 So what we have on our agenda this morning is amendments to extra reading and to have a specific amendment that I think we have protected and is available posted on our website or on our web page for representative Cooper and others, some of whom are members of this committee. So good morning, Mary. Morning. Just for the record, then walk us through what you have. Yeah. So good morning, Representative Mary, Cooper from Montpelier. And what I have before you are four proposals of amendment to your bill, S203. That really came out of a conversation when you were walking your bill through appropriations and we were chatting about what it does. Several of three of them I think are quite simple. So the first is simply changing the legislate, the reader heading where it says your bill said legislative intent and oversight has been added so that in the second section where we add a request that the Secretary of Human Services report updates on what's going on with the renovations at the retreat and the planning process is going on with UVM to develop the level one beds for mental health patients. So we just thought that there should be some, I'm proposing that there be some legislative oversight and a check back in that process. So that's kind of one idea there. Just tell us what you're doing. The next proposal of amendment is the third, which is at the bottom of the page and going on to the top. One, two, and three are what your committee said. Four is what I'm suggesting be added, which is that if people aren't in, if the transport officers departments are not in compliance, identify how you're going to come into compliance and if they're still not in compliance, how are you going to replace those services? And that quite frankly comes from however many years of us saying, we think you ought to not transport people that way. We really mean that we think you ought to shouldn't transport people that way. You ought to follow the law that we passed. Yes, we really mean you should follow the law. And so now it's kind of darn it, do it this way. So that's what I mean. It is out of a deep sense of frustration with the handful of people who continue to not seem to be able to follow the law. If I may, I believe there have also been conversations with the Department of Mental Health that a plan of correction is something that they would support. I think we simply said something a little... Representative Hoofers, not ours, but Representative Hoofers, first version of the amendment had said, tell us how you're going to replace the services. Yes. And they responded saying, well, how about a plan of correction first? First. So I think this is just a post note that this is embedded with this particular piece of the amendment. It is somewhat of a compromise. Next year we're not compromising. And then the fourth one is where I'll probably need some help in adequately describing this. But in the fourth section proposal of amendment, we're saying, I'm saying two things. It begins with recognizing the importance of the designated and specialized service agencies to our mental health care system and the important role that they play in preventing hospitalization and emergency room use. And then the substance of it is at the top of page three, which suggests two things. One, initially, now, use the same model that is being used to develop rates that you all have discussed for the Brattleboro Retreat. Use that same model for looking at how the designated and specialized agencies should be funded. And provide that information to us as part of the budgeting process next year. It doesn't say build the budget based on that, and that is the budget. We're just getting the information. And I can say as the person who's responsible for a portion of those budgets, I am totally out of my ken in being able to do any sort of analysis of their budgets. And we need some sort of other competent agency providing that sort of oversight, which is actually maybe more to the point of the second part of this amendment. But we need a better way of getting into what the DA budgets are. It's just beyond our ability to manage it the way it's running now. And that is then to the second one, which is to suggest that the process that is going on now should include an analysis of the mental health portions of the health care system, and that that should be incorporated in that evaluation process with the long-term goal of bringing this underneath the Green Mountain Care Board. And so there are all sorts of interesting policy questions that we as a body will need to answer as that moves forward. But to the point that I was making, right now we don't have the capacity to do the sort of careful analysis of those budgets that they deserve to make sure that services are being properly delivered. We need help. We've had kind of informal, we different members have had informal conversations about how to accomplish that. And we keep seeming to come back to the Green Mountain Care Board. So I've brought us to the Green Mountain Care Board here. And I would really appreciate help in making this better. It sort of accomplishes what we think it ought to be doing. Can you say again what you think the timeframe is as you're talking about particularly the review of budgets? So it's a long-term timeframe and I believe that it would be a five-year process. I think it's a six-year process that we're engaged in now. And we're in what I have heard described as year zero is kind of the planning and then the rollout I gather is a five-year process. And so I'm presuming that at the end of this we would be, if this is the path we choose to go down, DAs and specialized service agencies and the delivery of these services would be under the regulatory oversight of the Green Mountain Care Board. So there's the leaders. Okay. Can I just say I should add, I've sent copies of this to the Department of Mental Health and to my DA just as a way of checking in with this amendment. I haven't heard back, actually. I need to read my email. Yeah. No, I have nothing else to say. Okay. Yeah. So if you'd like, Mary was asking for help. I did help work on some of this and I can give a little bit of background on this section one and two. Okay. So let me say that, so we have some time here and I understand there are some other folks that wish to be heard on your amendment and as I, it's important that we take the time to actually think through what implications there may be. I say this having put my name on the amendment. I've put my name on the original amendment. It said revisions. I'll be happy to sponsor as well. And this is a section that I think deserves a little more consideration. So I think the whole community needs to be able to raise questions and hear from others. And if I may, in fairness to the others who put their names on the amendment, it grew out and we circulated it back to you, but it may have grown more than people had appreciated. Right. I think in the press of other people's attention to others, I'll speak for myself and probably others, seeing that there was a revised amendment did not necessarily capture the attention. There's some new elements that were not better substantial than working together. Great. I'll hang with you. Yes. Thank you. I mean, this is a piece that probably people need to know in terms of before restifying. Right. Because there are two pieces here that, particularly the first one, that this committee has not heard a lot of background about because I was sitting in on Senate Health and Welfare and they got their presentation from Aldo Bay. And I think he didn't go into that as much with us on this, how they're looking at the rate for the retreat. I'm not an accountant, so I'm not going to use the right words. But he was basically explaining, and the retreat was explaining, that in order to, you know, they've got staff that they can't hold on to because rates are better at hospitals and so forth. But in order to meet their needs of sustainability, the only way they can really address it is looking at the whole, their whole costs and their whole revenue and saying this is the gap and so we need rates that fill that gap. And there were questions raised about isn't that the problem the DA's have and the answer was, well, yes. With them, we look at the individual services and what the rates need to be to reimburse those services. We wouldn't feel comfortable knowing that they were really addressing, running tight budgets if we just said, tell us your total costs and tell us your total revenue. So we can't do it that way. And so members of Senate Health Welfare and in fact Senate Appropriations asked, well, wait a minute. You know, you're using a different standard. So the concept here was to take that and say, well, we think you ought to identify what it would mean if you looked at the DA's the same way that you are now presenting and asking the legislature for how to address the retreat sustainability. So that's where that comes from. That's what it means by saying the same model as the retreat. It's what's being presented this year to the legislature. And the second part, we heard just briefly from Michael Costa a few days ago about this Medicaid pathways, the all-payer waiver. One of the things that identifies is over the five years there's supposed to be a pathway for all of the Medicaid services that are not Medicare Part A and B, therefore, that are not in the all-payer starting waiver, that they're supposed to all end up integrated as part of the all-payer waiver. So this is something that's a work in progress. So that's the reference to the Medicaid pathways that part of the plan, if you're really following what the goal is of the all-payer model, is that the budget review process would come under the same board that's doing ACO reviews and hospital budget reviews. They can't actually approve budgets because that's a legislative function because of the Medicaid money, but they can review and they've had a trial run of that with Howard Center a few years ago that they were asked by the legislature to just do a kind of sample review. So that's the idea behind that. That's what that means by saying and that's what we're talking about. It being not something next year because this is a process as part of the all-payer waiver. Can I just say I'm not sure that's clear. I think one might, one could include that it's going to happen as opposed to meeting legislative action that's going down. I'd like to transfer the responsibility. Right. It could be some wording. Yeah, not too long ago we addressed the financial situation of DAs by legislation and doing some pay adjustment and stuff like that. Do you know what the current financial situation is for the DAs of this would impact them? I mean, wasn't that long ago how much of a change has that made? Changed the situation at all. So we, what, invested I think it was less than nine million dollars or as much as nine million, eight point something in the system last year so which comes into the current fiscal year and that was to raise everybody's rates to $14 an hour and if that wasn't enough we said focus on emergency services. I understand that in fact they were able to raise rates pretty much across the board to $14 an hour. It did not go further than just that and you may recall that last year when we invested that money we also asked that the Agency of Human Services report back to us on the additional investments that would be necessary to accomplish essentially the stabilization of the system and we received a report back that said we really perhaps I'm being unfair in my synopsis but they essentially said we can't tell you what that number is there's a lot of different things that we need to take into consideration I need to look it up but I believe there was supplemental information that was provided as part of that report that said something on the order of maybe $70 million was necessary to bring everything up to deal with wage compression and bring the care providers in that system up to I don't know if it was the hospital levels of pay but their peers within the private system so we didn't address that bigger issue can I just add a piece of what I'm remembering from what we did last time was that what the 8.37 million that was printed was considered to be stage 1 of what was then hoped for intended to be stage 2 stage 2 is not reflected in the appropriations in the budget of the House at this point and probably the chair is here to make me a question again what I've noticed is whenever we bump into a situation in healthcare we're always quick to say let's put it to the cream up care board I'm not sure how much capacity or what capacity the board has why would we not look at AHS AHS to look at I would suggest that there is a need for an independent review of that if the right now we are the check and the balance of that system between the legislature and the executive we do not have the staff to do that sort of analysis so I was looking around for who the other people are who are independent of the system the administration has a position that the secretary of the agency of human services supports and part of that has to do with funding goals and so there's not an ability to for that body to really dig in and report back to us on what the actual needs are of the system when you're dealing with that political imperative which is certainly their prerogative I'm not questioning that I just desire to have an independent third body that can look at it and if we were properly staffed to provide that service I would say that's our job and that's the way we're organized but we're not there I have a lot more questions and I'm quite convinced that we need this particular section so I was just going to say in our bill already we had a section of the report back from the agency to next year saying make recommendations for how we can be dealing with these budgets as part of the health care system as in the way that we deal with other health care system the hospital and so forth this would go a step beyond that because we're saying bring back recommendations in our bill and this is saying so maybe I missed something but I know that Green Mountain Care Board reviewed Howard Center budget a couple years ago and I'd be interested in hearing more whether all DAs are really interested in submitting themselves to this process because I know it's quite a rigorous process in other facets of budget review and I think that's something to keep in account especially since a big part of the hospital budget review is to keep costs down and pressure on the rise of these hospital budgets and here I think nobody would say that DA budgets are growing particularly fast and that's the opposite problem they've said we would love to have the same rate of growth that the hospital has squeezed down I might say that I think as I've reflected on this just over the course of this half of the biennium for a longer but particularly in this half of the biennium we just in our larger bill we are embedding in other statutory references references to ensure that we actually follow through on our commitment to parity of mental health as a part of healthcare and I think that increasingly when we have the Green Mountain Care Board a portion of healthcare and if we really think about healthcare then it increasingly makes sense for us to be thinking about the Green Mountain Care Board having that ability to actually look at all of healthcare because we're continuing to segregate mental health from healthcare and I think we do have responsibility to look at whether the resources is there a timeframe in which that could be accomplished etc and I think Ben your point is right on the point because in fact when my recollection was from the previous chair of the Green Mountain Care Board now Secretary Hovey was testified here that they were stunned to discover on what a how narrow, what a shoestring they were operating on that they were used to seeing X number of days of cash on hand and X amount of reserves and suddenly realizing that there's nothing close to that in the system that is an essential part of the healthcare system in the state of Vermont and so I think the dynamic might very well be a different dynamic when you actually get to see the entirety of the picture so but I think you're right all I was trying to say is there's a fundamental difference in the role as opposed to cost containment versus more appropriation which comes to the literature I think their role is also to have a sustained system and not just to do cost containment so it's like to have an effectively appropriate system but cost containment is absolutely a piece of that and so I'm going to so maybe a response to your question and then I understand there are others who wish to be heard we're going to have to figure out how to manage our time because but we have some more time so Julie Tesla is here from Care Partners which represents the designated agencies or is a cooperation or consortium of the designated agencies perhaps you could respond to the question which represents I suppose particularly about what position what would the DA's either as a group if there is a position respond to the idea I'm going to be about Care Board review the DA's and specialized service agencies which are not one of the same thank you for the opportunity to speak Julie Tesla from on Care Partners we haven't had discussions with the Green Mountain Care Board so it's a little hard to speak about that without having had the discussion but yes we have definitely talked about the value of having the Green Mountain Care Board review our budgets and for all those same reasons that we've been raised that we really feel like our budgets are very tight that we're part of the health care system we should be looked at as part of it the all pair model does lead us on a path to be a more integrated part of the health care system and in the interim we've gone to the Secretary of Human Services and said including the business manager at the Howard Center who went through the analysis and said at least let's start with an interim process that looks just like it you should be doing the same review and understanding our budgets in the same way on an annual basis so when we sign our master grant and we say we're getting this money to do that you know what we're spending the money on what our costs are increasing what our review are what our key performance indicators of where we are financially what cash on hand or debt equity ratios things like that and then let's look at what we can do how many people can we serve what's the scope of services what are the outcomes and expectations that are reasonable with the budgets you've given us so we brought that proposal to the Secretary and we're working on that so it's a work in progress and the Senate Health and Welfare please come up with some language for this section so we've started that conversation with him I emailed him at 7 o'clock this morning language I said can I share this and he said not till I look at it but basically it says please look at all this please work with us on it make this part of our annual process we want to be transparent, accountable and we want them to understand that if we don't get increases we can't keep providing the same level of service because we are over $70 million short of what we really need for staffing so how do we set reasonable expectations and I really appreciate the work of this committee to say it's our intent to invest in the community mental health system because that's going to make a difference in health care and it's part of what we do my understanding from my conversations with the Secretary is that he's not sure there is a will to make those investments and we have a capped budget and tough decisions have to be made and as the House did not put money in for workforce I can't fully argue with his perspective that maybe the will is not there to make the greater investments but it is interesting to me that we put a lot of there's been a lot of discussion about prevention and health promotion and the importance of that and that's in part of what community mental health does it meets people's needs immediately at the community level in schools and communities so it's hard to see an investment making investments in the symptoms and the acute care when we could be doing more up front so we are definitely open to better analysis because we feel like we're really at the edge because in part of it we take responsibility for when we don't get increases we haven't been saying sorry without some kind of inflation we can't continue to do the same level of work we somehow suck it up and do that but we're at that edge we can't step back anymore and I think we have actually articulated in language last year which was not acted on which was saying that rates should be established and if they cannot be established then work that needs to be identified which is no longer going to be required I think that's this is another way for us to I think be on the same page as saying it's not reasonable to not increase rates and increase adequate funding and have the same level of expectations as hard as those decisions may be absolutely and we do we really appreciate the legislature's involvement in this committee in particular in raising the issues and feel like that's added balance to the picture as we move forward in making funding decisions so Mike is that a question for the witnesses? yes, yes, eventually I think budgets in general are tight when you talk to hospitals or whatever and staff shortages exist in the DA's and hospitals but one thing that you said the lack of will I'm not sure if it's so much a lack of will to do the funding and those funds and resources but my question over the last five years what is the rate of growth for DA's? well there's if you could separate caseload and inflation I think that's really important because in developmental disability there's a growing population and it grows by about 8 million a year so if you and we're about a $400 million system of care so if you look at both caseload and inflation you would probably get to 3% or something close to it but if you take that new caseload out it's been we've actually had rescissions and some increases so I can't do it off the top of my head but it's been very minimal and even last year with that workforce investment $8 million is a lot of money but over a $400 million system it ended up to be 2.1% and it was very targeted state employees got greater pay raises and there were health benefits and there were other things covered like IT systems so out of that 2.1 we actually had to do more and so it kept us afloat and it certainly helped our lower paid staff and we can say, yes, raising a minimum wage really helps those staff a lot and helps with recruitment and retention but our gaps with the other staff actually grew so that you can go to DCF where there's more than the same job and a designated agency and so most of our staff when they're walking out the door and we say, why are you leaving the majority will say because I really can't afford to work here I've been working two or three jobs I can't handle it anymore I can do similar work and earn better pay and other forums whether it's state employment or a hospital or a school or other places most of our staff will love their jobs it's tough work to have to do two or three jobs to maintain it so we're not going to be able to get into the depth of this this morning this is to look at what the amendment and whether or not this is the language to look forward specifically this morning I'd like to turn to if there's a comment that the Greenmont Care Board wishes to weigh in since you're referenced in the amendment Dr. Kevin Mullen, Chair of the Greenmont Care Board and basically we have more questions than comments basically I understand the theory behind this and I think that those that were involved in the look at the Howard Center felt it was a productive use of time wearing my former legislative hat I have to ask similar to the questioning that was put in place earlier in that in hospital budgets we actually control the rates so I would hate to see an extensive process set up where we would go through and analyze all these agencies and then notwithstanding things just carried on in the same manner in terms of their funding so that's something I would have to look in the mirror on I would just say but if the point is that there wouldn't be any changes in the funding I think it would be a terrible waste of our resources to go through that process and I will say that and I listen to your argument Mr. Chair it's very consistent with what people talk about what a global budget should contain and it really is the whole host of things and I want to throw out that for example in home health we have a hospital in one part of the state that had to meet the payroll for the home health agency strictly because choices for care or state program isn't funded in a way that they can sustain themselves so I think you may be opening the door to other things in the future but as far as this particular amendment it really is just a reference to whether or not we should do it so I don't have too much comment there but one question I would have for Julie is everybody on the same fiscal year and if so what is that fiscal year we're on a July 1 fiscal year but there's discussion and payment reform of putting us in the same calendar here as the Alpera Model ACO so that we would be consistent so either one of those would be a slightly different fiscal year than the hospital budget because if we had to do everything all at once, forget about it you'd have to give us quite a bit more staff but if it could be staggered a little bit it sounds like either one of those could be so it really is just questions for you there are many things that would need to be worked out before this does not implement I mean I think that to be clear and that was my concern to be honest when I first saw the new amendment I was immediately concerned as the Green Mountain Care Board been insulted about this well I'm just saying so that and part of what needs to happen is that there I needed some assurance that there was not an immediate impact and that it's more looking ahead with lots of opportunity both for the legislature to weigh in further and for the Green Mountain Care Board to weigh in further as well as the agency at a minimum the word plan only needs to be proposal so develop a proposal I think everybody's on the same page okay thank you so I'm going to suggest that we have this so S203 is on the floor this afternoon there's time between now and there's time between now and then for any language to be modified there's a very least there's some language modification that could clarify what it is that's been articulated here and I think there's an answer looking for it so I'm going to suggest this that this committee not try to take any action on Representative Hooper's amendment at this time but that we ask that you and perhaps Representative Donahue and others review the language to see if there isn't a way to make it more clear that this is clear that there's not an immediacy involved other than to be looking ahead and planning or that in fact there I'll just throw out from one member's point of view maybe there is some piece where there is actually submitting of information for informational purposes only and not necessarily for analysis because there are I could imagine either as part of this plan I should maybe not overstep what their plan might be but there could be submissions on an informational basis that don't require a lot of additional staff work from the Green Mountain Care Board but that would in fact begin the process of providing the designated specialized service agencies information to have that holistic system because I'll tell you I am more and more persuaded and understand what the chair of the board has said that until and unless we have a full picture of what we're talking about in terms of the health care system we're wrongly focusing on just a significant portion but not the entirety of the system and I think we need to if we're going to be serious about working with the entire system sustaining the whole system because it's not just downward cost it may be downward cost in one part of the system and it may actually have to be holding another part of the system that's I think we need to be moving ourselves in that direction to speak for myself so if that seems agreeable to our committee I'm looking around and seeing some and I would welcome any committee member to be in with Representative Hoover in terms of seeing if there's language that my goal, my hope would be that we would find language that certainly majority of us, if we don't we won't support the amendment but I would hope that we can have language which goes in this direction but that's more precise okay so let's put that piece to a close for this moment and then we'll come back to it we're going to need to come back to it before the floor and I think we I arranged well we will come back to it before the floor yes we will, we have to because that's what we're going to do or we'll rearrange the floor that's also possible okay so let's shift gears we have a number of things on our agenda this morning I think I'm going to turn to what we're going to do is I'm going to committee to hear the setting proposals of amendment to 696 okay so let's just I'd ask committee members to stay put so we've got my wires crossed a little bit in terms of what we're doing when so it's important it's important for us to have everyone present for our committee discussion and I think what will be a light for you both today on a very important issue so what we have in front of us today is S-53 the Senate and as we we've taken testimony we've walked through from the beginning I said to the committee I want us to understand both what the Senate has said to us and I want us to understand what the Senate Health and Welfare Committee passed out the Senate Health and Welfare Committee as well and so we've had the opportunity to walk through S-53 and pass by the Senate S-53 as its command of the Senate Health and Welfare Committee and there are differences that are significant S-53 as passed by the Senate features a more of a continued exploration or study of universal access to primary care while S-53 as passed by the Senate Health Welfare makes a commitment to public and finance universal primary care and I think that's in some ways the crux of the issue in front of us we've heard the fiscal impacts of both pieces of legislation and quite honestly I think it's a little unclear I don't think either of the fiscal analyses are full part complete and so whatever action this committee chooses to take will necessarily go to the House of Appropriations Committee for God's conclusion and we will be looking to them to sort through issues, fiscal issues but particularly the impact in the 2019 budget which of course because of the way the Senate and the House we moved the budget first so we assume that the Senate is anticipating based on as they passed it having provisions in the Senate proposed we'll have a provision for that but we recognize there's nothing in the House budget to support either version so again there are many moving parts here and I think we've heard from many to be quite honest I don't know everyone who's in the room but I recognize the numbers of you and I've heard from and I think many of us have heard from folks who are in the room we've heard I think the whole committee has heard from strong voices of advocacy asking us to consider not just the Senate passed version but to consider reinstating the Senate Health and Welfare Committees version and so I think that's the choice point we're at and I think that we need as a committee long debates I think we concluded I think we're at the point where we need to decide in order to move forward and so that's where I think we are at this point I'd like to make a motion I'd like to make a motion that we restore the language of S53 to the version that came out of Senate Health and Welfare I'll second okay so we have a motion to restore which essentially would be to substitute to substitute a strike all version for the Senate passed version okay to restore what the Senate Health and Welfare committee did we have a second for that can I explain speak to your motion and then have a representative on it so Senate Health and Welfare which is the health care policy committee of the Senate worked on this bill for over a year with extensive testimony and deliberation and they created a proposal that looks at how we can make a transition from our current system towards the vision of Act 48 through a process that engages various stakeholders in the creation of a universal publicly financed primary care system for all of our monitors the results of that work was replaced by an amendment from appropriations in the Senate which is their money committee and that ultimately passed the Senate policy committee should be making policy not money committees and I propose that we support the work of our sibling policy committee whether or not this bill survives the rest of the process it becomes a law I think today we need to make a decision that makes a policy statement and what statement should we make I propose that we take a step in the direction of the promise of Act 48 by restoring the language of the bill to the version that came out of Senate Health and Welfare yeah so I actually think there's tremendous value to an approach to curbing healthcare costs that starts by ensuring everyone can get early intervention that can prevent higher cost healthcare later and particularly by doing it across the system not through small inequitable chipping away co-pays for specific services it would also start us on a path to more equitable access to healthcare regardless of what coverage you do or don't get from your job which is something I have consistently strongly supported in concept not always as a practical ability to do it because while almost all remuners have health insurance it's an incredibly inequitable cost balance the very poor through Medicaid and the very wealthy through a very small percentage of their income going towards healthcare pay relatively little or nothing but we know very well that there are people in the middle who have incredibly high premium and co-pays that are a barrier to care the problem is that for better or for worse we embarked on a healthcare reform initiative right now that makes huge alterations to how money flows through the system I supported that very reluctantly I remain not confident about its potential for success but it's very complex it creates huge pressures on the system in order to focus and sustain energy on it to take on a second major overlapping restructuring at the same time I think does doom both to potential failure and so I can't support going forward with this either version even just studying it further at this particular point in time I don't think we can be doing both at once so I don't support going forward with either so I thank you Brian for your motion and I'm going to support your motion and I've been sitting in this committee for a number of years and have now this will be our third attempt at enacting some form of universal healthcare and I have to say it's really frustrating to be in the position of considering this kind of incremental approach opposed to taking on the whole healthcare system but I am critically aware that there are so many Vermonters who either are paying through the nose for the healthcare that they have or are stuck in jobs that they would rather not be in because it provides them with a healthcare benefit and I feel like we owe it to Vermonters to say that yes we want to move forward with finding a way to do a universal healthcare cover so I will support your motion the senate finance committee took a look at the finances of this and it came to the conclusion that with 20% of the entire state spend being on healthcare that we had to move a little more slowly a little bit more pragmatically and I don't think the original version took into consideration all the money that it would take or even among our testimony the cost for this would vary between 4% we were initially told and by the time we were even done deliberating on this it was already up to 7% or 8% of the entire healthcare spend so I don't think this is really well thought through and it doesn't get to the root of the problem of healthcare and the root of the problem has more to do with a socialized aspect of healthcare and this that it's very expensive although I agree everyone should have healthcare we live in a very free country and I think that we should be promoting avenues that compete against one another right now we have quite a few monopolies within the state whether it be one ACO or two hospitals running the entire state very few private practices left and we've created this monopoly we have only two insurance companies and I think we can go down a different route which will create more competition not less I wasn't going to say anything but listening to everyone this has been one of the most difficult decisions I've had to make I agree with Sarah and Brian wholeheartedly I come from a family we have a small business we have a healthcare crisis in our family that will be paying for the rest of our lives so I see both sides of having a universally publicly financed system but at the same time I really appreciate Ann's words in that the state made a commitment for a process forward and we have some people in this room and many many other people who are putting everything they have into making that system work and to put another system change on top of that is very very difficult the other thing I've always I've struggled with the last two years here is we chip away at everything instead of changing a whole thing and so I will be supporting Brian's motion because this is one time where we need to chip away and we need to figure out how to do it I also support the motion and I do hear the viewpoint where we are looking at both I think we need to look at both because if the all payer model does work what will we have in this place and we need to the people of Vermont need healthcare and when I think about the all payer model it comes from the hospitals down to the primary care and the funding flow whereas I believe that funding flow needs to start at the base and primary care is the base and it feeds up to the hospitals and by doing that all those components of are you ill now I can't afford it now so I'm going to wait and you are much worse at the time you do seek the care are the pieces that drive healthcare costs that much further and by allowing everyone to go in and see a primary care I do believe that we may find there is an uptick in the cost at the primary level only because those people that have been resistant or unable to access the care will have issues that are more extensive initially but going forward I think we take that away and by treating it at the preventive level where it belongs we prevent those long term higher costs that we have when people don't have care and so that's why I support this I'm going to support Brian's motion and thank you for making it that when I was elected in 2014 the primary issue that I ran was trying to move our state to a publicly funded universal care system and I don't think I'd even take an office yet when that option pulled up the table in Vermont and acknowledging Lori's frustrations I think we are going at this in an incremental way and I view this as the most cost-effective way to go at this incremental way where our healthcare dollars are most cost-effectively deployed making sure that people have adequate primary care and I also want to acknowledge Ann's points because there are things that I'm concerned about as well but I am going to take a little bit of twist on it because while I'm concerned about the issue of can our state take on a major reform for the all-pair model while simultaneously taking a look at universal primary care a concern that I have about the all-pair model is I feel all our eggs are in that basket we are depending on the all-pair model to work to get to what I want to get to at the end of the day which is a publicly financed universal care model and I'm looking for for different baskets instead of just having that one basket with all the eggs in it and an incremental approach moving down the universal primary care road gives us an additional way to approach that so thanks for that promotion well our mantra this has been it has not been a hard one for me because our mantra has always been with the healthcare the right care at the right place at the right time right care I think this is the right care I do believe this is you just see all the people in need out there and you know this is the right care the right place if there's any place that's going to do it it's going to be Vermont except in my heart I really know that we need a larger platform if it's going to be publicly financed and we have to be nationwide or even regionally the right time this is definitely not the right time for Vermont we have two major health reform efforts that will be going which we do both and we will get nowhere the all-payer ACO model is basically a little more than its first year the layer of something else as complex as this is just not the right time it would just Vermont is even though it's hard to believe with all we get done in Vermont Vermont is a small state and there's only so much money and so many resources to go around basically on the right time I'm going to be voting against anyone else who wishes to speak I guess I might as well you know the only thing I would say I would be much more likely to support the Senate finance version just because I think it does a better job of distilling what the problem we're trying to solve is and then taking a broader look at how do is the best way to get people the access that they need we've heard from people throughout the system that there is an access problem we're dealing with a certain segment of our population that either for financial they can't afford a copay or both getting the base level of primary care that I think we all believe we should do everything we can to try to get them there so I would have much preferred an approach where we take a holistic look at saying we have this set population that we're not doing a good job of now how do we connect them and are there different types of innovative ways that we could look at to really reduce this problem of access that we're seeing I think many of us are working with the local hospitals on the crisis in primary care practitioners I know in the Bradborough area we're down 13 practitioners and we've got another one retiring so to take on a primary care initiative without having the the the the primary care initiative without having the underpinning support I think is extremely difficult to do and I also agree with Anne on the parts of trying to operate two systems simultaneously I think we really need to address this primary care issue that we've had with physicians within our states I'm not comfortable with this we need to say a few words more first let me express my appreciation for the committee and how are we arriving with this outcome this committee has committed itself to healthcare for Vermonters and from every point of view I don't question for a moment the individual commitment that each of you have to having high quality accessible healthcare for all Vermonters and I think we've demonstrated in a way actually in a way we demonstrate by even our conversation here today and what we've done previously where there are times when we have come to full consensus in this committee I think we have a good and proud record of moving initiatives particularly around prescription drugs which are very much in my mind even as we make a decision about this I went to a meeting yesterday outside the building I had nothing to do, people didn't know I was the chair of the healthcare committee so I came on a ride home and they said could you give me a ride I said sure what came up in conversation was healthcare what came up in conversation was the unaffordability of their healthcare what came up was they're having to make decisions about not accessing healthcare to the detriment of their own well being and in this particular instance much to my surprise they talked about the possibility of having to relocate outside of this country in order to have full access to the healthcare that they felt they and their family needed and I was stunned to hear that I did not know their history and this was a spontaneous conversation I think we struggle we've made great gains here in Vermont but we struggle with how to move forward and at this point knowing that I don't know what the path for this for our decision is here today in the building or outside the building but I'm at this point prepared to make a vote that makes a commitment and makes a statement in the direction of universal primary care because I think it also is a statement toward what I believe we should have which is publicly financed healthcare the fact that we have Vermonters whose lives are impacted on a daily basis who don't who are tied to their workplace whose well-being is in fact in jeopardy for the very reason that they don't happen to work in a place that has healthcare good accessible affordable healthcare I think it's our responsibility as a state of Vermont to create every possibility for accessible publicly financed healthcare for all Vermonters recognizing the barriers, the difficulties that this particular path creates so that's if we do nothing else here today I'm prepared to use my vote to make that statement knowing that there are it's not an easy path there's nothing easy about it and recognizing and appreciating the concerns that other committee members have expressed and I think I'm going to suggest given the business in front of us other business in front of us that we unless there's a lot more that needs to be said that we move ourselves toward the phone well first I want to thank everyone for making your policy statement because in my motion I was basically asking what is our policy statement and I feel like people really clearly made that so I appreciate that the only thing I wanted to ask just for clarity for the record that when the bill passed out of health and welfare it went to Senate finance right I'm looking at Jen because she's she could probably answer this and then it went to appropriations and my understanding is it was appropriations who amended the bill at the last minute so just for the record I wanted to clarify that the bill did make it through Senate finance without any changes right yes finance approved the Senate health and welfare amendment without recommendation and sent it on to the appropriations committee which is the committee that made the and I just want to say that because two people said the bill as it came out of finance and so not to I just want to be clear before we vote what the process was that it went through two committees and that was changed so thank you and I I realize that there is actually one amendment which I think can be made on the record and not have to wait for a new draft and I was reviewing this morning the language which I frankly asked to have available depending on what direction we went the Senate Health and Welfare Committee version says that the Senate Committee on Health and Welfare may meet up to five times and I don't know why but I think we should be included it just seems like so I would suggest that we amend on the record that in each instance I think it's just the one since it's section three that we amend it on the record to say the Senate Committee on Health and Welfare and the House Committee on Healthcare may meet and then Jen can assign us actually you can tell us what version will that change the 1.2 well then I would hope that you accept that as a friendly amendment and that it would be your motion would be to adopt draft 1.2 as a substituted amendment I think I can live with that I know it's tough okay I asked the court to call the roll Copenhagen says yes China? Yes Jinkling? No Ebert? No Brighlyn? Yes The Furt? Yes Houghton? Yes Take the motion carries okay okay thank you committee members thank you for those who have been having conversation with us from all different perspectives thank you