 Good morning. This is the house health care committee. It's Thursday, March 11th. It's 9 a.m. and We are Shifting gears this morning to two different topics this morning Excuse me the first issue that we will be addressing is to pick up again on some witness testimony and discussion around a proposal that is that would expand dr. Dinosaur to Additional Vermonters and I think with us this morning. We have commissioner gussison and Addie stromello, and I think I see Nisa James as well from the from diva Department of Vermont health access and we have Michael Fisher from the office of Health Advocates office And those are the witnesses that I'm aware of for this morning, but what we hadn't discussed is how to proceed and I'm wondering Let me let me do this publicly and with with all of you This proposal is initially has been brought forward to our committee by the office of the health care advocate It's a suggestion which we have as a committee said is of interest to our committee and one of our committee priorities I'm wondering if it might make sense to start with the office to put that proposal before the committee clearly Before hearing from the before hearing from diva would that be agreeable to Cory and Mike Fisher It just because I think I think we need to frame what what it is We're thinking about and what it is that's possible or not possible and and all the issues related to it Does that does that work for? diva and for the office of the health care advocate, right? Sure Okay, well with that I and again I want to be I want to be aware of our time This is our crossover week where every minute is precious in this committee right now So we have scheduled this to start now and to be completed by 10 15 10 30 We may need to pick it up again, but so Mike if you would start by reviewing I think you shared a document and that might be the basis for some of what you wish to share but if you would start by a What can I say a comprehensive but short and clear Description of what it is that you are Thank you, Mr. Chair Mike Fisher health care advocate here happy to spend a few minutes Reminding the committee of some of what you've heard already. Yes, and and and trying to put this in the simplest of terms I think what you know one very simple way of describing this proposal is to take a population of children and Pregnancies coverage for pregnancy for people who would in all other ways be able to get Medicaid Other than their immigration status Not proposing to expand Medicaid to a new Eight in a dr. Dinosaur to a new age group or to a new income eligible group Only to Take this one factor people's immigration status and And make those people Those very low income for monitors eligible for coverage Mike I apologize. I feel like I need to interrupt here Colleen we have someone who is quote in the waiting room for our zoom but not identifying themselves and I frankly am reluctant to admit anyone who has not Identified themselves so they are continuing to be there. Does anyone is anyone aware of a witness or someone who? has been authorized to join our zoom this morning and And or the person who probably can hear me at this point I would say unless you can further identify yourself. We will not be admitting you to zoom So if you could communicate whoever it is can communicate directly with Colleen McGovern our committee assistant to clarify this I'd appreciate it so we could proceed with our Testimony and with that I'll turn back to my apologies for the interruption I think mr. Chair. I'm not aware of anyone from my side So I Really want to put it as simply as that, you know, these are low-income people who live in our communities Who are more pregnant? and who are and or who well or who are children I suppose it could be and or and who are in need of care and I don't think I need to spend it any great deal of time speaking to the the human nature of this I think you heard directly from people who are living with this reality Nor do I think your committee has spent a great deal of time focused on the importance of up-front care in In you know for human purposes and for financial purposes that when you provide care up front It It results in less acute expensive care later if there is ever a Population that this applies to most directly its pregnancies and kids So You know and lastly I'll just put this in a racial justice context Yes, there are Structural racist structural racism in our system and And I applaud the committee and I applaud throughout the state house the focus on on these issues This is a very Small proposal a very minor, you know, it affects a small set of people we think maybe about 20 pregnancies and maybe a hundred kids Where where our current structure and our current laws Largely because of federal law or in part because of federal law Creates a structural problem where a set of people who Are you know people of color who are here in our communities? Are unable to get the care they need so I Don't have more to say other than that and other and I would be happy to have the opportunity to to respond After the after diva has an opportunity to speak Thank you. Okay. Thank you. Thank you Mike. Thank you for Just summarizing that and we have heard previous testimony as you indicated And in the meantime we had asked a number of our members Recognize represented black for having Put some time and attention on this as well as represent quarters So I think I think here. Can I I apologize? I neglected to do one thing that I think makes sense to do at this point Can I just remind you of the list of organizations that are supportive of this proposal You can very briefly but we want to get to the substance of what's possible. Not this is not just a matter of lobbying Understood only because it has shifted a little bit since my last communication with you It now includes ACLU of Vermont by state primary care migrant justice Planned Parenthood of Northern New England Vermont Association of hospitals and health systems Vermont's free and referral clinics immigrant Vermont immigration assistance project Vermont Interfaith Action Vermont Medical Society Vermont workers center the open-door clinic and The open-door clinic. Okay. Thank you. Thank you So thank you again. Thank you. I with that. I'd like to just I guess what I want to do is to turns give the Department of Vermont Health Access who oversees our Medicaid services for the state the opportunity to give us a And information about what is the current status? What possibilities exist and or are In your view achievable or not achievable Anything within that, you know with that to respond. So I represent our Commissioner Justice and I welcome you to To work to do that by having other staff from your Yeah, department participate as well I hope it's okay if I just say I don't know if you can see wrap you have it. There is a hand raised Okay, thank you Representative Goldman your question Just to clarify in questions one is is it 20 pregnancies and 100 children a year? I'm just wanting to understand that Okay, so that's pre-year and once the children are born. They are citizens. That's also true. Correct. Thank you You've born in Vermont, right? Well, or at least, you know, citizens of the U.S. Which then of course adds a whole nother thing. That's all I wanted to know. Thank you very much Okay, thank you. Thank you commissioner. I didn't see the hand Yeah, no, great. Just didn't want So Cory Gustafson Commissioner Department of Vermont Health Access and as you said Chair LePert the Two individuals with me today are Addie strumla who is deputy secretary deputy commissioner probably a future deputy secretary our she oversees the Enrollment eligibility unit and so is a real subject matter expert on what it would what it takes to implement the various policies and Changes that come through our shop. So she's here to talk about that and we do have Nissan on the line too who has You know been actively involved in in processing the proposal for what we have right now. I mean it has been You know to the extent that Mr. Fisher not sure what to where how to name but mr. Fisher Outlined for you hit that's about as much as we have sort of talked about so I think it's a good time for us to be involved in this conversation in in so far as As you consider it, I think there are choices you can make and we would like to definitely be able to inform What's possible? I so I appreciate you sort of framing it that way for us because that's exactly what our goal in this conversation There's no doubt that You have an understanding of what's in front of us in the near term as a as a department as far as enrollment eligibility concerns So just for simplicity's sake, I'll outline or highlight The unwinding of the public health emergency I think we've mentioned to you in previous testimony that that is going to be a significant amount of work for us In the near term assuming that we are in going to engage in unwinding in the relative near term Second is the bill that passed in the in Congress yesterday There are significant exchange changes as it relates to our systems that will be necessary to execute We do not have our arms wrapped around what that may entail but it is going it is You know in in the grand scheme sounds like really good news I don't have early info for you or numbers But it sounds like it'll be really good news, but it'll be a priority to get that those changes implemented efficiently and effectively and So then the the the other thing that we have in our systems is the The regularly scheduled IE any effort that is underway that you get You know, not very regular updates on but it is always happening We have a history would you translate that acronym integrated eligibility and enrollment system? So as I as I said adi oversees The team it's over 300 or excuse me over a hundred and fifty people that are on that team that are responsible for the state's enrollment of individuals in our various Medicaid eligible groups are 16, I believe and our system Is the system that you're well aware of it continues to Be evolving so we have scheduled efforts on that on that system. We have limited environments to do coding and testing and so What I'm basically getting at is this sort of broad scope of all the other things going on just to say that falls into the context of our evaluation of of Any work that we have to do and so I'm going I'm sort of staying away from any of the policy just to get to One of our big messages is about timing and about how we might do that and so You know, that's the I guess the big message we want to Share with you, you know as the conversations go forward and as there's actual legislation to sort of Look at and see how it might Be effectuated we we love the opportunity right now to just sort of talk about how we think it might be most efficiently implemented And so there's the efficiency of implementation and the timing and those are the two main messages We want to share in this conversation. So I'll stop there And hope that adi can provide you with a greater color on how it might be best in the Regulatory and policy sort of angle of just getting done what you would you would want to have done Thank you. And in the course of that if you would include what If there are financial estimates as well sure Right. Well to that sure to we so to that I think that Nolan has a final financial And so if you want ours we'll definitely do that with you. I I do want to raise that Jfo has been in contact sort of do the math as well. So If I can turn it over to adi now to I'm happy to talk through whatever What we think might be the best way to implement Or adi stremmelow deputy commissioner at diva. Hi everyone So as cori mentioned kind of in the interest of informing this conversation We have done some thinking about what a potential program would look like should the legislature choose to pursue one Our thought is that the most efficient and kind of flexible way to implement this type of expansion And the best for the customer importantly would be as a state only program I think this committee has heard some testimony about a narrow federal option to cover Quote the unborn child That federal option comes with significant administrative steps and it it translates into really complex operations and a and a sub optimal customer experience specifically Applicants would have to go through a full medicaid screening process and be denied So the mom would have to go through that that step and then so that we could then grant coverage to the unborn child so it would be prohibitive of kind of granting coverage directly to the to the mom which Seems like a policy consideration here It would also translate into kind of greater expense in terms of the operational build and the it build For for a program like this So pursuing a state only program would remove these kind of administrative and technical hurdles We could build a simpler application process that would not Require the full medicaid screening and denial as a prerequisite I think you've also heard testimony about how that Those types of steps can be a barrier in the context of emergency medicaid. Um, which is what's available to this population at the moment So but similar to emergency medicaid, I think we would seek to collaborate closely with the prep idea community so that applicants can be identified at the point of care and then in a in an efficient way brought brought into coverage So that that's one piece in terms of efficiency. Um, and then timeline and and build Corey really got into this Even with a more efficient and kind of nimble state only program We would need time to get this into place. We have On the eligibility and enrollment side really a a very very full plate this year Largely because of the public health emergency but now newly because of arpa The american rescue plan act which has a significant subsidy expansion in it that we will be charged with administering And comes with an it build Um, and then that's layered on top of the existing Integrated eligibility and enrollment roadmap. Um, this committee is familiar with for example the premium processing project, which is to Return the administration of billing for qualified health plans to insurance carriers rather than having the State having diva be in the middle of that transaction. And that's a project We've that's been underway for several years now and was extended because of the pandemic Um, but we're now really on track to have that implemented for open enrollment this year So we're doing this dance with a, you know, a number of different priorities. Um And Even though this type of dr. D expansion would be more efficient It would it would need to be slotted in somewhere. And so we're thinking Probably it some some time in 2022 we could Do that build and that implementation um Again, if it's if it's uh, you know pursued by the legislature So that would be much more significant if we were pursuing a federal Some kind of federal option Um, so I think maybe I'll leave it there unless it corresponds to the actual It expense I we think is not hugely significant probably in the low 100,000 dollar range Um, because we'd have to build some category codes and you know operational pieces like notices and application I think maybe I'll leave it there unless Cory you wanted If there's anything else you think I should cover but that's that's our general thinking at this point on the proposal Once you're meeting you're on mute Uh, I appreciate you mentioning, uh emergency medicaid because in one some of the testimony we have heard um to be honest, it's it's it's it's both perplexing and and a little bit disappointing to hear the numbers of Uh of Vermonters accessing emergency medicaid and as It it appears that that's a pretty daunting process um And I'm not sure I mean maybe I can just ask Briefly without getting into the weeds on this Does the state have any flexibility? in Streamlining access to emergency medicaid because part of what I'm hearing is that To do this as a state only program is what your recommendation would be for the reasons you've outlined and because of the tremendous workload that you're faced with right now and the Both because of the pandemic, but also because of the new federal law who I've gotten quite used to there the new acronym What is ARPA? ARPA so everyone get used to hearing about ARPA um But uh that there would be By your recommendation at least A continued period of time when there would not be access to a state only program But it occurs to me that that in that interim period Other access might continue but What I understand is access to emergency medicaid is So it must it must be pretty daunting because there's very very few people who have accessed it. Is that fair? Is that a fair assessment Eddie sure and then my question is whether you have any latitude without turning it into another whole project Whether there's any latitude to waive some Procedures that would give more immediate access on it even on an interim basis From my perspective, I think there could be room for improvement and efficiency around awareness of the program and you know getting getting the application process, you know started and More quickly The application process itself. I don't think we do have a lot of latitude Because again, it's this federal standard that we have to have gone through a full screening and denial Before we can pay for those services But you know, perhaps on the outreach side, I know that the assisters that we have relationships with are are kind of instrumental and in awareness of that program We can definitely look at whether there is is room for improvement there But on the straight technical administrative side, I I don't think we have a lot of flexibility Okay, there's no such procedure to deem someone Ineligible I mean, it it occurs to me. It's the kind of situation where you put people through a lot of hoops and Uh, everybody coming out the other end is found to have not been eligible And rather than sometimes there's a process by which we can say we are going to deem this class of people Not eligible because everything we have learned Has shown that they will be deep they will be found ineligible. So there's no there's no such waiver in that manner Yeah, we don't have that flexibility But I think I think that's exactly what we're getting at in our in our recommendations around this potential expansion Is a streamlined application that relies on an attestation Okay, so I see a number of hands. Uh, I'm going to put a couple other questions on the table quickly so that I'm uh, just Apologize for stepping here, but I do want to move this along So could you speak to the financial impact of a state-only program? As well as uh, which you which you alluded to as would be if if this were to be the legislatures Directive Do you have some estimates? Yeah, I think I will it's the information that we have shared previously. I think with nolan, but nissa, did you want to Oh, hi go for it Thank you for the record nissa james for the department of vermont health access Um, indeed we attempted to do our best to provide an estimated fiscal impact for this so that we could all fully understand what this could potentially cost On an annual basis where those proposals to move forward and as the commissioner and deputy commissioner confirmed We have shared this information with the joint fiscal office and so they uh, may have a perspective to provide on this as well So just to walk the committee through it from a high level um inclusive of what the deputy commissioner Referenced in terms of potential costs associated with it changes We would be anticipating a an annual fiscal impact for coverage of pregnant women and children regardless of immigration status Of about 1.4 million dollars a year and then i'll break that down. So I just want to start with what that total would be So as the deputy commissioner had referenced, we were anticipating approximately about a hundred Thousand so if you take that off the 1.4 that brings us down to 1.3 The 1.3 is then broken out by what it would cost for the coverage expansion for undocumented pregnant women and That calculation is based on an established methodology for determining a pm pm And so I think some of you saw some of those initial figures in earlier committee discussion So essentially what you do is you define your year And then you determine how many Medicaid members are covered And you develop a number of member months total And you come up with a pm pm and in this case to be able to provide coverage for pregnancy It would result in a pm pm of just about $3,800 So when we multiply that by the estimate for 22 Pregnant individuals who may be covered by this expansion That results in an estimated annual fiscal impact of just over a million for that category For the second category, it's the expansion for children regardless of immigration status and so that Calculation looked at what our historical pm pm have been as we provide in our sorry per member per month Payments as we have provided in our annual budget book or annual reports And we specifically looked at calculating the per member per month for the governor's recommended SFY 22 budget based on a combination of the general child eligibility group And then also with consideration for those who may fall into the Medicaid eligibility group of blind disabled or medically needy Because that per member per month payment is Significantly higher than that of the general child category And so when we completed that calculation for 100 children, which We need to acknowledge is the work of vermont legal aid To really reach out to stakeholder organizations and help us attempt to get our best estimate for the number of children Who could be covered under this that results in just about $300,000 annually So that's that's thank you. That's a it's a helpful summary of so a million dollars for pregnant women and $300,000 for Children and $100,000 in terms of operational additional costs. That's helpful I'm going to turn to questions. I know that I'll just say that I I believe we're actually paying these The state is absorbing these costs indirectly through Free clinics hospitals bad debt, etc. But let's let's I think represent court is you have a question. Did you had you had your hand up? I believe you your question and Nissa James's Information answered it for me. Thank you. Okay. Sorry Um Representative Peterson then represent page and represent black you're muted Thank you. Um, I I'm not sure who this question might be for it might be for uh, mike fisher. Um I think you mentioned there was 16 or 17 states that already do this Uh, I'm wondering if any of them border us or are in new england If any states here Or do we know that? Can I can I say I don't I don't recall hearing that figure but mike can you speak to if it's correct or are correcting it if it isn't And answering the question. Yeah, I hear the question The key part of your question Representative Pearson is do this Uh, we did say that we we thought there were 16 states who do the Apologies the child only the The unborn child chip expansion There are many states who have Who have carved out one area or another? For a state only program to cover people without documentation I don't have a count on that I can easily provide for you a spreadsheet that shows A state by state analysis of that But many states and many states that would surprise you have taken action like this No, I I don't need a list. I I'm just uh You know, I I I just had a question on that. Thank you. I I might I might say I would like the list Even if represent Peterson's not interested. I am so if you'd share it with the committee, that'd be great Uh, representative page Then representative black Yes, a couple of questions. Uh, this is very important. I think we should support it But I was curious The questions I have is one Is the agriculture committee looking into something like this it would seem that They would be very much concerned about about this issue as well and Regarding the agriculture committee Is there no way that These farming businesses Do they not have policies? Where they could cover their workers? for this type of care and and also we we hear and we And we read about how Undocumented workers are paying into the system Into various systems Whether it be, you know our state taxes federal taxes and things like that And it just seems to me that Um, they should be eligible for some of these benefits that they supposedly Pay into so those are my questions Thank you I don't think those questions are directed to whomever can answer it best. I think What It's a good question representative page and I appreciate your expression of support for this. I I do not know Whether these I've not been a part of conversations with Department of ag or with the legislative committees from at with ag focus And I think a question that representative page raised which which has been a question in my mind as well Do do we not have a process by which employers who do not provide health care for their Uh, employees actually have to pay into Help to assist the state. I forget the technical term for that, but I'm sure someone at diva can help us with that Uh, and do we know if that is fact taking place on these farms if they're not providing health care to their employees Does anybody have any information about that? I can talk to you about the employer assessment if you want That's that's what i'm trying to reach for in terms of the day. There is an employer assessment and who to whom does it apply I guess without saying that would it apply in these circumstances or in this cut to the chase Uh, I'd have to look at the definitions in the labor statutes to uh, or actually it's in the tax statutes at this point To see so I can look into that and and get back to you in a bit I would appreciate it. That would be helpful because that's what I was trying to refer to the employer assessment Yeah, okay Uh, woody did you get your questions answered? uh I mean, obviously we don't know what the agriculture committee has taken up But they did it and what's notable is that they did take the lead Uh at one point in the other body on, uh Some of the stimulus payments That the legislature ultimately authorized And that was that was an initiative led in part or in large part by an agriculture committee in the other body So it's it's worthy. It's it's we would be wise to inquire and In either align our align ourselves with them or see if they're already doing something. Thank you for the question Thank you And I'm sorry. I didn't mean to put you know, everybody on on I didn't mean to put anybody You know on on the spot with these questions, but no, these are questions. We need answers to These are these are good questions. We need answers to um, I'm going to go to a representative Well, I've represented quarters. I preempted your question previous. I'll go to you and then represent black if you don't mind Just a quick comment, um in relative to representative Uh pages question I'll point out that, uh I have volunteered with the open door clinic in Addison county with the immunization program Could you say could you say for a moment what again remind people the open door clinics some of us are more familiar than others Sure. The open door clinic is in middlebury, vermont, and it's a free clinic. Um, that's available to uninsured and under insured residents and A significant Part of the population they serve are migrant workers Working on the dairy farms in in other farms in Addison county And in the fall, um They always have a flu flu clinics a traveling flu clinics, so I've um volunteered with them and gone farm to farm to Workers that wanted to have flu shots But there are there were a number of farms that even when their workers Wanted flu shots refused To let Open door clinic volunteers On to the farm. Um, so I say that in reference to Representative pages there's varying amounts of willingness to participate In programs like this from the farmers Okay, uh represent black and then I see represent Peterson again I have a couple questions. Um, first of all, thank you for your support for this um Regarding the 22 pregnancies. I'm just wondering Where that number came from and You know, I spent a lot of time looking into this and was really It was really difficult to get a read on the number. So I'm wondering Where the number 22 is coming from Certainly, so I can provide our methodology that we use to calculate our estimate And then I would likely turn it over to the office of the health care advocate because they used a completely different methodology But came up with almost an exact number So for our methodology to estimate it, um, this is a population that's unknown to us currently and so we visited the American Immigration Council Research for the number of immigrants in Vermont There were less than 5,000 Undocumented immigrants estimated to be in Vermont, which is approximately 4% Of the immigrant population If you use the 4 figure and then calculate out the number of births from a foreign born population in Vermont Which is based on data from 2018 We then arrive at a number of undocumented individuals giving births per year to be approximately 22 So it's based on national data It is based on national data specific to the state of Vermont extrapolated out to the state of Vermont I would suspect that we because most of our population is farm workers that we would probably have a higher percentage of male Then say the rest of the country. I mean, would that be a good guess? So I think in response to your question, I would defer to the office of the health care advocate to Uh, inform based on their outreach to those communities. Thank you. And I'm wondering, um, also if Anywhere in the calculation of the 300,000 for children If If there's any thought behind how much more a child an infant costs when That mother did not receive any prenatal care and whether or not there's an increased cost for that child Because once that child is born, of course, they're covered Um, and I wondered if there was any calculation in that in possible savings Based upon the fact that we've given the mother prenatal care We did not calculate any potential for cost saving. Okay, and my last comment and With deep appreciation for all the challenges that diva is facing and The upcoming work that I know is on your plate I can't help I can't help but get the feeling as though your supportive of this But we're asking people of color that they just need to wait their turn and That actually is a little disturbing to me and I wondered if you had a comment on that No, I don't have a comment to that. I mean, I don't know what you want us to say about that We we're just here to talk about what it would take to to execute and what we have in front of us I think that the administration has Demonstrated its commitment to progress and I think I'll probably leave it at that Okay. Thank you. Thank you uh representative Is it golden at first or let's go to represent gold and she hasn't spoken yet. I don't believe On this and then represent Peterson Yeah, thank you and and thank you for your support at least for trying for 2022. I think that's really important um I'm also wondering though. Is there a bridge that we could think about for 2021 somehow because otherwise we're going to leave theoretically 22 pregnancies and 100 children behind And I'm hoping that somehow we could figure out a way within the regulatory model that you have to work in To help us support these families now As we get it all together in a more official capacity So I'm going to ask that question. Um, but before I go there, I just curious Did I hear correctly that you said that the per member per month for pregnant woman is $3,800? Because that sounds awfully high to me and maybe I'm misunderstanding that number Yes, well, I'd like a little more understanding of that So in calculating the per member per month, it did arrive at a $3,800 a month calculation that is based on pregnancy aid category codes for the last state fiscal year So that's July 1st 2019 through June 30th of 2020 when we use those category codes To pull the total number of paid claims for that defined year period The paid claims total just over $50 million When we calculated the number of member months for those pregnant individuals. It was 13153 member months So when you divide the 50 million by those member months, that's how you arrive at the 3,800 Now what I will say is the number of member months obviously impact that ultimate per member per month calculation So if we have more pregnant individuals who are showing up in that Member month total then your per member per month Calculation decreases we've been seeing fewer pregnancies And so those member months total are decreased which produces a higher per member per month calculation So does that mean that practices who provide Obstetrical care are getting $3,800 Per Medicaid recipient who is pregnant. Is that what I'm understanding? Which means over the course of their pregnancy nine months, they're you're getting $13,000. That's what you're saying That's what it costs to see a pregnancy from beginning to end The per member per month calculation correct Okay, thank you. So then back to my other question. So is there a way to Support you to do some kind of bridge to look at the population in the near term Yeah, I'd be happy to speak to that. This is adi strome alone again deputy commissioner And I do just want to clarify when cori and I talk about kind of the the prioritization and the roadmap We're talking about it. We're talking about the like the system And the environments that we have available for testing and you know what it takes to get the code in We you know should this proposal move forward and be enacted we would start work right away And I think we our best guess at what it would take To get all of the pieces in place and slot the it side in would be Next year, but I think I think what we would find really helpful is again, should this move forward working with the committee on a prioritization I You know the other Items that we have coming coming down from the federal government, you know also are incredibly beneficial to the the population And so we I think we'd appreciate collaboration and looking at you know, how to how to order these items that we have in front of us I I'm not sure I'm going to be able to think about this right on the spot now, but it just occurred to me that Let's just say theoretically there were funds available right now But that the system wasn't in place couldn't be put in place immediately the system that would be required to Make people eligible for the Medicaid services Is there any it would there can anyone imagine the possibility of By passing the system until it could be in place to actually Pay for what would otherwise be paid for through Medicaid by a direct payment to cover the equivalent in say an interim year in a transition year Who is that? I'm not sure quite what all I'm asking, but I'm trying to conceptualize something That would allow for access on a transitional basis And that may be asking something that would be outside of your realm because that's not what you do but Well, I I I think that we've we've given some thought to how to kind of minimize the impact on the eligibility system itself, which is the most, you know Significant and kind of difficult aspect of the it build. I don't think we could avoid needing to build a new category code so we would pay these claims correctly And that does get a little bit outside of the eligibility scope, but I think You know, that would not be overnight even if the even if the funds were available The bigger issue is is also so much of our work is operational and um, you know, we have You know, I hate to say this, but we just we do have limited resources. We've been you know dealing with the hiring freeze and and You know, all of these different You know extremely important initiatives that are coming coming down. So it's not I don't think I could safely say we could we could start providing this coverage tomorrow. Even if we had the money available Um, it will take some time And can I just clarify too when adi says operational? It's manual and process based work Um to make that 100 clear So again, I'm just going to think creatively here for a moment Assume for a moment, which I don't know that we can but let's just assume for money moment. We had access to 1.3 million dollars For the for year one while the system was created Right now these these these costs are being absorbed By free clinics by hospitals. I mean it seems to me that we're already as a state paying the bills Perhaps not as effectively and perhaps not as fully in terms of early provision of care, etc But but the costs exist in the system In terms of uh, and I believe and I'm I'm guessing this is a supposition on my part. That's I'm guessing this is part of why You see the Vermont Medical Society In addition to the humanitarian aspect, but that there are financial Costs to our hospital system to our free clinic system to providers Of care when someone presents, but doesn't yet have access to Medicaid So I'm I'm just thinking out loud. I'm not asking for an answer to a question I guess I'm just speculating out loud as to whether if we were to have access to One-time funds for a year Whether they could be used to help Subsidize this care to underwrite this care until we had the system in place I'm just let me just leave it there. No responses needed Welcome anybody thinking about it with me at some point in time. Mr. Chair. I would like to It would you quickly if you wish to comment quickly and then I see there's other hands. Yeah, I just want to There's one point that Representative Black said that I want to just emphasize Obviously, you know in much of health care You know regular care doesn't cost that much But you have a few outstanding cases that that you know blow the budget out of the water if you will and There's been a tremendous amount of study about the value of prenatal care You know, you have one If we through this coverage are able to prevent one premature birth and all the associated costs You know in a five-year period You know We've done a tremendous good financially let alone the human costs. So I I really want to say I appreciate the you know, you're thinking out loud Representative Lippert It might be that I'm hopeful that the committee can support some version of this committee bill Which would allow us Some time to can sit to continue to consider Alternative ways of thinking through this Okay. Thank you Nolan and then represent Goldman and then I think uh I'd like to touch base About what we might have in front of us Nolan There you are I just took my hand out as I moved I'm sure You're on the screen Sorry about that for the record Nolan Langwell the joint fiscal I just want to make a couple comments of things that have been said Versus, um, you know, I I have looked over The numbers from diva and they they are very reasonable Based on a lot of unknowns And the numbers make sense to me the the costs look high But from a pmpm's perspective it makes complete sense for how it was calculated the only things that they would throw in there is I also worked on the ag bill when we gave the stimulus checks Conversations that came up with how do you work it out? So those numbers make sense from an annualized perspective, but in the beginning There's going to be trust issues. And so you have to and I know that representative cordis has probably touched upon this as well Um, you know, it's how do you get the word out? Who do you work with? Do we do you want to put a little bit of money in the budget as well for outreach? For these folks and working with some of these organizations to build that trust to get the word out. So In year one, it may not be the full million As until until you get people to sort of start trusting and getting the word out So that's something to kind of think about I still wouldn't say we should not budget a lot of money But that's just a piece to keep in consideration when you think about it is Outreach is going to be huge and trust And implementing this program in the beginning Thank you point well taken And and and uptake might be slower than just the annualized estimate In in particularly in the early period Representative, uh, was anything else you wanted to add Nolan at this point? No, I just I worked on the Same conversation. Thank you. Thank you. I appreciate you bringing that experience to the table uh, represent goldman Yeah, I just want to emphasize the healthcare advocate statement about preventing premature birth. This is in huge huge expense Not only in the medical system, but in the educational system as well So there is really an important opportunity here Um, I just wanted my question is really more about process Um, because you both mentioned that corian addy about Is it my understanding that you add Medicaid codes all the time? Um, or do you have to go through this sort of laborious process Every time you make some kind of shift There is a process in our it's in our legacy access system To to build a code that can then be communicated into the mmis, which is how claims are paid I don't it's compared to some of the things we deal with on the eligibility side I don't think it's laborious, but it's not it's also not instant and automated There is a a build associated with it I'm not sure if that's I'm sorry, please. I'd be happy to speak more. I Well, I'm but you're so indebted in the system that you know, it makes total sense from where you guys are coming from As an outsider. I'm just trying to picture You know, you know medicine shows shifting all the time. I'm just trying to understand your process And just to make sure when you said codes you meant, uh, like claims codes not, uh, eligibility processes Well, I you know, maybe I didn't get the language right because you were talking about what you had to build And I guess what you're building is eligibility codes and that's harder Yeah, not codes, but but the processes that would be required to um To enroll an individual So your system is not that flexible That's like I can't understand how this works. Well, I think you could just put a period right there and without an insult to anybody I think they would have they would all agree Not attending any insult just trying to understand. Oh, I know it's just That's all recognized that there's not many these systems that one would describe as flexible Yeah, I I'll tell you if I had a time machine I wouldn't go back and make big bets on something I would actually go back to 2013 and we would do The build of 2013 a lot better It has created. I mean, it brings us to this point where we're talking about uh the operational concerns of a very, um An important issue and You know It's unfortunate, but it's true Okay, let's let's take one more question from representative Pearson then I think I want to take a pause and um think about And maybe just have some committee discussion even briefly about how to move weather and how to move forward and uh, I know that I had asked uh Our legislative council to at least Contemplate what might be possible ways for some language that depending what the committee's will the committee was to think about how to move something forward Representative Peterson Yes, thank you. And maybe this question belongs on a committee undocumented Workers that are people that come to Vermont. Are they given an ID? Is there any way we know who is actually a Vermont resident? I'm and maybe no one knows. I just a question occurred to me well, um I'm not sure who who to direct that question to but I can say that we have provided as the legislature the opportunity for identification Credentials, but that's that's uh dependent on someone coming forward to request that it kind of in lieu of driver's license We have we have uh, we have IDs available And there have been historically some difficulties there because you have to Yep, again the issue of trust the issue of the federal involvement with immigration It's been a bumpy road at times Um, but I don't think there is I think it would be fair to say There is no quote registry Anywhere in Vermont of those who are in Vermont who are not Vermont citizens undocumented Or not citizens of the u.s. I think that would be fair to say there is no such Registry and there is no requirement that people approach anyone to Officially acknowledge their existence in this they're they're living here in the state as a resident Yeah, I don't I think that may answer your question to some degree Thank you Yeah, so that that that results in all the trying to estimate Etc both for this and for when we did the stimulus payments as well And what worked which were still in the midst of frankly that's still an ongoing process Okay, um I'm uh Let's see. How can I do this? So let me let me let me do this You know, let's So I'm not wanting to, uh Take take the commissioner's time and and others valuable time while we have some committee discussion Uh, I'm also aware that there might be questions that emerge. So I want to find that balance. Uh Can we Can we ask you to stay with us for say 10 or 15 minutes more? Uh Perhaps someone from diva not necessarily everyone from diva Could one of you be volunteered to convey? Uh questions that we might have because I really don't want to occupy all of your time unnecessarily Uh, so I'm not sure if nisa Uh, you're I see you're you're with us but not on screen Would you be available to stay with us and allow the commissioner if he so chooses and addy to Go on about your day With appreciation for having made yourselves available now So that we while we have some committee discussion about how and whether to proceed You're certainly welcome to stay. I'm just not wanting to You know say that you need to be here That's fine. We'll we'll we'll do exactly that Thank you Okay, again, thank you very much for making yourselves available and for working to help us come up come up with some estimates Um, and I think what I'd like to do at this point is to open it up Uh, and for nisa if you could stay so that we could Use you as a conduit for further questions if possible Okay, again, thank you commissioner. Thank you deputy commissioner Um, didn't mean to chase him away, but I just know There's a lot of things to do as they said um So let's so I want to just open it up to some community discussion about Thoughts on how to proceed One one i'm gonna i'm gonna throw out i'm gonna lay out several things that I think might be options one of which would be First of all, we have no legislation in front of us. We would be creating what's called a committee bill And a committee bill could in fact um Lay out that it's the policy of the state of vermont to provide access to dr. Dinosaur for non for undocumented or find the right language citizens who are pregnant during their pregnancy and or children who are children of uh, non-citizens and that uh and and have that be Something that we move forward as a Uh, a directive if you will as of it with an effective date What I've heard so that's one option I think I think that might be an option and I'm looking to jennifer carby to help advise us as well in terms of how to craft something um We could do nothing That's another option to say well, we've looked at it. We raised the issue We've we've highlighted the issue if nothing else we've highlighted the issue and That is raising, you know, that that has value and that's raised the issue uh, or depending on the sentiment of the committee we could uh also try to do something moving forward and Simultaneously try to explore doing something in the inter in an interim period So i'm going to open it up to this committee discussion at this point. Just I just like to open it up So we can get a sense of whether and how to proceed And I'd like to suggest that we use the next 15 to 20 minutes to just get to get a general sense of what committee members are thinking So, let me turn uh representative cordis and represent donahue Think representative donahue was first All right, you represent donahue Yeah, and I and I haven't spoken yet and part of it is just my, um divided feeling angst Whatever which yes, I like to share. I I think it's incredibly important Um, this is an incredibly important issue. It's an incredibly important issue to try to address As rapidly as we can But there there is another whole side Which is is actually some of what i'm seeing in other tensions right now You know, I've been working for several years on how we can address and get to What we've sometimes referred to the the gap folks the family glitch and the Off the cliff from federal support folks And those are incredibly important as well. They are also people who Can't access preventive health care can't access what they need because of some of our financial structures and financial limitations um and then I and then I turned to some of our other pieces and and hate to say this on youtube, but you know There could be committee people sitting around in our committee room too You know, I I just was intensely jealous At looking at the child care bill coming out Which sets a goal saying no family should pay more than 10 percent of their income on child care And I say dang what why didn't we do that last year? Why didn't we Put out a bill that at least said our goal as a state You know until until or unless we get to some universal access That no family should be paying more than x percent of the household income for for health care um And and they're both important child care is important But health care is so fundamental and I I raised this on the floor last year in my boning against the The family Leave act it's like isn't Access to basic health care the most essential gap in our safety net Which is why this is so important to me the issue we're raising right now But I just end up with this real struggle in terms of There being a lot of gaps in in our system of protection for people and And I don't know how we prioritize or get to them other than I think we all know we can't we can't do all of them so So that's where I am. I'm I I don't know where I am I don't know how we move forward those are my struggles Okay, I'm gonna I'm going to jump in here before hearing from other members because I want to just put this in the context of we are on the cusp of some profound federal Changes in the health care system, which I think could very well Address some of the very issues that you've just articulated I don't know and this one and hypothetically this we just we don't know what they are Well, I I don't think it includes this one from preliminary information. I see This is this will continue to be a gap because in fact undocumented Citizens or not, you know non-citizens We don't know But the preliminary very preliminary information I have is that we may very well In the in the ARPA act that's just been passed and that is being trying to be understood now There are some significant health care initiatives embedded that no one fully understands yet That may very well address In some way that very issue of no no one should pay more than x percentage I wish that I hope that's true. I don't know that to be fully true And I do understand that that is part of my angst is is that we don't know that we don't know Where any of these things play in yet? So it's it's just I'm not saying I I don't support moving forward I hear you. I'm just struggling right now. I'm just wanting to make sure we have the other in mind as well in that What we can do is what's within our jurisdiction What we can't do is what's outside of our jurisdiction or our immediate Abilities to impact And so I think we just need to keep that in mind as well Again in the interest of time, I'm going to hear listen to others and so representative court is in representative black Yes, there are We have many gaps to address and we are In terms of of Dismantling institutionalized Isms including racism, which is actually what we're looking at right now. This is an example of how Our institutions our processes have Institutionalized leaving out members of our Communities at a national level and at a state level And and I know that we as a legislature are Doing a lot of work right now and I'm so grateful for it on addressing Systemic and institutionalized racism and it feels like we're building the plane while we're flying it In that I there are a lot of paradoxes For us And I'm going to speak Just as a white person paradoxes in how we How we address these issues because Right now we're the ones that that hold the power While the people who need To be included Don't and have been left out over and over and over again and I Appreciate representative black's point about you know, when is it the right time? We've already proven that we can act quickly in a crisis This crisis has been unfolding for generations But the pandemic showed us that we can move quickly. It wasn't perfect. I don't expect it to be But We do have to act and So I support this bill and I think it was The first choice that representative lipert mentioned and laying out the the choices that that he saw in front of us But I think it's imperative that we we do move forward And know that it will be imperfect But we will do the best that we can and I do believe that We have the skill and the capacity and the state does as well to do so We just continue to recognize people as we people wish to speak Representative black or page. I don't know who was had their hand up next The two of you just monitor that I just wanted to respond really quickly to representative donnie hugh Um You know, I have so much respect for you and your deep deep institutional knowledge I've only been here. I think it's like nine weeks now But the one thing that I've learned in nine weeks there are so many holes in the boat and You can't just throw your hands up and say well, there's just too many holes. So we might as well just sink I mean just And and there are and there are so many important things just what you were talking about but I I don't know if If you can just like I said throw your hands up and say well, there's too many there's too many holes. So why bother trying? And I know that's not what you're saying, but It seems I don't know I want to fix some holes I came here to fix some of what I was saying is sometimes we do Sorry, and it's hard to prioritize, but I'm not right. I'm I'm just saying sometimes we do have to prioritize and I At this point. I I'm not sure, you know, which I'm not saying Don't do anything I'm saying we can't we know we can't do all of it. So how do we How do we move ahead to identify right Thank you. That was all I really wanted to say Uh, I'm going to just keep hearing from members represent page represent golden and others who haven't spoken feel free to join in Yes, um one thing well several things One is what do we do When we no longer have all this federal Money's coming in. How do we pay for it in the future? Okay, that's one issue Um, right now we looks like we'll have plenty of money to do lots of things, but Whether we can extend that beyond who knows Yeah, the other issue is this This issue and and I believe firmly we should do something other although uh The chair's uh comment, uh where he said that we should You know put out a policy statement, you know where we want to provide access But this is an agricultural problem. This is a migrant problem. This is a um an undocumented problem I don't believe And I I I'm sorry if I alienate some people, but I don't believe it's a race problem So thank you And I'm going to suggest that we As much as that's an important issue that we Try to hear each other About how to move forward on this at this time uh representative goldman Thank you. Um, I really want to echo what representative donahue said. I felt the same thing It's like wow that is really amazing that they put together this bill and why don't we do that in health care? And really looking forward to an opportunity to that conversation once we get through our You know crossover kind of thing. Um, I would really like to support this bill writing a bill that I guess we can implement in 22 given the structure But I would also like to look really hard at some kind of bridge. I'm calling it a bridge so that These people the people who would be affected that we've heard about Can't get the care they need in this moment. So That's what I'm hoping where we can land Okay Thank you Representative houghton I'm hoping you can hear me. Okay. Yes. I think we can Okay, so just a couple of comments. I fully support us moving forward with a solution On this important matter and as someone mentioned earlier how this affects the whole system Um, when an unborn child or child does not receive the care they need in the early years We've all talked about social determinants of health in this committee over the years and That's that's what we're looking at here The other thing I'd like to say is I agree with ann with the frustration This committee especially and worked hard last year and the years before that On trying to find a solution For the family glitch and those that fall between the cracks And I think we as a committee just need to still be committed To finding those solutions as we move forward, especially with this new administration So I don't think we will we will leave them behind for long Um, the other thing I want to comment on and this is coming from a small business owner It is extremely difficult to offer health insurance to employees as a business owner And I look at these farmers as business owners providing crucial piece of Food to us two of our monitors. Um There is the the um, what was talked about earlier within the police having to pay in it is I'm just gonna say one last time is extremely difficult to provide insurance as a small business owner. Um And I had another comment, but I didn't write it down. So I forgot it. Um, so and oh my other comment was I completely agree with the fact that our systems and policies have made this an issue And it's an issue that needs to be addressed immediately But I also think that our state employees, especially diva Have and are working beyond what any limits we thought would be put on then or they thought of them when they took the job and We should not say that that's a reason for not moving forward But I think it needs to be part of the discussion as we discuss how we move forward in that we You know, I would love to put a bill in get it through Um with a plan of process of how it's all going to move forward But a piece of it has to be understanding that that um, we are still in the middle of the pandemic We need to get these people insurance. We need to ensure that our same employees also are Are not working, you know an hour's days Thank you, uh represent Peterson. Yes. Thank you. Um I am for this plan As a as a Christian and I like to hopefully think of myself probably all of you think I'm even coming in here But I I'm for a plan like this. I think that it's important that Mothers have the ability to have a baby in a in a humane and safe environment As long as it's as long as it's um Directed a little bit. Um I thought we heard during testimony that a number of the children the existing children of undocumented Add insurance I don't know that we need to cover them again. I don't know. I thought I heard that Yeah, and so if we craft something that um covers Mothers prenatal care up through birth and beyond and then now the child is At a u.s. Citizen eligible for all the things I think we have done done a Good thing The concerns I have of these though and They come from the questions I asked I'm very concerned that You know undocumented folks from new york could drive over the bridge Someone, you know a number of mothers and and access our system if new york doesn't have a system Same with new hampshire same with mass same with main Could be When you think of the money And what they could save and the health Would we now have an influx of 22 becomes a hundred and twenty two Just a thought I don't know if it would happen, but it's just a consideration The other thing do our Are we taking care of all the mothers? Of families that are here in bremont the same way are we are we giving Um these folks something that our own folks that might have lived here for a hundred generations Don't have Just a couple of considerations. I You know, I I think we need to care for for these folks But but just a couple thoughts Of of making sure we're in the framework and have narrowed it I I wouldn't be in favor of something. It opened it up full blown to every single health problem that everybody had. I just That's a lot. So that's my thoughts Okay Um, Mike, could you have something to add to this discussion at this point? I just very briefly. I just want to report that both new york and massachusetts do the Uh pre-natal care expansion And main as well I believe main does as well That's good to hear Yeah, so we'd actually be joining them They might be one they might be concerned about us in the meantime Sending people their way Um So I see your hand representative hodan, but I'm assuming that's what is now being called a legacy hand Okay Are there others who wish to speak who haven't spoken Based on what I've hearing I I hear a pretty strong Consensus to try to move to craft something To move forward I don't think I'm misreading what I'm hearing. Uh, I think there's some some questions and concerns being raised about the scope Uh, but I hear pretty strong support for doing something particularly around the pre-natal care and childbirth And from numbers of folks to support the health care for children who are here but not born here um I see representative boroughs And so I'm going to let's hear from representative boroughs and anyone else who hasn't spoken And then I'm going to we're getting to that hour where we need to stop because we have another issue in front of us Which I think actually will go faster Then or may but who knows and maybe we can return to this still Uh, and then I want to be thinking with legislative council to craft something on our behalf Uh, representative boroughs Thank you. Um I have a little receipt on my desk that says public health reflects the public and uh I so I am in favor of this But I'm also thinking about yesterday's testimony and the number of mothers who were hidden by by, uh our institutions and and systems And I'm wondering how It seems like such a big barrier to It's one thing to Put into place a system like this, but the trust issue seems like such an enormous barrier to me um and rightfully um, you know, we've heard testimony to that effect, but uh, but I'm wondering how how that can really And I'm not saying this in the context of not supporting the bill I 100% support it, but I'm wondering how we can how we can include the trust barrier in In all of this Can I can I try to can I try to speak to that briefly because I I and I don't feel like this is a full answer um We have some experience in having trusted Community partners. I'll call them trust trusted community partners. We know that in terms of outreach for vaccine uh, dr. Avila in fact, I think uh Has has established a program of and I don't I'm not going to have quite the term that she used But reaching for people who are trusted community members In order to do outreach around the vaccine issue We have clinics such as the open door clinic the clinic through the uvm medical center Again, the name is escaping me, but there's we heard testimony from these folks. These people have established Probably the high some of the highest level of trust. We have migrant justice which While some people might not agree with all other political point of view has has established high levels of trust And can assist In helping people make connections So I think we have we have we have some things we can build on and and we've and we've used that And some of the we've used some third-party intermediaries in terms of providing the stimulus checks in order to bridge the fear that Many of these folks live with on a daily basis and we know that that fear is real because Our systems have been flawed at times and people have Uh in reaching out for even a driver or non-drivers ID have suddenly found themselves In a situation with the immigration authorities that they had never anticipated But I think we I think there I think there are ways that we can build and use Some of the systems that some of the folks and trusted partners So I I think I I don't want that to be From my point of view A reason for us not to move forward, but it but it's I think it's a very real concern Person pierces that you have a hand up again or is it? Yes, I do Uh A few things I I kind of forgot to say in my testimony or in my discussion Someone else mentioned it here might have been a representative page or representative potent. I I really believe That this is a federal issue in the end. It seems to me that You know why a state's picking and choosing this stuff It probably is a more of a federal issue and the other thing I was going to say is I don't know what the stats are and it will use 22 pregnant mothers as a as a guideline In the past number of years of mothers having a problem And where they haven't gotten care. So I only reason I point that out is I don't know that This is An absolute emergency situation. It must be handled this minute. In other words They've been getting something And I think we should craft something that we can live with And and that's good and and not rush into it if if that means The things I've done right. That's all You can't hear you I'm sorry. I quit comic. I was the one that Talked about federal and I just want to be clear with what my intent was It would be really wonderful if the federal government would come forward with a universal health care plan They have not Hopefully with this administration and what we're hearing that has come out of this recent act We will You know have some more tools in our toolbox to help our carbon motors But I am not saying I will wait for the federal government to fix this issue. I do think we need to move forward. Thank you Thank you. Okay. Um Well, I've invited everyone to speak and uh Representative pierces their hand up again No, okay a legacy hand So, uh I I'm taking from this that And the reason I the reason this is on our agenda today is because crossover is tomorrow And if we wanted to move something about this Ideally, I mean it doesn't it could be done after crossover But if that would then preclude any likelihood if something were able to keep moving for it to keep moving And so my hope would be That we might See if there's some language that we could come to some general agreement on or or something that's In agreement for the vast majority of the committee somehow or all of us Uh that we might be able to put before the committee before our deadline tomorrow But we have other things which i'm going to say I i'm not going to apologize H2 10 is our top priority from my point of view to move across the line But with this I think that Let's let's golden. I see your hand up one more time. Uh Let's hear that comment and then i'm going to suggest we take a break Even though I think we have other witnesses scheduled like I don't have it right in front of me But let's take a break and then we'll come back and we'll turn our attention to 104 in the meantime I will We're going to take a long enough break so that I can actually have a brief conversation at least with Jennifer carby who has been thinking about this and listening in to our discussion this morning And who Whose talents we may turn we not may we will turn to To try to help us find a way forward with Committee bill or language to that effect represent golden I just want to say that you know as I've been following the federal For a process they work late late into the night sometimes I pass bills at 11 pm. I am willing to do what it takes tonight Whatever from timing for these bills to do the work we need to do to get it To cross over so I just want to say that's my position. I'm willing to work as hard as required to do this Okay, thank you and I will I will uh Take advantage of that We'll see if other people will be here with us. Okay, so let's let's take a break. This is I think this has been a fruitful morning