 health care committee and house health care committee. We're meeting jointly today to hear report from the affordable accessible health care task force that met during the summer and fall, and now we have a final report we were fortunate. During our meetings to have a consultant work with us, and we've asked the consultant to put the report together and to provide us with some information so that we can understand next steps in improving health care our health care system. In terms of accessibility and affordability representative Lippert and I co chaired the committee, and we had joining with us, two other senators and two other house members. And I think, as you look at the report you will see that the house members were representative Donahue and representative Lori Houghton. The two Senate members were representative Senator Keisha Ram, and Senator Richard Westman. So those folks were on the committee on the task force. We worked very hard we were limited in the amount of meeting time that we had. I think we were limited to five meetings bill representative Lippert. And so, getting the work done to look at turning the Titanic away from the iceberg, trying to improve the health care system. So that is more accessible for folks, and more affordable for folks was quite a challenge. The report that you have before you and as we go through it you will see there are recommendations, but it means that once we have understood the recommendations that we will be working at least in our committee in the Senate. It will be our job to begin a committee bill or to integrate some of these recommendations into a bill that's currently in committee. There's work ahead of us, but we are extremely appreciative of all the work that Joshua Slen has done for health systems transformation and others who you'll meet today. So I'm going to ask Bill representative Lippert do you have any comments that you would like to make, and then we'll turn it over to Joshua Slen to take us through report. I would say what we're going to do today is relatively high level overview of the work of the task force and recommendations. Because of timing and other issues there's not been a formal adoption of the report, but we will be moving toward that in the next day or so. Again, I think we today will get a high level and there will be opportunities throughout today for some questions but there'll be opportunities to ask more in depth and hear more in depth presentations at another point in time. So with that, I think, so lines off. Turn it back to you or turn it over to Joshua Slen to why don't we yes I think the thank you for your comments because they're important to the process. Joshua, welcome. Good to see you. And we have two documents on our web pages. One is the full report from the task force. And the other is a slide deck. And it's my understanding that we'll begin to go through the slide deck today, and then we'll, at least, we'll take another day or so. And separately in our committees are together will be going through the rest of the slide deck and more depth so I'll turn it over to you. Yeah. Nice to see you again. Happy 2022 to everyone. For those who don't know me I'm Joshua Slen, and my firm health system transformation was contracted by the legislative joint fiscal office to support the committee to support the joint task force on affordability and accessibility. I'm going to walk through today with help from a couple of other folks that I want to let introduce themselves here in a moment. So we all together a team in order to address all of the issues that were in the task force charter. And so we did look at a number of different things including what's going on at the federal level, what's going on in other states, what Vermont has done contextually over the last 20 years. So what could be done today in Vermont and what else is being done today in Vermont right so all of those things are important as you know because the health care is a complex beast and making little changes can have big impacts. And so with that, I want to turn it over to Beth and then Tim and Lorraine to say in that order to just say who they are where they're from, why they're here, however you want to do your introductions. And then I'll start off by running through we're going to try and run through about 15 slides today. So the slide deck that you have in front of you is like 40 something slides, and the rest of the slides after slide 15 start to get into the individual options in depth. And we're going to provide some overview of those options and we can keep going today to time allowing and how how much energy people have. But we expected that we would get through the high level sort of what we've done, how we got here, and what we're proposing, and that that going into the depth on those proposals would be something that would happen at future meetings. So that's the outline for today briefly and Beth let me turn it to you Tim and then and then Lorraine to do introductions. Great. Thank you, Joshua. Hi everybody I'm Beth Wildman I am from Baylett Health purchasing and we are a small consulting firm based in Boston, Massachusetts, and I have known Joshua for quite some time I was the Medicaid director in Massachusetts while Joshua was the Medicaid director in Vermont and at Baylett Health where I've been for 15 years. We work with several states including Vermont on many strategies to contain health care costs and improve access to health care so happy to be here and participate in this project and I will turn it over to Tim. Great. Thanks Beth. Good morning my name is Tim Hill I'm a Vice President here at the American Institute for Research, which is a social science research firm here and based largely Washington DC. Happy to be on this project I think what I bring uniquely here and what we've talked about is my experience at the federal level, thinking through the implications of changes of state policy on federal payment and coverage programs particularly Medicaid and the marketplace so I've been very happy to be part of the process and look forward to your questions. Thank you. Hi good morning I'm Lorraine Siciliano I worked for the state of Vermont for over 30 years in the Department of Health and in the Department of Vermont Health Access and in the Department of Taxes and I joined Joshua at Health System transformation his firm in 2021. Thanks. So thanks guys. And then for those of you who don't know me on the call. I worked for Dean and Douglas. So a long time ago but I worked for two governors here in Vermont. And prior to that I worked for 10 years in Ohio. And I worked for the state of Vermont in the legislature so I worked for about 20 years in state government 10 of which directly in Vermont, and I worked in the budget office in Vermont I was the Medicaid analyst. And I was the deputy commissioner of finance and management and then I was the, the Medicaid director for six years. You don't know me. I recognize a number of faces here, which is wonderful. And a number of you don't know me and hello. Here I am. After I left. State government in Vermont I worked with Beth at Baylet for for a time I worked nationally with Malina healthcare as a national accounting sec for them they're up 99% virtually 100% Medicaid managed care organization. In 2017 I've been running my own firm and working across the country on healthcare and almost exclusively on state facing Medicaid issues. So, so anyway it's great to be working on a Vermont project. And with that, I'm not sure how we bring up. We need to share Lorraine's going to share her screen, so that people can see. So, we're going to run through the slides the slides you should be able to see on your screen. And you should, I probably have them in your own inbox and posted to the website as well. Let me just pause, make sure everybody's ready to go. There's no questions or technical issues. I think we're probably good. And and and just FYI for committee members. If you have a question. Please. I think you're going to have to just say I have a question because neither representative Lippert nor I can see the entire group. Josh is we're going through I made or representative Lippert may do some explanation as to why something isn't in or I don't you may already have that prepared. And some of the decisions that we made along the way. I think there's absolutely and if the raise your hand option works Aaron Lorraine can watch for that as well and cue me if people can't get a word in edgewise but can raise their hand on their screen. Okay, so with that Lorraine the next slide please we'll just run through sort of what we're going to do. We'll talk a little bit about the task force charge just as a reminder for everyone level setting, talk about the process because it was a robust, although time, time limited as, as all of our, as all of our legislative processes are crunched. We'll talk about the process, we'll talk about the summary of recommendations. And then that's where we expect today to end and not to get into each of the four in detail so this deck will just be to be continued at that point. So part of the summary, we will talk about why, why we chose some of these who they help, how much they cost to implement, and how long they take to implement, and how much they save, potentially so we will talk about some, you know, a bunch of significant issues for each of these options and probably produce many, many questions, which is good, and always happens as we go through, you know, big processes. So we welcome those and those that we can't get to today we certainly will be around throughout the legislative process this year and available to meet with committees and explain options and dig into questions. Next slide please. So the task force charge was to explore opportunities to make health care more affordable and accessible for Vermont residents and employers that charge included a whole bunch of things if you look at the actual legislative language right and include sort of what could we do what's going on, you know at the federal level that we could take advantage of what is Vermont done before what are other states doing. How long will it take to do these things. Can we afford to do these things. How much benefit do they have to individuals and families and how expensive are they to accomplish. And do we require federal approvals in order to accomplish them. Those are all things that are critical as we think about our health care system, where we are today and how we might implement things. I'm going to take up just a brief pause here again and Bill or Jenny. Are there other pieces of the task force charge that you'd want to that you'd want to point out. One of the charges was regarding equity in health care. And we will I believe we'll be commenting on that a little bit later but that was a that was a standalone important charge can be more inclusive in our health care programs and holistic holistically perhaps something will more will be said along the way but one of the other decision points was also and perhaps reflected in the charge some degree that we wanted to focus on areas where we could which were that could be implemented in the near term or near long term rather than just a long term vision. Very good. Thank you very much. Add one more thing, because it's not it wasn't in our charge, but it is in our charge. And that is, as we look at cost savings to health care and the health care system. We want to ensure that those savings go directly to Vermonters pocketbooks. And that is with legislative charges they're, they're beefy right there's a lot in them. And there requires necessarily some attendance to detail on on what we drill down on and as we drill down that we don't lose sight of the larger charge, but that we find things that can be accomplished and so throughout the process which I'm going to talk about next. We the task force made a number of decisions and health system transformation supported those decisions with research meetings and a number of other pieces so what I'm going to talk about next is the process that we went through to assure that the task force charge was actually addressed that we didn't leave things out in the consideration and sort of how we got from from start to finish here. I want to recognize as part of this that that I know we all know we're never finished right state government's going to be around for a long long time, and people are going to need health care for a long long time and so we recognize the place in time that we are as well as the space and time that we are for accomplishing these things and I think that's just an important backdrop for this. So, what did we do. We were contracted in September. And we had the first meeting we had public meetings on 929 of the full task force on 1028 of the full task force. We had a meeting in November as well that was scheduled to the first full task force but it was canceled due to a special session that was scheduled at the same time. And so we had a third meeting on 1215 of the full task force so three meetings throughout the fall of the full task force that those were big long meetings five hour meetings. They're all online and the materials that were produced and the process we went through our part of those, you know it's all part of the archives there for that. There was a lot more work that was happening throughout that time period with regular updates weekly, nearly weekly updates with the task force co chairs, and multiple meetings with task force members individually, and in twos there were a lot of areas that were of importance to them, and to make sure that we were including the things that were necessary within each of the meetings. So we did meeting preps as well as updates on research and additional items. We had regular meetings weekly meetings with the joint legislative joint fiscal office and ledge council staff to talk about many things including what's going on in other areas what's a truck doing what's happening with the, with the telecommunications and the task force for interstate for interstate telehealth. What's going on with the Health Equity Commission. What reports are is GMC be an OPR working on so we wanted to make sure that we were aware of all of those things that were happening and we leverage the, the information that your joint fiscal office and ledge council have inherently from working on all of those from soup to Vermont from the last legislative session and prior legislative sessions. We then we concurrently so this is all happening concurrently pretty much over the four month period. We had informational interviews structured informational interviews with healthcare leaders from 20 over 20 different throughout Vermont. And in some cases we had multiple conversations with with individuals from those organizations so when we get into later on talking about the, the individual options that ended up in the four options that that were actually recommended here or will be recommended here. When you look at some of those options it may be obvious to you right like the, the moderate needs group option, the Department for aging independent living right that department has owns that program right they operate that program and so we spoke to them a number of times and same thing with programs where the Green Mountain care board or other departments would be impacted we spoke to those departments a number of time to understand their programs and to make sure that we were making recommendations which the governor may or the governor staff and departments may or may not agree with the recommendations in whole, but they certainly understand them. And what we're doing right there were part of that process as we walk through it. And we recognize that there's lots of decision points that often are driven around, you know, really tough choices between doing one thing or doing another. And so, as part of what the governor staff recommends and what the legislature ultimately chooses to do. We understand that these options that we're going to get to, you know, fit in that big pantheon of things, right. So, we were careful as we did this to make sure that we understood what was happening in Vermont today and to the extent that it would be shared with us, what was being proposed to be done tomorrow. And some of that will come out as we walk through things that we chose not to spend a lot of time on some of which were are just as important. And that was being done and sussed out through these interviews that were being proposed and done in other places. So to the extent that important and critical things that that do improve affordability and accessibility being done in other places. As we identified those things in talks with leaders across Vermont. We also received last force conversations about to do or not to do, given that they're being done in other places. We also received correspondence from advocacy organizations we met with advocacy organization those advocacy organizations. In some cases multiple times. And, again, to make sure we understood what those recommendations were. And that they were included in the discourse. As the task force considered where to go on different items. The input included as it always does those informal conversations at the task force meetings, but they included, you know, formal schedule discussions as well. Some significant time early on in the process, researching other state activities and federal activities related to the task force charge. And in a number of cases. Well, when you look at the actual option papers themselves, we've included the state activities and the federal opportunities as part of as part of those papers themselves. In a number of cases where other things were being considered in other states. You know Vermont is a leader in many ways and so there are lots of things that other states of doing that Vermont has done has partially done, or has decided not to do and has done something else. Similar, but slightly different. And so, when, when we see news articles and papers and presentations from other states, and from the federal government. We should just as a reminder to us remember to pat ourselves on the back in Vermont and and think wait, have we done this already did we do it and decided didn't work well for us. There's quite a few things that others are trumpeting at any point in time are announcing at any point in time which Vermont, you know has done, you know, you know very well already. So, many of the things that we identify when we do that type of research are things that that quickly go to the side because Vermont's already doing a pharmacy expansion for seniors already doing an adult expansion a child expansion. Things that we've done, you know, very well for a long time. So, next, next slide please. So, Vermont has an all payer claims database and a PCD, we've had one for a long time. It's a mature database. In other words that's worked out a number of kinks there's always improvements that can be made to that but it's a it's a treasure as far as being able to compare information it has limits to it. It has limits with the the lives that are not included in it. Those are recipe pairs. So the large payer lives that are not included in it. It has limits because not all of the information flows over from commercial and and Medicaid claims in a way that can be compared, but the benefit of it is that the things that are in there can be compared. That's an important distinction. We chose to use vcures to mine data and to understand the Vermont health care system as it stands today. We recognize that that has limitations and in fact in some of the options, meaningfully in the in the moderate needs group expansion option. There are further data and that there is further data analysis that certainly the the state will do. Should you proceed on that one that will mine the Medicaid claims data directly and will not allow for some of the extension of thought to the commercial side of the equation so how would an expansion impact the commercial side but would provide additional detail that we didn't mine out in in our analysis so it's a key piece of information but again, as we do complex health care analysis we're always making those decisions right what to go into in depth with the time we have and what not to. So, what I wanted to get across here was that we we thought about those things, and the team that's on the phone here as well as an expanded team that included data analytics professionals and project management professionals, and additional subject matter experts that we worked with throughout the process. We gave some significant consideration to what we did and what we chose not to do. So, number nine that was number nine I just covered presentation of policy options then we presented the options so we started with over 20 different policy options in the first meeting. That could be done potentially in Vermont some of which are being done in Vermont, and some of which don't fit exactly into Vermont, and then we narrowed down to seven different options. And then we narrowed down to four different policy options to go into depth so that was the process as we move throughout the fall and early winter. We drafted a white paper on the Medicare savings program which is included in the, the final report. And that program is another significant program operating in all states, it is a program that provides assistance to individuals. And it provides assistance specifically to individuals who need assistance because of their level of income with paying for with paying for their Medicare premiums in order to help them obtain and keep their Medicare coverage. It fits in with a number of the other options, but it was not included as a full option here. And we can have that discussion I think when we talk about the four options papers that were included. But we wanted to recognize that that was included as a white paper. And we, we also included an affordability white paper and again, affordability is an important piece of what the task force was charged to do. The affordability that affordability white paper was rolled into our was rolled into the first option on cost growth on cost growth and so it fits in that in that quite well. And again, those white papers if you go look are are posted they're available you can read them the pluses and minuses to them are there, who they impact is included how they impact them. That's included as well. We made some decisions again about what to include what could be done, and what the pitfalls of trying to do too much all at once might be for example, as significant discussions that we had. We collected and analyzed all of the above stuff and created a final report. The final report is actually pretty digestible so a moment on that right which is, there is four pages of executive summary in the final report, they're reflected in this presentation that executive summaries reflected in this presentation today. They're part and whole in that in this presentation today, using the tables and charts from that here in this presentation. There are then 40 something pages in the report, or maybe more than that, but there's, there's a whole bunch of pages in the report around 40 something maybe 50 something that are directly the options papers being described to you in detail. There are a ton of appendices that include everything else that we discussed and received, and what the task force did so all of that is in that final report. Should you want to go through it, and there are citations throughout the body of the report that would lead you to okay where's this list of other things that you looked at or where's this list of people I want to know who you actually talk to. So things are in appendices so they're there as part of the record. Next slide please. So what did we do, you know, okay enough on process what did we actually do. We looked in starting back in September we looked at how much did different things affect the affordability for people and at what level how much does it affect so how many people does it affect broadly. And how much does it affect those people individually deeply. We looked at that, we looked at accessibility. Again, how many people broadly have more access. How many people. If it's a smaller group of people that get more access you know how much more access that they get how how critically important is that access, where are those gaps in the Vermont system today and where do we improve affordability and accessibility by a policy that the legislature could create and implement. How long does it take time frame. How long is this going to take is this is this a conversation like some of the conversations you've had that have been going on for decades and haven't happened right. So, there are those types of things that can happen. And I know, having sat through many conversations out about expansion of health care, and many experts, like myself, right, who have talked to Vermont about single payer and about other programmatic lifts that are similarly attractive and very large and very complicated and very hard to get done. Right. And one of the things that we talked about at length with the task force and the co chairs was sticking out is that we could do that that could actually be implemented. That would not be so large and so complex that we would end up doing a report that didn't, that didn't bear fruit. And so we, we recognize that and there were decisions made around that about how, how what could be done, and how long it would take to do it. And then in the same line number three, what's the programmatic lift we're very aware that people are stretched that state government has had one thing after another, given to them to implement, and that we are small but mighty in Vermont in the state government, but there's a limit to how much capacity we have and how, how much can be taken on and how much can be done in any single year, or in any multi year period. And so those things were discussed and talked about. And, and I know that you'll have those same conversations in committee as you, as you consider different options this this session. We considered health equity impact. And honestly we had health equity as its own line at one point internally that we're talking about what can we do on health equity specifically. And we moved away from that purposefully to say that health equity is not something that you do by itself it's something that has to be embedded in each option that gets considered and implemented. And that's because, of course, if we implement a technological advancement, if we use, for example, COVID as an example. We rolled out purposefully nationally and in Vermont as well to priority populations who would most likely be, you know that vaccine that we rolled out was rolled out purposefully, and purposefully to the most vulnerable individuals. And that successful or not will they'll be a retrospective on how successful that was in different geographies and I think Vermont has been lauded at our for our approach and our execution in in accomplishing that roll out, but that's an example of considering equity and protecting the most vulnerable and Vermont has a long history of that but we can do better at it and we can consider equity in different ways. And certainly as we mature as a country. We on the health equity front Vermont will learn from what others have done in that space and we'll be able to implement it and we have several slides on health equity that we'll talk about. I want to point out that it is, it is and necessarily needs to be embedded in each option that's considered in each programmatic option that's considered, and can be discussed theoretically outside of those but the rubber hits the road when you're actually doing implementations. So I lost the screen. What happened there the did others lose the presentation. Yeah. Yes, we don't have it anymore. So we'll see if we can get that back. Was that Lorraine. That was Lorraine, I think we lost her. It looks like. Oh, oops. I'm wondering if maybe they're Claire or can you share your screen and put the slide deck up. Claire, are you able to do that. I can give me one. So, I'll continue talking number five. Sorry, I would continue with. Yeah, we have it we each have it on our iPads but some iPads are occupied with people so. Number five on the on this slide six is the level of federal involvement needed. And so here we recognize that there's another committee. The a truck that deals with waivers and Medicaid issues in more depth. And we again made a decision to keep track of that and to recognize that there are things that. Might be such a big lift or the federal government isn't going to do it that that we shouldn't consider them. But in other cases that there's, it might be a big lift and it belongs. The discussion belongs in another in another forum. And so that's something that we did look at quite carefully. We have a great deal of experience in our team, working with working with federal involvement necessary. We, we took that into account where it would be a stopper or where it would be something that was likely to push the timeframe in a significant way. We did not get to the point of drafting waiver language or something like that. If the policy gets adopted by the legislature, there would be another process or further process and this is normal for the governor staff to put together at the Medicaid agency level, the federal engagement necessary. There will also be some front end conversations as you develop policy with with CMS and other federal agencies to float ideas and sometimes white papers are pushed up from states to the federal government to get their thoughts on things in advance of actual an actual application or letter requesting a waiver. So things are all potentially in the hopper and for some of the things that we're proposing it might make sense to do some engagement, almost certainly make sense to do some engagement with with your federal partners and and in the Vermont way I think that would flow through the administration with with involvement or direction from the legislature. And that's where we did that's where we are with federal involvement we'll talk about that some but keep in mind that we tried to stay out of a trucks lane on on those items and and so that that's how we manage that. And then what's the state and federal cost savings. We're in what, how we're going to improve affordability and accessibility for Vermonters, but keep in mind that we can easy way to improve affordability and accessibility for Vermonters is for the state government or the federal government to pay for it right pick what it is and if we can get the state government to pay for it in total or the federal government even better right to pay for it in total from a state perspective. And then the cost savings accrues to individual families and individual Vermonters. Without a state or federal cost, but in where there is a state or federal cost but it doesn't and it's huge, but and it saves individuals and families lots of money. Things are obviously opposite sides of a coin right where we save Josh, Josh's family lots of money by giving him free pharmacy, but it costs society significantly to do so. And so, I know that makes sense to everyone but occasionally, as we get into some of these policy discussions we're like well that's great let's do that let's go ask the federal government to pay for it. And, and sometimes that's possible and sometimes it isn't and some of our options we're going to talk about the trade offs there. Sort of how much we can do now quickly and and how much it costs to do those things right and so and who pays for it. So, the next slide please. So, slide seven. So, slide seven options now that we drill down to right so I spent on how much time here but I spent some considerable time getting us to sort of the options themselves. And now I'm going to spend the remainder of the time talking about the options themselves so before I dive into this I want to pause. Any questions about what we did why we did it how we did it. Happy to talk about those things now representative Goldman. Hi, oh you can hear me that's great. Um, I think we just got a letter from a group about being included in the appendix I was just wondering, you know what criteria to use for including advocacy letters in your final report. Go ahead. So, we included the letters that we had available to us I'm not sure if if we missed one we're happy to include it. But if there's one that came after we produced the report then it's not included. Josh, I think this is a letter that we actually had and put on our web page of it so it would be fine to include it in the report and we can decide to do that tomorrow. Absolutely should be a part of it. Yeah. Yep, just an oversight. Well, there was so much coming in and it's difficult to get it all, you know, the thing that that hasn't been mentioned that I think is important as in June. I forgot when it was was either June or July I met with some of the health care leaders at NCSL and asked them to support our work with what other states are doing and engage them so they're not listed. I don't think they are but there certainly are a number of folks who were very much a part of the work and and helped us with this. We don't, we really don't want to exclude anyone that's not. I agree completely any that we've missed we're happy to include the the information that they supplied and and credit that they participated and so any oversights are on us in the production of the report right now, and we're happy to make to make those adjustments. Thank you. I know the chairs got the letter so anyway it got sent to all of us. Yeah, well, so we can we can put that in. I don't I don't think that requires any action on the part of the committee necessarily. Representative Donald you have a hand. Yes, thank you. Yeah, maybe I can help clarify because if you look at the report itself it's the report it's the recommendations of the consultants. It's not the report of the task force where we might have things that were sent to us but not the task force, because we actually haven't voted on on adopting the report yet. But there was a letter of September 21 that they hope would be included in the final report but we don't need to spend another minute. I think we do better to actually continue with understanding what's in. Let's go. Let's go. Okay. So, on slide seven we're going to get into the act the options now. And then we're going to move on to the next slide. So, as we went from 20 to seven and I have the four that are here on slide seven and then when we turn to slide eight there's three others that were of considerable importance. We're not going to turn to slide eight yet. But when we do there's three others that were considerable importance but we're being done already by the legislature and that's why we didn't address those with research and research that are being done in other places. The four that we did go into depth on substantial depth on these and wrote papers for them options papers with appendices and all that stuff are cost growth benchmark and affordability standards so these fit together really nicely these four they can be done independently they can be done together they can be done partially together and they can be sequenced throughout time there's a lot of different things you can do. But cost growth, think of these in a few different ways here cost growth benchmarks and affordability standards. Get implemented in order to manage the total cost of growth in the health care system so you have a six and a half billion dollar health care system in Vermont. You have a whole series of agencies, including the Green Mountain care board diva one care that all play a role in that and huge institutions right uvm medical, all your fqhcs, rhcs. And also federally qualified health centers, rural health centers, community mental health centers, all of those different providers and insurers blue cross MVP workers comp, all the public employees, all of those folks by health care and consume in Vermont and the cost growth benchmark and affordability standard says hey we could apply an affordability standard as other states have done and say that for family it shouldn't cost more than X. And we can apply a cost growth benchmark that says, you know, for the state we should not grow more than why, and we could tie that to things like wage growth, CPI consumer price index you can tie it to different things. That's the level thing, right. And if you save money on it, who saves the money requires tools to make sure that to Senator Lyons comment earlier that the money that you save doesn't accrue to brew class or to uvm to a big institution. So I think that we may, but that we have mechanisms in place to have those savings that happen at the cost growth benchmark and affordability standard level that those savings accrue to families in Vermont. So, think of number one is that high level. What are we trying to do as a state in managing growth in the future so that met so that healthcare doesn't continue to gobble up more and more as a percentage of household income. It allows us to put a target, and then to build underneath that target specific things that we would do as a state in order to in 2022 2023 2024 in August, right, pick a date like we're actually going to implement another program that would have an impact and that would help to meet our cost growth benchmark and affordability standards, right. Think of all the other options underneath here as options that would help to meet our cost growth benchmark right next year and the year after. So, extending moderate needs supports, you have a moderate needs program today at the Department for Aging and Independent Living it helps individuals with their activities of daily living, it helps individuals who, you know, need help getting in and out of bed and going to the bathroom and getting their groceries. And this is important we'll talk about it later it's important because when you hit 65. If there's three of us standing here, two out of three of us will need those ADL supports. Before you before before we pass on, once you hit 65. You'll need those supports. There's individuals that needed underneath it just that underneath 65 below 65 as well and so they're not. We don't miss them as part of moderate needs supports but when we supply those supports. We believe that we can improve people's quality of life, importantly. We know that there are individuals who don't access those supports for lots of different reasons. And we know that when you do access them that you're able to stay in your home and not go to an institution for a longer period of time. And so that's an important thing Vermont's done a great job at this over time. An extension here is one of the options public option. Public option is an insurance option. So think of this as a, as a price option, how do we control price in the market, how do we improve access to, to healthcare is one thing you can think about public option in some states, people don't have access to insurance products in Vermont. And so that we have the singular place where we have a problem here is in our individual and small group market. And so when we think of public option here, we're not thinking of it in some other states you might implement an insurance product that's that the state government has mandated. It's a smaller benefit right it's not a benefit that's that's as broad as other products. We don't believe that would be very attractive in Vermont, given the market and where we stand as far as providing accessibility to lots of different services. So, what we're really talking about here is addressing the employer market, the small employer market, right, about 35,000 individuals in that market today. The costs there have spiraled upwards. And it is a place where we can control price with a public option that has impacts for sure. And those impacts are directed here at being positive to the employer purchase of insurance and offer of insurance at the small group level to individuals and their families. Notice that cost cost growth benchmarks high level extending moderate needs very specific to a group of individuals, right up to 18,000 people, individuals that we could extend moderate needs supports to primarily older folks. So option, a price control mechanism that extends them up to 35,000 individuals, perhaps some more if we looked at the individual market but we're really targeted at the small group here. And primarily those folks are younger and healthier. And, and price is the problem there. Right. So different groups. They're impacted there, expand the blueprint for health so here's another one Vermont's done a great job right don't forget again to say hey we've done a great job we have a nationally recognized community health teams all over Vermont that provide supports to individuals that are opioid dependent, or substance substance use dependent, as well as others who have chronic conditions and just complicated health care that they need to help coordinating and managing our blueprint teams, take referrals today and support individuals across Vermont right so what we say here is, we should expand the blueprint for health, but we should apply some return on investment. Yes, we should apply some ROI analysis and we should apply some front end identification and stratification of the population, in order to assure that we are helping folks and we can demonstrate that the blueprint is successful financially to the the payers and providers in the state as well as the state government. That's important because C number one, in order to drive down our cost growth over time, we have to demonstrate that each one of the things that we do from a public policy perspective, the impacts number one. And we have to do that. In a diligent way over time. So for everything that comes before us. One of the one of the items that's that's not explicitly listed here but that health system transformation is recommended. To discuss that length with with the task force is is having a statewide population identification and stratification and return on investment vendor that would be located in number one that would be hired and utilize to do the analysis in a standard way for big policy changes that were coming before the legislature so that you would always have in front of you when you had a proposal to consider you would have a vendor a third party that was doing that analysis consistently for you on the question. Who is this going to help. How much is it going to cost. How much could we potentially save. And then in follow up in future years. How much did it cost. How much did we save. How many people did it did it help. So today we improve affordability and accessibility over time systematically. Right. So, when I say when we say these things fit together. These aren't the only things we could do but keep track of the fact that these are things that Vermont needs today they fit into the context of what Vermont is has done in the past. There are things where we believe the federal government will be a partner and want to support what we're trying to do here and have a financial stake in what we're trying to do here. And their items that can be done in pieces so that you don't have to bite off extending moderate needs to 18,000 people today to help start helping right you could extend moderate needs to 500 people today, you could extend it. And there's lots of ways to go about slicing these up which we're going to get into in the next slides. Josh, you know, as we went through a lot of this in our task force work. We did identify programs and people that we felt were key to the success for the options the chosen options and maybe as you're going through you could talk a little bit about our, our discussion or support for primary care in particular that is sort of the bottom line for the options that we're looking at at the on the provider side. Yeah, for sure. Okay. For sure. Next slide please. So, few other things that we that task force very interested in but we're, we chose not to pursue as options full options where we applied the full Monty of analysis to because they're being done in other places right in Vermont not that they're in, but postpartum expansion so that's a Medicaid option to expand for moms and babies to 12 months and we believe that we understand that the administration is proposing or has proposed that or is doing analysis on that for the legislature already and so we didn't pursue that analysis. We, we believe HST believes that that is something that should be done. It's a very close to a no brainer to do it. And, and so, and that's important from an equity perspective and as well as when you think about cost the federal government's going to pick it up for the first period of time. Remo access to care there's a whole bevy of things happening in the legislature on that from coordinating telehealth across multiple states to to supporting broadband expansion, and, and technologically approving options to provide technology in the home and so all of those things are being done in Vermont it's not that we couldn't do more there it's just that's a crowded field where there's a lot of attention already and so the task force chose not to spend our research time on that. Pharmacy benefit manager regulation again, there's a bill on the wall. I understand that the task force is supportive of not to speak for for the task force but I believe that's the case I've heard it said. And so, how that comes out at the end of session will be what it is but that that's another area that we, we believe that HST is an important area to consider. And we, the task force chose not to have us pursue it since it's being pursued in other areas. Next slide. So, I talked about this already, I think implementing options strategically, how they fit together is something to consider, and also importantly, that they should be evaluated in relationship to initiatives that are already underway, right, or under consideration. And I know that you do that as part of the legislative process and that my friends in the administration in Vermont and in the advocacy community will continue to make sure that that you are aware of the things that they are doing and that they are advocating for as part of the process as they should. So, I just wanted to point that out. Next slide 10. Next slide please. So, here's the summary description. I'm not going to spend a lot of time here because I think I spoke about the summaries of these in the in the prior slide when when I was talking about them. These summaries include a little bit more detail than I spoke about or slightly different detail. I'm going to take questions on them. I'm just looking through to see if there's something in particular that I want to note here. Okay. I'm good. Next slide. So, here's the summary justifications for these slides. I mentioned, for example that under cost growth benchmark and affordability standards that we need to have underneath it, a return on investment and that we need to tie what we choose to accelerating savings so that we can capture those savings for ratepayers in the system. Also, I mentioned as part of this that 70% of us once we reach 65 will need supports with ADL. I think that's a primary justification for extending moderate needs supports. In the public option that there we are and I want to be explicit about this, you know, when I talk about using it on the price front for small employers that we are talking about price being different here as a primary way to drive savings. There's other things you can do, but competitions been talked about by my friend Tim, and in Vermont we know that competition is a different beast than it is in California or New York, right, where New York has 19 plans in the Medicaid space. Last time I checked, maybe it's 21 or 18 now, but it's, you know, a dozen and a half or more. That type of competition across different offerings in the space is just not going to happen in a small state like Vermont, and so competition is different here. But I also wanted to be expressed in the point that having a rate that is below today's commercial rates doesn't mean that every rate is below in a design in order to create savings and it doesn't mean that every rate is so far below that it would be devastating to the healthcare system, right. And so some of the, some of what you will hear from folks that will be against the public option with the rate structure that's differentiated will be that this is an apocalypse right like this will be the and we have workforce issues and it's hard to and let me say we know that there's a workforce group, and we know that there are workforce issues and explicitly the workforce issues that we have not enough nurses graduating doctors at the primary care level being paid less than specialists that you know and it's getting harder to get people to go into and stay in primary care and locate in rural areas. Those issues aren't new issues. They are significant, and they are national. And so, when we raise rates for nurses, for example, in Vermont. And our rate goes to say 10% above the New Hampshire rate. It puts New Hampshire in a position of needing to raise their rate, right so we become. We have an issue as a state, and we have to deal with it and there's a whole workforce group, and we chose, and the task force shows not to deal with the workforce issue because it's being dealt with in other groups explicitly. And that I think is the most important thing. And, and Josh will say also that this is an issue on the workforce front that should we shouldn't allow to stop us from doing other good things. So, that's a Josh statement, right and others can disagree with it, but that that we will have the workforce issue for a long time and we will have lots of options that are on the table. That have been that push dollars to and other incentives to keeping the workforce vibrant in Vermont and attracting folks to Vermont. And we, we error, if we allow the workforce issue to become the reason we don't do other policy things. So, I'm going to move off of public option now and expand blueprint for health. Again, I'm purposefully putting things here that I know are challenging right these justifications on page 11 include things that we know are challenges, the ERISA player, ERISA payers, the large employers who have their own who are carrying their own risk and have and have an ASO or TPA a third party administrator like Cygna supporting their lives in the market are different beasts because the state can't regulate them in the same way. My friend Beth will talk about how other states, those payers do participate in the cost growth benchmark and affordability standards exercises and supply data. And, and I think that they can be influenced to do so in Vermont as well. I think it's true that you can't regulate you can't mandate them to do to do stuff like participate in the community health teams, the blueprint health teams. But we can make a case for them again, go back to the ROI that that paying for the health teams is something they should do because it has benefit that accrues to them if we can draw the line for them with our return on investment then we can pull those ERISA players payers in to participation in supporting the blueprint teams for example. And I believe that is true. And in order to know that it's true we would have to do that analysis on a regular basis and that's one of the recommendations. Next slide please. Okay, who does it help how many people does it help how long does it take to do this. So, the bottom line is that if we do this if you look in the estimated number column the third column over there. The cross gross benchmark helps everybody as we push down rates helps every rate payer in the system. It helps all Vermonters. And, you know, less we again let's not error and say that if I'm on Medicare or Medicaid it doesn't help me. Because the extent that our growth is lower. We can afford to pay for more services right like prices lower unit units can go up right. So, there's a direct relationship inside of inside of the healthcare system to things like increasing rates for primary care. So, one of the issues that we have is a primary care workforce issue. Another issue that we have is not enough is not enough access to those appointments those primary care appointments, right. To the extent that we are able to implement a public option. Let's just use that as an example, where we push down on lots of rates, we could still push up in that public option on primary care rates. Right so you could push up on certain rates and down on others in that design purposefully to encourage and support primary care. Right. And, in addition, as we do rate setting at the GMC B for our payers. We could push primary care rates and other states like Rhode Island have done exactly that, which is to push up primary care rates as part of rate setting. So, that those things are things that are underneath the hood here as we start thinking about how these play off of each other and how we impact more Vermonters how we make things more accessible. Hey, I don't have access to primary care today what can we do about that. Can we push on price with a public option. Can we push on price with the cost growth benchmark and affordability standards. The answer is yes in both cases. There's, there's reasons why that has impact other impacts that should be considered. But I wanted to point out that as we look at affecting as many Vermonters as possible and as deeply as possible, we are trading off affordability and accessibility throughout these packages. Right, like, necessarily we are. So, impacting 600,000 people plus with cost growth benchmark and affordability standards but not impacting them, gigantically, or all equally, right. When we get into doing the moderate needs supports and the public option and expand public expand the blueprint work, we're really targeting different different folks for different reasons in the moderate needs 500 to 18,000 Wow that's a big range purposefully a big range because we could impact 500 today and 500 tomorrow and not blow the bank, like not be able to afford it right like if we try to implement 18,000 today I recognize that's a big lift right there's going to be a lot of state money, a lot of federal money that has to go to support that right away. And, and frankly we, there's almost certainly not 18,000 additional people that need that support today. But over the next five years or six years. That's a number that absolutely we could build build up to and individuals will come on and need those supports as we go public option up to 35,000. And that's a real number that's about 70,000 in the individual and, and small group market about half of them are in the small group in the employer plans today. And so, to the extent that you have a public that we implement a public option specifically targeted to small employers, you impact 35,000 people and, and the number of employers is significant those small employers, right. And the blueprint for health. The analysis is analyses that we've seen show that about 10% of states population at any point in time could benefit from care management services. We don't have the counts of everyone in the state that's receiving care management services today there's lots of different ways to count that there's lots of different ways to define care management and care coordination. And that's another piece of work. That certainly could be done, and perhaps should be done as part of this expansion, and certainly is something that is doable. But those community health teams help people today in lots of different ways and they're not all identical in any, they're nowhere near identical in how much help an individual receives for how long and for what services. And there are other care management and case management services so let's keep this in mind as we think about making the case for for the ROI analysis and actually doing stuff in the future. Cross Blue Shield UVM Dartmouth the FQHCs go around the list, all do some amount of care case management care coordination. The definitions are different the programs that are being utilized for different groups are different, you know so there's case management and care management that have to do with individuals receiving high high cost services or lots of services and managing managing on that front and there's coordination of different types of services for people. We don't have to at the, at the legislative policy level, get into all of those nuances what we do have to know is that in order to convince the system, the blue, the payers, the big integrated health systems, the primary care physicians in order to convince them that the what they're referring people to is something they should refer more people to. We have to demonstrate that there is a benefit that there is an outcome benefit to the individuals and that there is a cost benefit to the payers. If we can demonstrate those two things, then we'll get increased referrals to programs and we will guarantee that will happen if we can demonstrate that there's a that there's a cost savings to the payers and an improvement in quality to the individuals you will get increased referrals to a program. And that that that's what we're targeting here. Next slide please. So what does it cost to implement these things and what's the ongoing costs and how much savings is there. So I want you to continue, and just to know that the house health care committee has a hard stop at 1030. Okay, I will spend some time on this slide then there's a lot here and in seven minutes I'm not going to get to health equity which is the next two slides and we can pick up on health equity. I don't think I can do both in seven minutes. I think, and our committee will be picking this up on Friday, I think house health care will be picking it up. Another day so let's, let's go through what you can on this slide and then we can always retrace our steps at some point. Okay, so I'm going to start with potential savings on the right that's sort of the most exciting thing like that, like the newspaper man would start with the potential savings right there's a lot of savings here. So, but I want to point out that these are savings that are hypothetical right like they, they could happen, but it depends on how we implement what all the stuff under the hood to the left right like how many, how big do we go to begin with with how how many people we enroll and how much do we spend on on analytics and ROI and, and what are the policies what what are the policy levers that we give to the two in the programmatic levers that we give to the departments you know so how aggressive, do we allow folks to be essentially. So 1% we have a six and a half billion dollar health system 5% growth, you know 1% growth is 65 million a year so if you have a 5% growth trend and you carve it, you say it's not going to be more than 4% then you say it's 65 and we can do that states are doing that it requires levers underneath the hood like okay in order to save that money, how do we do it right and so I wanted to point out for the cost growth benchmark that you have to do the things. down below, or some other things down below that allow that allow us to achieve those savings, I'm just saying we're going to slice 1% off of your trend, it's got to come from somewhere right. And so you can push on price, you can push on utilization you can, you can push push on coverage. So a lot of different things you can do to push down to tamp down cost growth. They all have impacts on some buddies, and in some amounts. So what does it cost to to. So let's go down then I stand the potential savings on the right hand side. The skilled nursing home annual costs are in Vermont that's actual number 117,348 dollars on average per year for skilled nursing home in Vermont. It's an extent that we roll out moderate needs supports and we avoid 100 admissions a year we save 11.7 million dollars, and that's not unreasonable to consider that we would extend moderate needs supports and that we would that we would avoid. And 200 300 it depends how many people we extend those supports to. And how we target the individuals that we extend those supports to so again, doing that identification and stratification of individuals and extending supports in order to save dollars is something that can be done. There's equity choices in there. There's a bunch of significant issues in there about how about how to roll this out that we need to think about as part of it. But but certainly there are cost savings to doing it public option. And Tim keep me honest here, Nevada is that a Nevada number the 1300. Yes, okay. So, so in Nevada they targeted 1300 a year. And, and if we were to target a savings number so again here when you roll out a public option you can say, we're going to say 5% off of last year's rates, we're going to save 10% off of last year's rates. So now let's figure out the program designed to do that. And so you can target this number to not any number you want but to a broad range of numbers. And this is not an unreasonable number to target it to but it is, it is, it will have an impact it is aggressive right it is, it is an impact that folks will claim it's, it's, will have a deleterious effect on workforce, for example. That's something to keep in mind and to think about the blueprint for health expansion the honestly the literature is mixed on the range of financial outcomes for care management. So see my earlier comment that care management and case management care coordination there's a broad range of things you can do. If we do a specific targeted group of things, and we get that definition down, we can peg an ROI to it. If we do sort of broad range of all kinds of different stuff. The ROI disappears in the in the in the melee, right it disappears. And so that's something where diligence is really important to identifying and stratifying populations and going after interventions where there's actually a benefit. We can go after benefits that are harder to measure, but we, but see my earlier comment about getting payers to drive people to programs. They'll drive people to programs consistently over time, if there's a return on investment from those programs if they save money on those programs, tying it to increase improving health outcomes is also true. So if we tie those we look for those things where we have health outcome improvements and payer savings, we can guarantee that will continue to drive enrollment. When we can't do both of those things we can't guarantee that will either have savings one or two that will drive that will continue to drive people those programs over time. I recognize that we are right at the end. The ongoing costs and the cost to implement our estimates. Happy to talk about those in detail, I think that the investments in the cost to implement. For example on cost growth targets that four to six million. There's a bunch of stuff in there there's staff for GMC be or who I think that's where that would happen, as well as for the vendor at the statewide level. It assumes three years of those costs for those individuals in order to, for example, say, if you wanted to use one time money for the things in the cost to implement and say hey in order to do this we could do it for three years because you can't do it for one year and then say did it succeed or not you have to do it for three years so you can actually get look at all three years and see how you succeeded. And then in the ongoing costs that's after that implementation period so I just wanted to be clear that you don't add these together and so we have to budget that this year, that's not the case you would implement the cost, the cost implements for now, and the cost for ongoing is for after. And at the end and so I wanted to be respectful of that and there's so much I hope that it was. Joshua thank you clear we could take the slides down. Thank you for that and thanks for chipping in Lorraine lost her electricity. That's why we lost her. So, Joshua thank you and our Senate Health and Welfare will dive into this a little bit more on Friday and then we'll be setting up additional time in our committee to go through the report and to see what it is that we might want to put in place through the legislation this year, and I know that House health care will also be working on this, but the Senate, the Senate Health and Welfare Committee has been given the honor of beginning that process. So, we'll look forward to having you in our committee. We don't have more time today for questions. We were going to have to go back and do that, whether individually or collectively are two committees together so we will definitely do it and Senate Health and Welfare. Anything else representative leopard. No, we do have we do have other witnesses waiting us so thank you Joshua and others and we were, we will return to this after consulting further with Senator lines and the Senate Health and Welfare Committee. So with that I would just encourage or walk suggest that House Health Care Committee members. Go off of the joint, you have to move out of our joint zoom room and go back to our individual zoom room. At this time. Thank you. And Senate Health and Welfare just stay right here don't go away.