%, there will be enough money in the system that if you want the subsidy, you want to send your kid, you'll be allowed to. It does not assume 100% take up of that. So we used, you know, looking to the literature to see what would be the likely take up given that. What is that? Lynn, do you have that number off the top of your head of the percent that would likely take up the policy? I don't have the exact number off the top of my head, but I'll just say a couple of things. One is that the assumptions are that families would be making choices about how much care to consume. We know from existing data about the number of hours that children families choose to purchase, if you will, of childcare and early learning, that it's across the population. It's not 100%. It's much lower for infants. It grows a little bit for toddlers. And by the time children are one or two years away from kindergarten, typically we see around 75 to 80% of children at those ages, participating in some form of early care and education, not necessarily at a full time rate. At the younger ages for infants, particularly for families where costs is not a constraint, we might see somewhere between 50% and 60% of infants in care, again, not necessarily at a full time rate. So our assumptions are that participation grows as children age from birth to kindergarten entry, and that by removing essentially costs as a barrier because of the subsidies, we would see less of a difference across income levels in the consumption of early care and education than we do now. In other words, more of a convergence so that children at lower income levels would be participating in care and high quality early learning settings comparable to the participation rates of their higher income peers. I get all that. I heard it, but I'm still kind of searching for some assumption used in the study to reach the final number. I mean, the story goes all the way through to the end. So I think the point that I was trying to say is that it's not one number, right, because it's going to vary, right, but about 50 to 60% for infants, and then probably, Lynn, do you have the upper bound? I'm thinking for kindergarten for the greatest degree, around 80%, yeah. So those are the numbers you used in your study? Yeah, exactly. Thank you. Senator Wood, I have a question. It's a lot of information, and I'm sure what I'm reading, I'm going to have different views on it, but one of the things that I heard was that maybe I didn't. You didn't use any federal funding to come up with these calculations or did you? We did, okay. So we took into account all the federal funding that's currently in the system, so that $125 million number that we use that's currently in the system is a combination of the federal funds. So you get from Head Start, from Pre-K, from the child development block grant, and then also the state funds that you have currently appropriated into the system. And we subtract that from the total cost in order to get that down. I've been talking to a lot of constituents that were in the daycare business, and now they're not, because of too many regulations. I get a question I've got. Do we know what the average price at the ground level was? I mean, do we know what people were paying, an average in the month or daycare? Yeah, we do. Lynn, I think you have the exact number. It's around 13,000 to 14,000 per year, I believe. Glenn, can you correct me if I'm wrong? Yeah, I mean, I'll look at it. It's document number report. I'll pull the number up while you're talking just to confirm that. Yeah, and if you look at the prices, they're kind of flat. So it costs more to have an infinite toddler in daycare than it does for a preschooler because you just need more adults in the room for that number, right? So what providers do often is they take that charge and they spread it across the different ages so that they'll kind of undercharge if you will, relative to what they pay to provide that care for the infants and toddlers, but then they'll try to recruit that on the three and four year olds. Then pre-care, in my time, again, look at the local level, we have two systems. We have a part-time pre-care, which most people use, a lot of people use as a daycare. And then you've got full-time, which is in the elementary school system. And my understanding is that pre-care uses federal funding. They're funded differently than... So did you take that into consideration of this? Right, so PAC-166, which is a stat-less, universal treatment or garden program in Vermont, is those funds already in there, as well as any federal funds that you get for the pre-care services as well. Yeah, it's a different funding. Yeah, I mean, that E-system takes lots of different parts, right? It's a little bit more complicated than just like the P-12 system. Page 20 of your report has the full table of the funding sources. Yeah, but I can't find the table of the cost, but lots of tears in there. I don't think... I don't have it memorized yet. The cost of our birds are on page 15 in a paragraph that's in the middle of the page. They're not a table, but they are about $14,000 a year for infants and toddlers and $13,000 for preschoolers. And that's for full-time annual cost of care. It's a sticker price, not necessarily what it costs to provide. Yeah, I should say yes. Those are the prices that parents pay, not necessarily what it costs the providers to deliver. That's one of the stress that they're under. That's another table. Yeah. Okay, so I'm just going to ask a question. I don't want to deviate the system here because everybody's got interest in the discussion. I'll ask a question that you might be able to go through with us tomorrow. So the four-year phase-in review. So if we could look at the four-year phase-in for the different gap filling, that would be helpful to drill down into that a little bit because we will spend time on that in this committee, so that would be helpful. Happy to do that. Yeah, and we give it to you over different scenarios too. Yeah, that would be nice. And in the presentation, we kind of gave you a big shot of numbers, right? And it was going to be a big hour going down. So in the report, there's like what happens at 25%, 50%, 75%, 100%. That would be very helpful. And along those lines, Senator Weeks brought up the issue around the middle class as compared with what we have here for going up to different levels of poverty. Is there a way, and I'm looking at Nolan, maybe this is something you could get us from Vermont, or Joyce maybe, where the middle class is, a bell curve, a middle class income, get an income distribution, and then how that fits with the federal poverty level that we're talking about between 100% and maybe 500%, because I think that's what's in the report. Yeah. Yeah, if we could get that, that would be terrific. I'll get Joyce to see if there's something you can do. Yeah, I know, I've seen that information somewhere. The Federal Poverty Guidelines also give it by family samples, right? So for example, five times poverty for a family of 3 is 115,150, but then for a family of 4 that goes up to 138,575,000. So it's also dependent on your family size. No, there you go. It's here, but you're right. It does sustain you between family size and maturity. Yeah, in this case. Okay. Are we doing more questions? We are. I've asked for my information, so we're going to move back to the Senate Party. When Senator Gullick comes in, she gets some... Okay, I'll ask my two last questions, and if we don't get to them today, then we can do it. But the report goes up to 350%. Did you model out of poverty? Did you model out the potential of going higher? Because I'm concerned about the cliff at 350. I mean, it's pretty stark on your chart. And what it would take to sort of smooth it out up to maybe 500% or where? So we do go up to 500% and we model out 500%. So with those larger DAPS estimates of about $270 million to $280 million a year, that models it up to 500%. Okay. And so the largest DAPS estimate, I think, which is around $280 million, caps it at 13. So it goes, caps it at 7% if you're 350 or below, and then it goes up and caps it at 13% if you're between 350 and 500. So even at the 500% level, you're between 13% of this level. Okay, and the 7%, can you remind me where you're at? Yeah, so the last schedule says if you're 350% of the level, you cap it at 7, and then for 350 to 500, you increase, but you cap it up at 13%. Okay, and are those the 7% to 13% or are those just ranges that worked? Or is there some research behind those percentages? Yeah, what we try to do is, I mean, Lynn, maybe you can provide a little more context on that. Yeah, they're kind of within the ranges of what you would want to expect as somebody of that economic well-being or income level would. But Lynn, would you want to talk to more about that? Sure. Let me just also note that schedule three uses the 10% cap all the way up to five times poverty. So what was a little unclear as we were reading Act 45 and the desire to have a cap on the share of family income that would go toward the cost of childcare and early learning programs was whether that 10% cap or the 7% cap would apply past the current threshold of 3.5 times poverty. So on 10% cap, we actually did it both ways. So schedule two is what we focus on in the presentation and sort of view that as our main estimate, if you will, but there is a version schedule three, which is somewhat more generous and that that 10% cap applies all the way up to five times poverty. And one of the things you'll notice is that under these schedules that we use, which get successively more generous, in other words, families paying less of the costs and more of the costs would fall to the public sector, is that we're not changing, you know, each of those sort of lowering of the rates and moving up the income ladder is having incremental changes, you know, overall of maybe the $20 million that we mentioned at one point. And part of that is that, you know, we're moving through a range of the income distribution that is relatively fewer families as percentage of all families compared to those below 3.5 times poverty or even at five times poverty and above. So some of these changes, you know, represent relatively small increments and amount of public sector funding that would be required. And if you look at the report, there's a fairly detailed breakout that shows you going from 3.5 times poverty up to four, then 4.5 and five. So you can sort of see at each of those increments how much more the public sector contribution would be or conversely, how much less the family contribution would be. So what that's picking up in each sort of segment of the income distribution as you move higher. Okay, so the 150% or 1.5% of poverty is that the 7%? Do you start at 7% on there? Because under 150% there's no family contribution. There's no family contribution. So that would be 0% essentially. So 7% starts at 150% of poverty, yes? No. No. So this is, I don't know, Chris, if you could put up that show. I am exactly what I'm doing. Okay. But what you'll see when Chris puts the chart up is essentially it's flat until 1.5 times poverty. Then it starts at around 2%. And then it goes 3%, 4% and so on up to that 10% threshold at 3.5 times poverty. And then it continues to increment under some schedules and other schedules that's held flat. So you can see that the flat line between zero and 150% of poverty, the arrow that Chris is using there, that's where it's no contribution. Then under the current CCFAS schedule, that's the higher line that's both green and black and red. Yeah. And that's it. So it actually hits about 10%. Again, this is for families of three at more like 2.5 times poverty. And so the current schedule goes above 10% for the smaller families. And that's because it's a flat dollar contribution within a given ratio of income to poverty, regardless of family size. So that flat contribution is a larger percentage when families are smaller like size three and size four compared to the size five and six families. So that's why these are plotted for a family of size three where these percentages are essentially max out. So it's a sliding scale fee across the income distribution. And then it gradually goes up. And in some cases it's capped. And depending upon these schedules, the two schedules four and five, what they do is that regardless of family size, it's always a fixed percentage rather than a fixed dollar amount. So regardless of family size, those two blue schedules, which are the lowest shifted down, it's always 2% for between 150 and 175. And then it goes to 3% between 175 and 200, you know, and so on. So those are always the same percentage regardless of family size within a given point on the income distribution. And because we were aiming for a 10% cap on the schedule four, it's a little bit above schedule five, which was aiming for a 7% cap again, applied at 3.5 times poverty. And we do allow it then to continue to rise. You could convert those also to a flat schedule at 10% or at 7%, you know, beyond 3.5 times poverty. Any of those shifts, you know, essentially it's more area under the curve that the public sector will be picking up rather than families contributing. And you're assuming family contributions regardless of the number of children, not individual child contributions. Okay. All right, Jim, where in the actual report is this, the table that you... No, I think it might be good to come back to this again tomorrow. Okay. Yeah, I'm not saying don't ask that question now. I'm just saying that in addition to looking at the phasing, it would be helpful to look at this again so we can solidify our thinking of that. The one thing I would point is that in the report, the lines aren't as nice and curved. It's exact a little bit because of the way that the salary schedules are, but not just the contribution schedules. So for the stylistically, we kind of smooth it out here so we get the higher points, but just if we're going to try to look for that, it's going to be a little bit different. Okay. The chapter three section, the cost study section. Okay. The other question I have, which we can talk about more tomorrow, is that I think in your analysis, you're assuming the same structure that we have now in the overall early child care system. So you don't make changes to the number of hours for UPK or any kind of changes. We model the number of hours that people would ask for based on the revised subsidy schedule. So we don't necessarily say that you're going to change UPK or the way which providers are going to provide that extra, but we are assuming an increased number of hours that are going to be... Beyond the 10 hours that are... Yeah, so we don't really look at it as saying they're going to take 10 hours of UPK and then five hours of private center care. We're going to say these are the total number of hours that they're going to ask for. They're going to have to be provided in some way. You can perhaps do that through the expansion of the UPK system, for example, but we don't necessarily say that this is where those hours are going to come from for UPK or universal PK programs. Sorry. Yeah, I loved... I think it was your comment about... We didn't look at property taxes because it's too complicated. I mean, our data's not... Yeah. We don't want to... So, okay, for now, Senator... Yes, sir. Senator, would you like to... Do you have anything for... I'm still back on social... Yeah, go ahead. Yeah, that's okay. And if I say something, I'm going to acronyms a lot so like if some of you don't understand, please let us know. Yeah. Thank you. I appreciate that. Okay, so assumptions. Education requirements for child care providers, lead teacher, bachelor's degree, assistant teacher, associate's degree. These are, I assume, these are all the contact teachers. These are not... This is obviously support staff. That's elsewhere. Yeah. How does this compare to maybe, you know, federal requirements or other states, other certificate programs, you know, which are used for the assistant teacher level? Right. So... So what... The purpose of the report is to model high quality care. So there's a couple of things. So for example, federal programs like Head Start and a lot of UPK, Universal Precate Programs in different states require that bachelor's level for the lead teacher. It's also shown that, you know, the extra skills that they get by pursuing a bachelor's for the whole child to, like, understand child development as well as how to teach the child is really helpful in providing high quality care. So the charge of Act 45 is say, how much is this high quality care going to cost? So we made those levels to assume that. But if that is commensurate with accreditation standards, that's commensurate with requirements for other criteria like Head Start and it is also commensurate with what the direction of other states are moving in. Okay. And I may have missed it in the presentation, but when you're talking about gaps, this is taking into account all the federal money that we've got right now. Was there any other factors regarding how we filled the gaps? So what we did is we generated all the money into the system from all the different, right? And then we calculated how much money is it going to cost. And so that gap is what's going to have to be funded by Vermont. And so those seven, or those six options, basically, and there are options where I do not restrictions about different combinations of taxes that could be used to fill that gap is what we did. And that's what we modeled on the supply of the economy. But of course, you know, you're free. It's a basis, right? For you to make up to make your decisions. You might just want to go in that direction. You might want to go in another direction. So you didn't factor in any employers and contributions? We factored the core contributions to what? To what? I think I can help out center. I think if you go to slide, just maybe if you pull up. Yeah. Let's have a different way. Slide 25. And I think this kind of gets at the top of the system. And then you have the there's an assumption around family contribution. And then how much is existing in the system? And then you have what's left is the funding gap. That's the financing part where they offer a menu of options. So they took into consideration multiple funding options for you to consider. So they're not assuming that there's a payroll tax in the assumption. They're saying there's a $250 million gap. Here's a menu of ideas and how you fill that. And that might include. So for example, payroll tax could be played by the employer or the employee. So that's like one of the options that I think. So I think, Linda, you still have your question, your hand up to. Add something. Go right ahead. Okay. So I think we viewed our charges looking at state revenue sources that could help fill the gap. But having worked with other states, you know, there are some other strategies and certainly even for Vermont, some of these are relevant. And we referenced this also in the concluding chapter. One is the possibility that there will eventually be new federal funds allocated to this system. So the federal government has been, you know, increasing the amount of money of the federal dollars in the child care development fund, which is, you know, then allowed states to either add to that or make their own decisions about how much more they want to add. And that was certainly part of the. Original bill back better. Plan was an increase in federal funding. So if that comes along, that would reduce the burden that the state would pick up or the gap that the state would need to pick up. There's always the option of reallocating state budgets. So if there are areas of spending that you can identify to reduce current state spending that you could allocate without raising taxes to this area, that would be another possibility. Some states have also looked to see if there are ways that they can be even more efficient in the use of the dollars that they have in this area to see that more of the monies are spent directly on care. So that might mean being more efficient in how subsidies are administered or other administrative costs in the system. And I should also mention in the context of federal dollars, some states have found that they under the federal budget are not spending the full allocation of the federal block grant or optimizing the ability to shift funds from TANF into child care. So those were not options that we directly considered. And they may have less relevant in Vermont than some of the other states I've worked in, but I just want to mention that as part of your deliberation says maybe something else you all want to look into. Great. That's good. So a quick question. I know that I think Senator Hardy brought up the issue of value quality. Maybe you could talk a little bit about high quality child care and the implications of that just to give us that general concept. I think that's an important thing for us to understand why we're doing this, why what's financing, financing one thing, but maybe talk a bit about what high quality child care is and its value. Sure. So we talked a little bit about the presentation kind of those cost drivers. So when we talk about high quality care, we're talking about cost, the ratios between teachers and kids so that kids can get enough attention from teachers like making sure that the curriculum you use are evidence based, making sure that teachers have enough professional development opportunity to further their skills as they progress. And it also things such as making sure that you have rigorous oversight and assessments of the quality of the care through the STARS program, for example. So these are some of those features and the reason why you really want high quality care is something that's not necessarily high quality, won't necessarily get to those benefits, particularly the ones that Senator Hardy was talking about, those long-term benefits that a child in society can improve over the long-term. That it's really that these high quality care that really talks about how do you support the development of the child intellectually, emotionally in those early years because nurturing those types of things in the early years is what sets the foundation for learning and being looked at that is what can capture those benefits in the long run. But Lynn, I'll let you add something. I think the only thing I would add is that this all comes from a very deep base of research, especially in the child development field, but we've also seen a convergence where evidence from neuroscience for example has informed our understanding of the importance for brain development during these early years, what's actually happening in the brain based on children's experiences, contacts with adults, with peers, the shape of those environments that they're in and the role that they play in preparing children for school, but also setting a foundation for social-emotional development as well as cognitive development and so on. I think it's important to recognize that this is a very extensive base of research around child development that informs our understanding of what high quality looks like and then what the benefits are of that high quality. And just to kind of reiterate what Senator Arden said is that these are long-term benefits that we'll see. It's hard to quantify that in a short-term study over five years, but you are setting the stage for the future so the whole brain behavior and neurodevelopmental areas are so critical. The brain is most manageable. One of the favorite courses I ever developed and currently there are some folks out there who have benefited from that. Let's hope the kids have benefited as well. This is an area that we don't talk enough about and then what the benefits are. Anything you want to add tomorrow on that would be really helpful. Similarly the workforce impact, you estimated the number of potential new workers in the workforce and then the tax impact of increased collection of taxes because of the increased number of workers. Does that increase tax I think I know the answer to this, but I'm going to ask anyway. Does that increase tax amount also include the potential increased tax amount for the increase in salaries for childcare workers themselves? Excellent, I thought so. Is there any way to measure or did you measure the workforce benefits to the childcare workers themselves or the sector itself to having higher wages and compensation? We modeled it in terms of general statewide gross state product and then the increased revenue basis. The workforce is a relatively small share of the Vermont so in aggregate you're talking about short people of higher wages that can be better off kind of financially emotionally things like that. Again those are kind of hard to measure not for fiscal models but to the extent that they then contribute to the Vermont economy in bigger ways because they have more income that is modeled and Erin I'll let you add something if you'd like. Just one thing to add to that, yes within the early childhood education sector there will be increases in wages but because of the way that we've modeled the financing of this income by all families due to those increases in taxes and there will potentially be a decrease in disposable income by those families that are participating in early childhood that weren't and so on net all of that will in some sense net out to be roughly zero. Thank you. Terrific. Okay well Senators welcome back want to introduce yourself to Chris great for looking at this. I'm Mr. Mark you look at the senator from Valentine, the Jitman Central District and I've really enjoyed your presentation. I appreciate it. And actually what I'm going to suggest is that Senator Bullock will have questions and she can if you have them right now that'd be great and some of the we've asked some things that they're going to bring back to us tomorrow for a broader discussion. So it's been it's been a good, this has been great. The question was the one around the middle class. Okay. Everything else I just need to take some time to ask about that. So for tomorrow she can go ahead. Yes, okay. All right. Any other burning questions at this point? Do we have time or Yeah I was going to say let's take another three or four minutes. I know that some of us have obligations at 12 o'clock so I'll give us a few minutes before that. Wait isn't it 10.49 right now? It's 10.50. Yeah. What are we doing from 11 to 12? Oh we have something else? Yes we do. Yeah we just want to have a little break before Ena comes in and that's all. Oh okay. I was getting lost. No problem. Maybe we're all to be easy question but in the presentation you noted that special needs children account for roughly 10% overall children. In their early childhood right okay. And they stated that essentially the estimate was if special needs children are accounted for in the study cost study that that amounts to about 1% increase in the estimate and such is this recognizing that special needs children population often require one-on-one educator to child ratio? Right well so special needs is also a spectrum so on the severely disabled and then there's so yes that cost kind of takes all those and bundles into like one average okay so you're pretty confident about the 1% estimate increase? Yes and also something to note that you would add some of the special needs money into the total cost of the system that $125 million number would increase a little bit as well because we didn't specifically model the extra costs for special needs we didn't put in that extra money that's currently in the system as well. See that extra money it's to me you know there's layers of money and I just want to make sure that in the end you know you had a very nice summary graph of you know what's currently funded et cetera that number really has represented all the contributors to this faucet and I'm not in any way denigrating the quality of the study it's phenomenal just want to make sure that when we're talking about current state money or federal money that we're accounting for all the layers not just And this is an area that's difficult because we have children's integrated services where there's been some funding changes and how that is applied and it doesn't all go to child care centers it goes to different places and I don't know whether you can get into that the CIS bit or not but and so we can understand I guess why that wasn't included as a larger discussion. Special accommodation grants and so on. Linda do you want to say something? I'll just reiterate that our estimate $125 million does not include the federal funds that come through IDEA individuals with disabilities education act either through part C which is for children zero to three which in Vermont falls under the CIS umbrella or for part B funding which is for preschool age children so those funds are not being counted as part of the system leaving them available should you want to increase that number to account for what would be the incremental cost over an already high quality system to serve children with that full range of special needs those funds would be still available to help cover those costs both across that continuum from birth to kindergarten entry so just want to be clear about that and part of it is a complex sort of set of funding and not all of it is the equivalent of providing childcare and early learning some of it and other kinds of special medical care and other outside of those kinds of care settings services and supports for children in those early years so because it is difficult to separate that out we didn't want to confound funding that is being used for other purposes in with our estimates for directly for childcare and education that is something to consider in the next step how it all fits into whatever we do this years probably difficult to pull it all together I know it is concerned about the community I think another thing to point out is that there is very much an interest in inclusive approaches to education even in those years and the kind of estimates we have for high quality ECE would be consistent with inclusive settings where children with special needs are included in the classrooms with their typically developing peers and the assumptions we make for example around compensation would be sufficient to recruit and retain teachers with bachelor's degrees in education in the early years so that is one of the reasons why that incremental cost is relatively small 10% overall because we have already assumed a very high level of teacher qualifications of compensation one last question I don't have a question it is just a comment even though I hear you wanting to have the special education funding included in it I think it makes sense that you have not included in it because as I think Senator Lyon said it is often for very specialized services for individual kids not as a sort of access to child care directly they may be accessing those services within the setting of a child care center or pre-K or whatever but the funding is for the services to address a specific disability not access to child care so it does I think make sense that is a very good way to approach it but it is also difficult if you are in the child care center to say something yeah no I just given the 10% estimate of total special needs and given the continuum of course I just want to make sure that that 1% estimate was really reflective and those costs were embedded there or somewhere else that is all I am not going to jump back I think we are going to call a wrap for today and then we will be back I think this is just an additional time to go through the report look at your slides again and bring more questions I am too glad and then we also have asked for some more specific information and I will go ahead two things one does anybody need a hard copy of the report yeah I just I asked for a copy oh I actually love it I really love a hard copy well in this room I think we all deserve to have a hard copy I already have well here I lose it yeah it is true and just keep those copies and just give them back to somebody to give them another feedback are you the only one here in person did you draw the short straw I am the closest physically to you and now you sent us that report right it is on our web page and it goes with notes like that it is correct it is good thank you Lynn thank you Erin we are going to go off now remember we are back tomorrow so if you have more questions everything you mentioned we will do it all again okay I was going to have you guys give me a skinny we are off on thank you alright so this is senate health and law fair committee we are back live on January 18th and we are moving from child care to health care reform and looking at the all care model and we have with us a director of health care reform in the agency services Ena Bacchus and Ena Welcom you have I don't think you have been here yet this year we have a new committee and so we are going to have the committee introduce themselves we will start with you senator hello I am Martin I am senator from I live in Burlington and I am chitin and central and nice to meet you nice to be here oh good morning gave weeks well in county live in proctor nice to meet you nice to meet you and senator hearty will be you know her from previous years so it was great so thank you for being here why don't you introduce yourself for the record and then we would really like to hear do you have something to share on the screen I did send to should I join the meeting sure I would be happy to do that for the record my name is Ena beckis I'm the director of healthcare reform at the agency of human services I am the outgoing director and I'll be joining senator welch his team starting next week working in the department office it's nice to meet you today and hopefully we'll see you in a different capacity in the future I am from so well you'll see how poorly I do with multi asking as I joined and speak believe that person I live in Montpelier but I grew up in Bristol Vermont New Haven Bristol area it's a pretty poor city yeah it is a pretty thing of like Chittenden now that I live in Montpelier Chittenden county feels like a banana boat it's like warm and ugh perfect I'm in Chittenden county and of course I grew up in Addison county but that whole slide is deep okay so I have a nice screen and so just so you know why you're getting that up for us the new members of the committee are totally don't haven't had experience with most of what we're doing here so okay we'll have some basic questions as we go through but you've got two things here for us one is the all pair model and the other is the healthcare workforce update which I'm thrilled that we can we can look at both of them they're just great you know there's a lot of interest in both so which one we're shouting out with books I don't know why I'm having different that was just I I'll try screen sharing one more time yeah I was just doing it and the other committee I'm not sure what to share okay thank you great there's something up there are we starting with all pair or with workforce it's your preference let's start with all pair and then we'll go to workforce and and just you know it would be great if we could wrap up probably with five minutes to spare okay and I see that I'm joined by my colleague Wendy Trafton yes to remote and to welcome her as well good and if you'd like to introduce her to the worker deputy yes thank you for the record my name is Wendy Trafton and I'm the deputy director of healthcare reform within the agency and services thank you thanks for being here we appreciate it you may get some questions okay um so the intent of our conversation today is to talk about about um to talk about act 167 of 2022 which asked that the director of healthcare reform um which asked that the director of healthcare reform continue work to explore a potential future all pair model agreement we're moving to calling us multi-payer model as we have our conversations with our federal partners and in fact act 167 uses the terminology multi-payer which is great but I know that people have heard a lot about the all-payer agreement and we do have a contract with the federal government today that is called the Vermont all-payer accountable care organization model agreement but as we continue and as we continue to talk about this with other folks you'll hear the term multi-payer being used more frequently um 167 asked that the director of healthcare reform collaborate with the agreement to continue to look at and develop a proposal for what a future or subsequent agreement with our federal partners would look like and what the state would want to propose now I'll back up a little bit to just get a very high level explanation of the agreement that we have today we since 2016 the state of Vermont has had a contract with the federal government so that Medicare can pay differently for healthcare in the state of Vermont and it does that through an accountable care organization model the contract has three signatories the governor, the secretary of the agency of human services and the green mountain care board all three of those signatories agree that in exchange for Medicare doing its business differently in the state of Vermont that the state of Vermont will meet a number of requirements including that the green mountain care board sets the rate that Medicare grows in this model the green mountain care board helps to define how Medicare pays and aligns with other of the payers in the model in the agency of human services which is where I work the director of healthcare reform but also has six departments I think you've had the introduction the department of Vermont health access one of the agency's six departments is ministers the medicaid ACO program which is aligned in this all pair model that we have and we are required to offer that program by the state federal agreement and then the state federal agreement really strongly encourages that commercial payers in the state also pay differently for healthcare in this model and the reason that we have used this terminology all payer in the past the reason why we'll continue to use a multi payer terminology going forward is because fundamentally we're talking about shifting the payment model for healthcare services and the payment model in the united states there are numerous payers so many different payers that contract with providers commercial insurers Medicare and Medicaid represent three broad categories of payers and the model is trying to get those three broad categories of payers to align in a different reimbursement model for healthcare services that's can you just are you, I'll ask you are you going to talk about a distinction between fee for services and our multi payer system I can absolutely do I don't have it in this presentation but I have it in another one and I toggle, I could show a slide even that would be helpful if you want just a quick explanation of the differences would be helpful then we'll be on the same page because when you say multi player it needs one thing to me one thing unknown someone said one of your colleagues just took the thank you very much I appreciate that kind of make them feel yes can you can you all see this this is something that's called it's such a boring name learning action network payment alternative payment model framework and this learning action network is something it was set up by partly by the affordable care act and it supports the federal government and the center for Medicare and Medicaid innovation which Vermont works with really regularly to think about alternative fee for service and it was really set up because the affordable care act anticipated that in order to bring health care costs under control in the United States that we would need to explore and consider a lot of different models of reimbursement other than just the fee for service reimbursement model and so the learning and action network set about to create a framework of if it's our goal to move away from fee for service here's a framework of different categories of health care payment models that are moving away from fee for service but the essential point is that with the fee for service reimbursement model that model pays for health care services that are administered there's a payment for each and every service that's administered and every service that's billed and that payment is provided regardless of whether the service is contributing to better health outcomes regardless of whether the service is a high quality service or the most appropriate service in the right setting of care and again the learning action network and federal partners all hypothesize that needs to change in order for the health care system to better meet the needs of individuals in our country and here in Vermont we hypothesize that to be the case for the citizens of our state so then we would want to start to move away from the fee for service reimbursement model to a model that does reimbursement that does have a link to quality and value for people and there are three categories of payments that have that can be defined as having links to quality and value and that includes investing more in category two investing more in quality performance paying fee for service but accompanying that with bonus payments for quality or accompanying that with infrastructure payments for supporting let's say primary care providers in offering more comprehensive care and connecting to community based care and then there's also in terms of the health care payment and reimbursement system there's a strong theory that risk and holding risk is an important component in better managing overall costs for the system and that if more risk is transferred to health care providers rather than sitting with third party payers exclusively that the health care providers will have a stronger incentive to provide the most high quality most appropriate care versus any care that any care and they're going to be reversed for that regardless the other key component of why we want to test this move away from fee for services that fee for service is a very rigid model and it's based around how how providers and their particular services are kind of valued relative to the time it takes to perform the service the training, the materials needed for the service and so on and so forth but the reality is that providers time and speaking with their colleagues about best practices, providers time and following up with people by phone checking in with their patients having enough time to sit with their patients and have a complete kind of conversation and understand and look people in the eye and provide for care those things are not typically reversed so there's no payment for spending your time that way so that's another that's another motivating factor in moving away from the fee for service model and when you move all the way into category four which is the furthest from fee for service and is really setting a budget for providers, a predictable payment for taking care of a population of individuals then again the hypothesis is that really allows for more flexibility for providers to meet the needs of their patients in the most appropriate way this is how the system has been set up and any individual provider is not they're always for the most part always working in the clinical best interest of their patients but they are working in a system that may limit their time with a patient that may mean that any opportunity they have to make a phone call to a patient isn't until 11pm at night when they've finished all their other paperwork so their system the system is what we're really looking at we're looking at the lens of reforming the system so that it can be so that it has it is a better working environment for clinical individuals to provide the best possible care and for the patients yes, yes, yes the first objective is to improve the patient experience of care and quality and quality includes high experience care in the system I know it's like oh themes yeah right so why don't we just go back and I think ultimately we'll all have a discussion in here yes sort ourselves out somehow which is great so we've been working in this model to move away from fee for service that's the basic premise of the model moving away from fee for service and that contract has been in place it has five performance years in the original agreement and it included one year that was like called a year zero and it wasn't a performance year so it's 20 actually have a quick if you don't mind me toggling back and forth between presentations there's a timeline of the original agreement term we're currently in an extension of this agreement because of a a couple of key factors our agreement and the timeline for us to propose a future potential agreement happened to be in the time that we had a global health pandemic and we still do so with that made the work that we needed to do with stakeholders and with for monitors and certainly thinking about the providers who are already experiencing this change in the system and wanting them to be able to come to the table to think about what's next we needed to delay that work so that's why we have an extension of this current agreement and we have an additional we're in it, active extension now and we're likely to we will be offered an additional year and that is because our federal partners anticipate that a new model wouldn't be available until 2025 okay I'm going to go back to the presentation that's the update good, yeah thank you thanks for digressing I'm happy to as long as you don't mind me toggling back and forth here I don't move as fast in zoo every time I'm like am I doing it right okay so we have been tasked now that we have an extension we've been tasked with doing the work that I just referred to to think about a future potential model and I wanted to highlight the work that we initiated over the summertime what's called the healthcare reform work group and that work group is and has been and we'll walk through what work it did over summer and fall looking at a future financial and care model thinking of it as a future financial and care model but I did want to make sure that the committee understood that in order for us to get to that work we also had to spend some time with healthcare stakeholders addressing some very short term stability issues the pandemic certainly disrupted as everyone knows all aspects of life but then had some very particular disruptions to the healthcare system and it's been important that we spend time strategizing about some things that can be done in the short term the pressures that have come to bear on the system and we also talked about some of the impact of the federal regulatory environment and how that is and that environment is in some ways exacerbating those pressures by cuts to home health providers for example by sun setting some really helpful waivers that allowed skilled nursing facilities to be able to meet the needs of their residents and patients in some more creative ways now they cannot do that because the waivers that were in operation during the pandemic have closed and we are in other states and other places are struggling too so we've advocated with our federal partners about those regulatory changes that are creating continued challenge and pressure and then talking about the financial and care model that we would want to pursue in the future if we want to continue having Medicare be a part of all payer reforms just a very high level summary of what the workers did in terms of summertime work they generated recommendations in terms of short-term stability in these key areas and you can certainly dive deeper into that as you choose in future conversations but I'm highlighting this here and then moving to the financial and care model so that's what Act 167 was precise in asking us to do is develop that future potential all payer multi payer model and to propose a subsequent agreement for Medicare's participation and Medicare's participation and paying differently is really critical with Medicare you know being for many hospitals in the state you know Medicare represents 33, 39% of their total revenue green matter care board with a great chart that lays out how much revenue from Medicare each and every hospital in the state receives if we're thinking about paying differently and Medicare doesn't pay differently too then we're missing at least a third or more of the payments and then that's not a very consistent signal for the providers if Medicare doesn't pay differently that's why we're continuing to pursue Medicare as a partner here the work group the work group met between August 25th and November 29th on this particular topic how we would continue to engage with the Center for Medicare and Medicaid Innovation for Medicare future participation and during that time we had two subgroups that did specific work relative to global budgets as well as total cost of care which is the total cost of care is a high level target if you roll up all the services and spending in a state how much does it cost and how much should it grow over time what is the 7 and 5 there were 7 meetings and 5 meetings I thought that was how you named the groups 7 people and 5 groups oh that would have been hip and cool 5 groups I'm shut so this is a little bit more of a timeline for what we expect in terms of we had an agreement we signed the extension for that agreement in November of 2022 we probably have an amended and restated agreement that will operate in and then a future potential agreement would take effect in 25 and we're looking at approaching this work in three phases and we've done the first phase of work which I discussed where we talked over the course of those meetings with healthcare stakeholders in the state and specifically we were working on a very regular basis with this group to solicit their feedback because it was our understanding at the time that our partners in the federal government weren't going to engage with us past January so we thought we would be ending our opportunity to inform our federal partners about what a next model would look like so we were rapidly soliciting feedback in a number of areas and I'm just going to go back and forth here in these seven areas which our federal partners said have to be components of a future model so in these components are going to look I think familiar especially because Act 167 has a requirement for developing methodologies around global payments and global budgets our federal partners looking at how Medicare will participate in the future in these state models what they're putting forward to us as well as other states that have these models today in Maryland and Pennsylvania is that a future Medicare alternative payment model that's customized for a state will include a global budget component for hospitals it will also need to include a statewide total cost of care target that is likely there would be a multi payer target and there would be or an all payer target in that case or and a Medicare specific target because Medicare in these models is keenly interested in spending that there be multi payer participation across those three groups commercial insurance Medicaid and Medicare that there be goals in a future model for minimum primary care investment that there be inclusion of safety net providers from the start of an agreement and that means potentially federally qualified health centers or safety net providers they participate in our model today but also access hospitals are considered can be considered as a part of the safety net that a model would address mental health substance use disorder and social determinants of health or health related social needs it is very refreshing it doesn't sound good thank you great we can't have oranges in my other committee because one of my I don't have any others I brought from home that's my name and there's chocolate chocolate and oranges well together since we interrupted can I ask you a question first of all I assume your slides we have them on our website could you print me a copy of her slides please are there anything in the if I may madam chair I'm sorry it doesn't deviate too far no no I think it's and is are there other things that are required or you think may be required regarding the specifics of payment and payer and sort of around an ACO or what an alternative to an ACO may have to do I don't know if I'm being clear but you mean that's clear well so these are I think there's a lot of alignment between Vermont in terms of what this legislative body has discussed what we've discussed with stakeholders you know in our current model what we're doing today with these priorities which are our federal government you know these priorities are CMMI's priorities CMMI and Medicare Medicare numerous ACO programs that it offers you know more than there's between 700 and 850 ACOs in the country that are participating in a Medicare ACO program there's a large number of ACOs across the country and I think that from Medicare's perspective it's trying to consider how a model could potentially allow their global budgets for hospitals without excluding necessarily hospitals that might be in an ACO model if that makes sense they're concerned that their models can't always be exclusive of each other if that makes sense not exactly what I'm getting at maybe you and I should have an offline conversation because I'm trying to wrap your question do we need an ACO in order to accomplish our goals well ultimately yeah but if we do have an ACO or whatever we have there may be a different thing than an ACO are there parameters for how that will work because right now we have an ACO that isn't doing what we thought it was supposed to have done and trying to put tighter guidelines on so now we're going now we're going to come back to that and I know we're going to have that conversation as we get to ACO Accountable Care Organization Accountable Care Organization is a group of providers that agree to work together to coordinate around the delivery of patient care and to be accountable for the cost and the quality of that care so the providers come together in a legal arrangement which is under the ACO and then do that work together it's it's one pair in Vermont so here's what I'm going to start with we're moving off of where we want to be right now we're moving into a different discussion I'll let one more question happen and then I think we're just going to listen to you present your thoughts because I'm very aware of the time and I know that you are moving to a new position with Senator Welch and I don't know when we'll ever get you back and Wendy and I have so many great workforce updates to healthcare and we want that if we don't get to it maybe Wendy will share with us if we don't get to it absolutely yes and you have you have a handy chart too okay Senator Welch one question thank you alright okay so I'll go backwards now a little bit here um we did we talked about paying differently than fee for service one of the ways that you can pay differently than fee for service is through an ACO model where accountable care organization um is responsible for a total cost of care for a population of payments and the accountable care organization receives the alternative payment you know that's contracted with the payers or um so that is the model that we're working in in today and we've been you know accountable care organizations have been active in the state um since 2012 uh one care of Vermont is the accountable care organization that participates in the all pair model agreement there is another accountable care organization that is has had a budget review by the Green Mountain Care Board and there have been a couple of other accountable care organizations at different periods of time and are not active today but there is one other active one called lower healthcare and it has one Vermont provider group that participates in it um so when we're thinking about what would it mean for Vermont to continue in an alternative payment model with Medicare specifically which is part of what we're tasked what we are tasked with doing the work group over the summertime elevated some really key considerations that we have then turned been trying to advocate with CMMI which is the federal partner Vermont has a number Vermont has um a number of factors that make it really critical that we consider what Medicare does differently with with our state the first is we're one of the oldest states in the nation and we're also rapidly engaging in Vermont and this would suggest that we might see higher Medicare costs in our state um in fact we are the lowest spending Medicare state in the nation and we are also even in spite of being an older and aging state we also consistently rank as one of the healthiest states in the nation Vermont has been engaged in iteratives healthcare reform over many many years and these healthcare reform initiatives that are are shown here in this chart are specific payment and delivery initiatives I also want to acknowledge all of the work that Vermont has done in other healthcare reform projects like expanding coverage and expanding coverage wrap around services and supports for individuals in the state program that we have through our 1115 waiver that allows Vermont to do a lot of very unique investments in services and supports that otherwise wouldn't be paid for so we have in our state a history of many iterative reform pieces that I think taken together are impacting the health and the cost of care that does not mean that we can't and that it does not mean that care is at a place where people would view it as affordable that people would view their experiences as being the best possible experience we have continual work to do here but when we think about doing that work with Medicare specifically it's really important that we get some credit for what we have achieved and that we get Medicare to agree that it will continue to sustain some of the real innovative work that we've done in the blueprint for health for example which Medicare is paying for now through the current contract that we have so we we really want to ensure that our partners understand that we're overperforming relative to other states and it's critical that that understanding is there sorry for toggling around so much because we are at a point with our system which I reflected on early in the presentation where the system is not stable and the United States is having a challenging time in healthcare across the board there's no doubt about it but for months healthcare costs containment efforts with Medicare in particular we've bent that cost growth curve since we entered this model agreement and we've instead of growing more rapidly than national healthcare with Medicare which we were we're growing consistently through all of the years of this agreement we're growing less quickly so when we have achieved what we set out to do in that 2016 contract that we signed we've achieved that with respect to Medicare if we continue to do more with Medicare to grow to continue to grow less quickly than the nation we will be we will be doing a disservice that will not make our system sustainable it will impact the sustainability of our provider system a future Medicare payment model for Vermont when we look towards the next model it has to reflect the actual cost to deliver care it has to provide financial sustainability for participants we think about how these budgets are set if you set a global budget for a hospital for example based on this year where so many are ending the year in the red there's no way that looking forward that's going to be sustainable and we really need our partners in Medicare to understand this critically we've also like I said maintained growth that's lower than the national average and we would like to get some credit for that so money back which we never do which we never did no credit investments I just want to say that Vermont has been a leader in all of this across the country regardless of your feelings about individual components of the system that this has been a real it's been a help to other states and to CMMI but we would be great to get benefit and CMMI is real I think that I can say that there's a recognition it's not from CMMI itself but there's a recognition at the federal level that Medicare in particular hasn't kept pace with investing in primary care and I think that's something where there's been a lot of work on if there's a new relatively new 2021 report from the National Academies of Engineering Science and Medicine that recommends that the federal government needs to step up its investment in primary care specifically so I think we have some share values yeah so the work group I'm going to give a high level summary of the subgroup activities of this work group because the Green Mountain Care Board is going to talk a lot more in depth about the global budget development methodology which we've been doing all of this work with them in partnership the global budget subgroups that spun out of the healthcare reform work group we co-facilitated those with the Green Mountain Care Board to even deeper in the weeds global budget for hospital technical group that's launching and we will co-lead I won't be there but others in the Agency of Human Services will be co-leading this work with Green Mountain Care Board and we are working as close partners with Green Mountain Care Board as Act 167 requires but also in close partnership because the hospital sustainability work is critical and there is a very strong relationship to the work that we do with our federal partners in terms of long-term stability for hospitals which are just referenced if we are working in a Medicare model that doesn't support the long-term stability of our hospitals as our state ages more rapidly and is older than others you know very problematic so we think that in the global budget aspect we would like to see as much flexibility as possible from our federal partners to set the model for hospitals so that the state the way that the state today can influence how the ACO program works that the state would have influence and flexibility in a potential global budget model that would be for hospitals those have been key objectives and other states join us in that perspective it's probably not surprising why wouldn't the states want more flexibility but I do think that we have good company with those other states that are likely to work with CMMI in advocating that there be that the global budget model for hospitals not be rigidly prescribed from a federal level I think that would be difficult there's some difficulty today already in a number of CMS models that have been put out those models are so rigid and are a bit of a black box that I think there's been you know hospitals have declined to participate so I think we need transparency and flexibility so as we as this work continues there will be ongoing weekly meetings with CMMI one of our places where we advocated with CMMI strongly was to say that we weren't ready yet to stop talking with them they felt that for their clearance process to be effective we would offer a next potential model that they would need to stop engaging with states starting now instead we've advocated that we need a lot more conversation with them and they will continue engaging with the state of Vermont through the summertime so we'll continue meeting with them the state of Vermont also has a regular monthly meeting with the director of the innovation center the state of Vermont is launching this more deep in the weeds technical global budget workgroup we're also in a launch and this is a place where Wendy has really been lead in thinking about when part of why we seek these partnerships with Medicare specifically to do things differently is Medicare also has some really rigid rules around reimbursement regulatory rules who can bill Medicare for example if you're going to go to a skilled nursing facility in original Medicare you can't go to that skilled nursing facility and have Medicare pay for it unless you've been admitted first to the hospital in the model that we're operating today the ACO model the person's Medicare beneficiaries can go directly to a skilled nursing facility through a waiver we want to explore how well the waivers that are in place today are working we want to look at waivers that are in place through other ACO models because there is a new ACO model that's called the reach ACO model and that provides waivers that allow nurse practitioners and other advanced practice professionals to bill Medicare and we want to look at what waivers have we not considered that we think are crucial as we've highlighted is Medicare paying for licensed mental health and substance use disorder clinicians whereas right now they're more limited in paying for master's level social work versus licensed alcohol and drug abuse counselors for example there has been Congress has taken action to expand Medicare's reimbursements of mental health and substance use for professionals and what we need to do is determine what gaps still remain even after Congress has taken action we think there's still maybe some gaps and we would be interested in seeing if we can fill those with a custom model that so that work group will be fun and I think it will sound fun and then from there there's going to be much broader engagement of the public and of citizens on this topic through town hall meetings and other forums to share what we've learned to share the frameworks that are being considered or under consideration and to gather that feedback close this was my last slide in terms of the update and we did have the workforce update for you as well but I'm not sure that do you have that one? the grid? what makes sense I would like to give everyone I need a minute that's all I guess I'm being selfish so why don't you go ahead and we'll see where we get I think we could do an overview of it pretty quickly and I might ask Wendy if she can share her screen of the grid because I don't have it pulled up currently on my computer if that's faster I don't know if you do Wendy it's okay if you don't whatever you think is most efficient with a small amount of time we have and Wendy we can bring you back if you don't mind we can't see that yeah I think it's just magnifier there we go that's good correct perfect okay so this will be switching gears to initiatives that were put forward in Act 183 of 2022 to support the healthcare workforce we talked about the disruption from COVID-19 the particular ways that that's impacted healthcare providers probably understand that the healthcare workforce typically when there are huge economic disruptions recessions, depressions the healthcare workforce actually remains fairly stable and can even grow during these times healthcare has been a growth sector it's been one of those sectors where people are encouraged to pursue opportunities because of that growth with the pandemic which was a public health emergency that certainly has changed the healthcare workforce in huge ways and so Act 183 is a whole and the overall workforce Act 183 legislation sought to provide for investments to improve Vermont's workforce across the board and then in particular with some ways relative to the healthcare workforce the first activity was for there to be emergency grants that would support nurse faculty and staff so these are educators who would be training and educating future workforce, future nurse workforce this is a $2 million investment with emergency insurance grants to Vermont's nursing schools over three years to be the deliverable this was something where the Vermont Department of Health was responsible for this activity and this activity and all of these investments were funded through state fiscal recovery funds federal funds for coronavirus relief but not coronavirus relief funds for state fiscal recovery funds and so this is something where working within the SFR requirements VEH has sought to determine whether the nursing schools can meet the expectations for the state fiscal recovery funds and once that assessment is complete they're going to take the next steps to try to issue these funds you may have heard that the state fiscal recovery funds and certainly I invite Wendy who's worked with these much more extensively than me speaking of rigidity and requirements there are some very narrow ways that you can meet the requirements in order to use these funds appropriately and in compliance with the federal rules and guidelines so here's what I'm going to suggest I think this there's enough here and enough activity going on outside and our various institutions and communities that would be great if we could have Wendy come in and do a deep dive unless you want to return to that Wendy Wendy is the expert Wendy is the expert Wendy can we have you schedule in with Alex have you come in on this because this is a big deal and we'll also be looking later on in the session about what do we need to continue what more needs appropriation and so on so having your expertise and bringing in the information would be terrific yes we like this partnered with an understanding of where the premium pay program is coming it's going I realize that this one is focused on Act 183 helping to talk with Alex about the best steps in the next test money terrific thank you so much and Ina thank you we are going to miss you but we'll see you in another capacity most likely Ina is moving on to become what is your your title the title of outreach representative which means I'll manage the health and human services portfolio for my office senator just a minor job huge thank you exceptional we're going to miss you a great deal thank you thank you for today this is a good start introduction we'll be coming back to every single bit of it in one way or another so it's good thank you you're good we can go off and thank you