 Okay, so we're now on YouTube again. This is Tuesday, May 11th. It's a little after 2 30 We're starting late. The floor went long And caucuses followed the floor so to come break here. We are so we're gonna we're gonna start this afternoon with We have two things on our agenda one is the children's mental health around children in emergency rooms and so we're gonna start with that because we have our legislative counsel Katie McLoone with us and and so I'm going to Yeah, can I turn it over to you to get us started and then I know Leslie and Brian were both part of this discussion and Depending where we get to will continue and Ian has a commitment for the rules committee at three so So since we we went through that brainstorming list and had had the ideas down So I think what would probably make the most sense is to to have Katie walk us through the letter We you know had a chance to see it and made some made some tweaks and ideas, but I think it's pretty well organized at this point and Everybody can check in on whether it seems to line up with our discussion on where it should go from Friday So take it away Katie Katie McLoone office of legislative counsel, let me put the letter on my screen. Are you seeing the letter? Yep, great so This should look familiar it very much follows the template that the committee looked at I believe it was last Friday But I'll just read through it because I know some committee members. This is the their first time seeing it So dear secretary Smith and French and mr. Timon as you are aware the house committee on health care, which will call committee throughout the letter has taken testimony regarding the Prolonged emergency department wait times for children experiencing mental health crisis The committee appreciates the Department of Mental Health's Responsibility to the concerns of the committee particularly its Prioritization of children as part of the request for information process outlined in the Capitol Bill The committee believes it is important to establish a guiding principle to ensure that every moment of involvement with children in the mental health system is used to provide treatment and promote recovery To that end the committee is requesting that the agency of human services take these specific steps with the assistance where appropriate of the agency of education and Voss and then go on to list the specific steps and these this bulleted list is is in chronological order. So immediately begin soliciting input from family and peer stakeholders to help identify immediate and ongoing progress points Immediately establish the expectation that services in the community are robust enough to ensure that there is not reliance on emergency departments. By May 24th begin providing ongoing weekly reports on the manner, excuse me on the number of children and adults waiting in emergency departments and their lens of stay regarding regardless of the custody or health insurance status, including the hospitals in which children and adults are healthy. Hospitals in which children and adults are held or treated and any other critical information regarding pressure on the mental health system. By June 1st establish a target date by which the average length of stay of boarding time and emergency departments shall not exceed 24 hours. By July 1st begin to maintain emergency department weight data disaggregated by age and future policy. By July 1st proceed with establishing the mental health integration council and use the current child emergency department crisis as the initial case response for integrated whole health care health care system approaches to mental health. And by July 1st identify the best practice regarding a length of time for the assessment and disposition of patients presenting with a mental health crisis and an emergency department and the target date for achieving this best practice. In addition, the committee requests that the following reports and specific timelines for action be provided to the leadership of the committee, the Senate Committee on Health and Welfare and the Health Reform Oversight Committee. By June 1st provide an initial outline of ongoing and completed emergency action steps, including timelines for the identification and completion of action steps that are under the department of mental health jurisdiction. And provide monthly updated action timelines through January of 2022 on progress points, including the identification of new action steps, completed action steps, and the progress on medium and longer term action steps with collaboration from boss with regard to the inclusion of the actions that has taken in the timeline. Just to pause for one second before the last part that the one I didn't catch it on the first time around on the very first the going back to the beginning of the bullets. The first one we also wanted to include foster care status. Whether they were in foster care or not. Yes, yes, including the hospitals they were held at whether or not they were in DCF custody and any other critical information. Sorry, I missed that on the one you had the dread. Okay. Great thanks. And then we're looking at immediate action in this last paragraph. In the immediate future the committee requests the steps be taken by boss with support from the agency of human services where appropriate to immediately improve the experience of children who are forced to wait for case disposition and emergency departments and their families, such steps would be intended to use available resources or additional training to improve the physical and social environment and emergency departments as recommended by families. Some examples. The place where I would like to recommend some do you want me to go back. We'll go back. Yeah, we'll go back to that once we've finished that read through. Okay, since you didn't do that I wasn't sure. Okay. So I would like to recommend some examples to address this immediate crisis might include emergency department or crisis staff providing more direct emotional support activities and regular support and information for parents or caregivers. Ensuring that children are segregated from adults or other emergency department stressors increasing comfort items and other environmental improvements such as dimmer lights and expanding the use of telehealth when it creates improved patient services, particularly an expediting transfer from an emergency department where an admitting psychiatrist is not available on site. And lastly, the committee appreciates the agencies of human services and of education and boss for their commitment and bringing this crisis to a close and looks forward to hearing from them by June 1 of this year. So Leslie that the new piece you wanted to suggest was on the as recommended by families. I didn't know where you were suggesting putting that in but that particular section is this is what we're asking the hospitals so that includes the their own staff. In other words, that's internal to them. And we're saying, you know, get get recommendations from families on the outside. Yeah, I just thought it was important, you know, boss is a big organization and I wanted to specifically call out emergency room staff. So, that was my. I think that's fine. Yeah, yeah. And what I was thinking was as recommended by families and emergency room staff. Right here. No, the next family is down. So two lines down yeah right there. Yeah, as recommended by. Thank you. And the other. The other piece I realized just now as you were reading it the expanding the use of telehealth that captures exactly what we wanted to say. I'm wondering aloud. Can you clarify for for voluntary or, or, you know, with consent, because we, I don't remember. I don't think we have it in led to. Yeah, we do we put it in our legislation on telehealth. You cannot do an involuntary an assessment for an involuntary admission by telehealth. Can I suggest that I think that's getting way into the weeds on this. Okay, that's in statute so they wouldn't write. Yeah. Yeah. Okay. I just think it's, I think this is broad enough that capture, which I'm writing. So, if I may say, I just want to thank Representative Donahue who did the bulk of the work and thinking on this really wonderful to work with and thank you for that and also thank you Katie who took our mushy hand scratching and made it into something sort of reasonable so thanks to both of you. Thank you. So other thoughts. Yes, Bill. Well, I just couple of these are, you know, if you go back up to the first set of bullet points. The two immediate lease. I would, I would just flip the first two immediate lease because the first and the second one that's the one that's listed second now is the broadest, and I think we should start with the broadest expectation and just flip just flip them. Because that's kind of an overall piece. It works really well with the guiding principle. Yeah, so I think that just, it just kind of follows and I like the way it's organized with timelines on that. And then lastly, I found myself thinking, I wonder if we, I would like to suggest that we might in our CCs copy the commissioners of Department of Mental Health Dale and DCF, because we're addressing this to the secretary but I think because we heard from the commissioners or their representatives. And the people that we actually most interacted with. I think we should, in addition to copying the speaker the house we should copy the commissioner departmental health commissioner department of DCF and the end of Dale. So that they get a good point. Yeah, it would have gone directly to DMH if it weren't that they it was three. But so that makes total sense to directly include them. I really think I think it's well done. So, thank you. I just have a grammatical thing. And the last sentence should it be instead of to commitment in should it be commitment to that sounds right but now I don't have it in front of me anymore. Now commitment to a hospital is it. No commitment to there. That looks better. Oh yeah, commitment to yeah. Okay. Well, and now also hearing from them would be hearing from you. Right. I'm not sure. Oh yeah. Yeah, yeah, right. Yeah. Yeah. So again, I think the CCs just go to the two other commissioners from Dale and DCF. I'll add them now let me take down the documents I can. Was that pushing it over on another page. They have to, we may have to squeeze it up a little to not have just two stray commissioners. Go ahead, Lori. No, everyone else has their hands up. So I'll wait. Oh, oh, I didn't have I wasn't. Hold on. Sorry. There we go. Mari. Oh, that was that's a legacy. Oh, okay. Representative borrows. Now I gotta be proper. Yeah. I think that would be fine. Yeah. Should we also copy. The chair of Senate health and health and welfare. Yeah, right. Cause it's not coming from them. And we're including them in getting the reports. What Mr. Chair, what's the protocol there? I think that'd be fine. Yeah. Thank you. Anyone else. That was my question. Thank you. So I'll just put out to the. The committee that there had been some conversation about depending on what, how things. Move forward in terms of the week that we might invite. Representatives to comment. Later in the week. That, that may be. Too early for them to actually have a response, but we'll, we'll explore that later. Right. When I. That, that was a representative Houghton's idea to, to rather than just leave it vague to, to put, you know, put dates on for expectations, which. I thought was really good. But they were not put with necessarily an excellent sense of. Some of the feasibility. Particularly, I guess I'm thinking around. I'm not certain on data collection. Which things can be done when, and so hopefully in sending this out, we'll also hear back on. Yeah. Yeah. Get the feedback and. Clarify any. Anything that's not clear about our intentions and so forth. The answer. Yes, Katie. The answer is yes. We're going to copy. Senate, the chair of Senate health and welfare. We're going to do that. We're going to do that. We're going to do that. We're going to see what he has his hand up. Sorry. I'm not yet. Not used to looking for those. Representative. Page. Thank you representative Donahue. And members of the committee. I just have a quick question. We're, we're going to be. Departing the legislature here in another week. So hopefully. Let's go. Follow up. Who's watching the, the. You know, the chicken house, basically, you know. You know, I mean, this is the real serious issue. And, you know, and, and it's. You know, from what I've seen in my own area. There's some, some issues that are coming up. And, you know, I just, I just. Just curious how this is going to play out for the next, for the next few months or so, you know. That's exactly the question that representative Goldman asked me when we were talking about it. Yesterday evening. And I said, well, yeah, that is a challenge of us being out of session, but that's actually really the reason for the request of the committee. And I think it's really important to remember, you know, this kind of outline of bullet points of what's getting done and what they're progressing on. Because we can't ask them to come in and give us updates. And obviously. We, we, the. Leadership. Committee leadership will be sharing these. With all the members. And that would be, that would be on, or if we're hearing that, or in fact, if the data is showing, there's no improvement. Then that would be incumbent on. The leadership to follow up directly and make contact with the department. We can't. Also don't forget that we have a commissioner that's going to be leaving. Service here shortly. You know, there'll be a vacancy there. And so I'm just. Raising this issue. Well, can I, can I also say, I think that's all the more reason for us to do this now. Because we have a relationship with commissioner squirrel and with deputy commissioner Fox. And I think it's important for us to have. They presented to us, we've heard testimony. And I think it's important for us to put this on the table. There will, I'm sure there will be an interim commissioner appointed, if not a permanent commissioner. But I want this, I would. I think the work of this committee. Should be reflected in this letter. Before commissioner squirrel commissioner squirrel is going to be here for a few more months. But nevertheless, you're right, there will be a new commissioner. Month month and a half. Yeah. July, July 1st. But yes, I think to that point, setting it in motion where there is a report really helps. You know, not, not asking somebody new, new to start something, but to have it already set in motion. Representative boroughs. Thank you. I just have a. Seemingly random logistical question. And that is a. That's the reminder for my. When we get these reports, is it something, are they something that can or should be posted to our committee website, even though it's during the off session? Well, thank you. Yes. And I can read. I can follow through because Colleen will not be working through the summer. I was going to make a joke, but no. Colleen is not going to be working through the summer, but there are staff who are working through the summer. And we can request that those reports be posted. On our committee webpage. Working with Peggy Delaney, who's the. Ahead of. I mean, supervisor committee assistance and can arrange for that for us. Representative Goldman. Just to follow up with that's a great question. Would it be possible for Ms. Delaney to let us know something's been posted. On our website. I also think it might be possible for some of these to be copied. Just put, had there be a distribution list. Other people don't have to check. So I think there could be like we have now a distribution list for the whole committee. And when something comes in, have it just. Quick and get distributed to folks and people can then look at it or not at the, you know, as they're able. Yeah, I was picturing myself like what Monday morning or, you know, having to check. No, no, no, no, we would be forwarding them to all the committee members. Thank you. I just meant for any, any member of the public who's been following along wants to keep on top of. Yeah. But from committee members, I'd have it forwarded plan to have it forwarded. So I know, and you have to go. So I, I'm, is there, I think it seems like we may, maybe at a point of completion on this. So that we're ready to go. I think we are. So we'll work with. Katie to make sure that this gets sent. And this should be, I mean, there should be a, not a formal CC, but, you know, everyone on the committee should get a copy of the final life letter as it goes out. And we'll send it out today. And then we'll take next steps as it seems appropriate in terms of any feedback later in the week or not. Depending what else emerges. Okay. Good. Thank you. Thank you. See y'all later. Thank you. Representative down here represent Goldman represent Gina for each, for the contributions. I think this is a, this is an important next step and brings us to. Kind of brings us to some, not closure. It's not really closure, but it's, it's kind of a next point in time to. Move this forward with this issue forward because it is a very important issue. Okay. Thank you all. Yeah. Thank you. Okay. So I'm going to suggest that we turn. Our attention that the thank you, Katie. Appreciate it. And let's. And Jen, even though Jen is not here. Let's turn our attention to the. The other piece that we had said, we put on the agenda today, and I had to do with work around the clar, you know, final decisions about the scholarship. Scholarship. Incentives. For primary care physician. Physicians at the learner college of medicine. So Alicia, you and Woody had a chance to. No. Alyssa. Thank you. Thank you. Thank you. I apologize. Alyssa Alyssa. I'm sorry. I have a relative who goes by the other name, which I'm not going to say out loud right now. And that's, I think where it's coming from. Sorry. Alyssa. So. I think. I mean, there's, there's pieces here that. Let's just, let's just walk our way through it and maybe try to make some decision points and bring it to closure as well. If we can do that. So I don't know. Alyssa. Thank you. Thank you. Thank you. Thank you. Thank you. And representative page. How do you want to best proceed? I think representative page should. Go ahead. Cause he's done a. No. Thank you, Alyssa. You're throwing me under the bus. No. Distributed to everybody. Yeah, I saw it, but I can't remember where. So was it in our email? Yes. Okay. Thank you. Just kidding. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you for being with me to begin. Yes, I would. Yeah. I mean, I've come to the two of you, but I'm looking to, I'm looking to have you take the lead. Yeah. Okay. So. You selectively. Yes, I can't remember when it was Thursday or Friday. Yeah. Jen went through. The differences between the house. And the Senate versions of our scholarship language. And if you go through the topics. You can see that there were no changes at all to those two items. And you go to the next one, the stated purpose of the scholarship program. It's something that you may want to consider. To strengthen it. The Senate changed it. We didn't have any provision in the house. The stated purpose of the scholarship. The Senate said. To strengthen workforce pipeline. Increased number of new physicians. I was wondering whether we wanted to also add. To strengthen. A primary care or medical specialties. Something of that nature. I don't know. It's just a suggestion. As we walk through, do you want to walk through the whole thing and then we'll come back and just go through. Yeah. The people we are in contact. Number of scholarships. Eligibility. We initially had five. The Senate had 10. We seem to be. Listen to myself. We seem to be good. We can. The amount of the war. Of the award. We said it was for in-state tuition. We said it was for in-state tuition. We said it was for in-state tuition. We said it was for in-state tuition. We said it was for in-state tuition rate. The Senate said scholarship is for amount, not less than the in-state tuition rate for UVM college of medicine. I added a section there. Perhaps it should be based upon need. Something to consider. Then we go on to service obligation for each academic. Year of tuition. We had a two-year for full-time or four-year half-time. The Senate had at least a one-year practicing primary care and eligible practice setting. I think we were good with that. And then finally, then following up, service obligation, medical specialties. We had primary care approved specialties, or those recognized by National Health Service Corps at time of award. We had primary care approved specialties, including family medicine, internal medicine, pediatric OBGYN psychiatry. The Senate had added some other stuff. Primary care approved specialties, including family medicine, internal medicine. And as I recall, and representative Donahue raised the issue about focusing on primary care specialties. And Jen was going to look at that. Jen was going to look into that wording, and I don't know where that is at. So we still have to look at that wording that Ann raised. And continuing on for administrative provisions. I've lost my place now. Okay. Administrative provisions. The Senate did add quite a few items. We in the House had AHEC and VSAC to enter MOU, establishing responsibilities. But the Senate took it a lot further. They added not only what I just read, but program is complied with federal law. Amants go directly to students at UVM Student Financial Services Accounts. Terms and conditions to be described in award contract promissory note. And basically I think we're good with the Senate version. Additional role of commissioner of health. We didn't have any such provision. Whereas the Senate said that the commissioner of health in consultation with AHEC and VSAC may establish additional medical specialties, recipient eligibility criteria, selection criteria, award terms and conditions, and it goes on. Again, we felt that the Senate was probably their terms, their verbiage there was fine. Scholarship program sunset. It's the same as I recall here. And then the appropriations. Mari raised an issue. In the House version, we said over $2 million in global commitment funds to VSAC for registered nurse students who commit to practice in Vermont for medical students. In the Senate version, over $2 million in global commitment funds to VSAC for nurse students. And Mari, as I recall, you were contemplating that issue, whether it should be LPNs or registered nurses. You may want to make that distinction there. And it just says nurse. It just says global commitment funds to VSAC for nurse students who commit to practice in Vermont and for medical student incentive scholarship program funds for medical students incentive scholarship programs available for distribution after approval of initial MOU between AHEC and VSAC. And I recall you raised the issue. Did you want to delineate what type of nurse students it was, whether LPN or registered? And Alyssa and I had this conversation as well. She's more in line for LPNs, whereas I'm partial to registered, but we could just leave it at nurse. Yeah, I think it might, I mean, that there is less and less of a role for LPNs. But if there is a significant, they do have a significant contribution. So I think it would be better to allow flexibility and just keep the word nurse. So if I'm backtracking, then yes, I'm backtracking just to allow flexibility, depending on what the needs are for specific kinds of nurses. So I'm okay with it as is. You good with that, Alyssa? Yeah, the only reason, I guess just in my personal experience, I've always seen LPNs as kind of a stepping stone to our ends. You know, it's a when you're interested in going into nursing, it's a way to get into nursing. And oftentimes I see LPNs then expanding on their education to get their RN. So I. Yeah, the nursing profession has been trying to, at the same time, we're trying not to create barriers to accessing the profession. We're also trying to lift up the profession in the standards. So we can still get a two year associates degree, which is almost as long as it takes to become an LPN. And there are not that many LPN programs left, which adds another barrier to becoming an LPN. Okay. And then one other thing I overlooked was the service obligation for practice settings. We briefly discussed UDM and as well as Dartmouth. And we talked about whether we needed to add the FQHC, but must be outside Chittenden County, or inclusive of all FQHCs practicing in rural areas outside Chittenden County. And Alyssa, you looked into that as well. And you said Bay State. Yeah, I received communication from Bay State and they, they were good with the language of no Chittenden County, even though they do have a presence in Chittenden County. They recognize that the need is really in rural Vermont and they don't have problems recruiting in their Chittenden County. So I will defer to their organization. So I think the only, the only items we need to check with is service obligation, medical specialties that Ann raised with Jen and Jen was going to look at the language. Well, I think, can I just, because I think there was one piece there that you touched on that frankly was the one thing that jumped out at me when I first read the whole thing, which was to allow for the commissioner of health to have a special, a special role in adding other specialties. And I personally, I think I'd like, I liked keeping the focus on primary care. And I would, I would suggest that we, at least my point of view would be that we delete that language in our recommended language that gives the commissioner the role to designate other specialties other than primary care. I mean, as someone said, I think if they want to expand the program, they can come back to us and ask us to expand the program, but this really was about primary care. Okay, so for the additional role for commissioner of health, we had no such provision where the Senate had quite a long verbiage there. You would want to eliminate that verbiage, I guess. Just just the part about the commissioner being able to designate other special, I mean, if there were some other language, I don't have it right in front of me right now, unfortunately, but there were some other pieces that seemed okay. But the idea of the commissioner being able to modify the program at some point with adding whatever other stuff. Okay, yeah, at the end, commissioner may also adopt rules to plan, implement, maintain, evaluation program. At the very beginning, I said commissioner of health in consultation with AIAC and BSAC may establish additional medical specialties, recipient eligibility criteria, selection criteria. I would just strike that first phrase, and then they can go out and do the rest about the recipient eligibility, et cetera, but this establish additional specialties, I think I would just strike that. Okay. Now, that's what that's what that's the nature of the suggestion I'm making. Okay, so we'll change it to establish additional medical specialties. Does that work for other people? That's what I'm looking around the screen just to get a sense of, you know, I see a bunch of nods and thumbs up, okay. Okay. So Woody, do you want, do you want to just, I'm sorry, I just jumped in here. Do you want to, why don't you call on the other folks who hands up, Woody, and then you'll- Well, I'm sorry. Get used to the needing to see who's wanting to talk. Okay, we'll go with representative Goldman. Well, I'm convinced that the need to notice hands up is going to be over really soon. So that's all I'm caring about. Um, thank you, Woody. Oh, the representative page. I'm just wanting to go back to the nurse question that you had talked about whether to say nurse. I just wanted to understand this program in relationship to the LPN program that's been funded through Vermont Tech because there is a whole program there for LPNs. Am I remembering that right? So, in a way, I would, I mean, I see what you're saying about, if it says nurses, then it has more flexibility. But on the other hand, we're down 5,000 nurses and we need RNs. So there is sort of leaning to the idea of just specifying RNs, given that we have this VTC program as well. So I was wondering what other people thought about that. So can I comment on that? So the program that you're referring to, Representative Goldman, is specific to, I believe, nursing homes. And it is for only one year of a point in time. So, you know, I would still prefer the flexibility, I think, in this specific bill to allow for LPNs and RNs. Anyone else have any comment, other comments on the nursing issue? I'll just say that sounds fine with me. Yeah, I like the flexibility. And I guess we'll go to Representative Holton. Thank you, Representative Page. I want to go back to the service requirements. I could be wrong, and so I'm looking for folks who maybe were here last year. But I thought we heard testimony that service requirements work better when they're more than one year, so say two years, because the people become embedded in the community that they're in. And so I would like to potentially increase that back to two years, not to die on my sword for it. But I just think if a year isn't long enough, if we really want these people to stay and continue to be in primary care in Vermont. I hear what you're saying, but I think wasn't there an issue regarding our competition with other universities in the New England area, and that's why it was changed. Is that why? To make it more parallel with other programs, I think. Got it. Also, I think it's not just one year, is it? Is it a new year? I mean, it's one year for each year covered by the scholarship, so it could be more than one year. It could be. The Senate version says at least one year practicing primary care in eligible practice setting per scholarship year. It just says at least one year practicing primary care in eligible practice setting. Oh, yeah, that's a service obligation for each academic year of tuition covered. Yeah, thank you. First scholarship year, yeah. So Elizabeth, Representative Burroughs, you're correct. I think if they have two years of scholarships, then it's two years. It's not reduced to one. So is everyone good with that one year? Can I say something to that? Absolutely. So the reasoning is because other universities, medical schools in our area, offer that obligation. But these scholarships are being given to people already at our medical school who have been accepted into our medical school and they're in their third and fourth year. So I guess my question is what difference does what other states do? They're, it's not like they're going to be in their third or fourth year at University of Vermont College of Medicine and say, oh, Maine just offered me a one year obligation instead of two. I think I'll transfer over to Maine. Am I missing something with that? I personally would like it to be two years. I think one year is, I mean, that's nothing. Could I comment on that? Please. I'm, I just, I guess what I don't know what I'm missing. Well, I think the people that are deciding to get these third and fourth year scholarships have already decided in their first and second year that this is an incentive to them. So that's what brings them to this medical school is that they know if they care about primary care, they will have this scholarship opportunity. So it's all, that's the thing about these scholarships. It's a really long term commitment thinking that, you know, you've got four years of medical school, you've got three years of residency. So it's a seven year training event. And so by the time you're in your third and fourth year getting paid for, you have already, at least mentally made a commitment to primary care way before then. So when you're applying to medical schools, hoping to get into medical schools, before you've even started, are you looking at, oh, hey, this school has a program in their fourth year that I might possibly qualify for. If I decide to go into primary care and only has a one year obligation, but this one also only has a two year obligation. So I'm going to go with the one year obligation. Yeah, I think when people apply to medical school, they're making an enormous financial commitment way beyond what you can imagine. So there is considerable parsing of how they're going to get this paid for. It's huge. And we all know that the primary care specialties pay the least salary through everything. So if you really, like since you were eight, you know, there are some people, of course, who knew they were going to be a doctor forever because that was important to them. They're going to pick primary care. But I've also seen many people, you know, they go through their training, they started primary care and they end up in radiology all the time. All the time I see that all the time. Or, you know, because they don't want to work that hard and primary care works hard and you don't make a lot of money. So they end up in dermatology. So, you know, I think that these scholarships are tricky. I'll be really interested to see if they meet our goals, which is to get more primary care providers. But I don't think we're going to know that until we try it. I've just seen an awful lot of brand new primary care straight out of residency. And I know how long it takes to establish and build a practice. And it takes well over a year to have a full slate. Yeah, two to three years. And if somebody has a one year obligation, they're not going to have a full practice. And they wouldn't be established. And what is the incentive for staying when your obligations up, you could go elsewhere easily. I don't want to interrupt, but I'll just make a comment. I think the National Health Service Corps is a really good model to follow. And they, I mean, it's national. So people are really familiar with that program when they applied to medical school and look at how to help get it paid for. So I think following their model is a really smart thing to do in terms of if we increased it to two years when we have less takers of the scholarship program, do you think? Well, I think it would have to be one year per year of scholarship. I don't think you can get around it. You couldn't say one year of scholarship, but you are obligated for two years. I don't think people do that. So can I just throw in something? Because I don't, I mean, I initially, I mean, we supported having a two year obligation. Obviously, that's what we did as a committee. The feedback that, and I have the feedback, the only, the only information I have in addition is that AHEC, which handles scholarships, is the entity that said we recommend aligning it with one year. We, one thing we could do, we could try to resolve everything else and, you know, see if we hear from, hear from it, you know, get them to talk to us briefly about that. And because we're, you know, frankly, we're not in that world. They are, we may not agree with them, but we could at least hear what they have to say directly. And that's something we could, but if we ask them to get on the phone with us tomorrow or get on Zoom with us tomorrow, we could probably do that and try to just hear something further that would maybe influence what we're going to suggest to the appropriations committee. Because we need to do this soon because that at least, these, you know, I'm checking in with the appropriations committee tonight again, but so anyway, that's what would be helpful. Just see about hearing from AHEC, hear from someone from AHEC tomorrow. Should I see, should I reach out to see if that's possible? Okay. I see a bunch of things. And if we can't, then we'll make our own decision, but I feel a little bit like I'm kind of speculating because I don't have a lot of information, although I have ideas. For people that are in healthcare, most of you here are in the profession at some level. If we offer the one-year scholarship and someone's established for a year, if they halfway like what they're doing and like where they are, what's the chances of them pulling up stakes and going somewhere else? I mean, with that, does that happen? Or it seems to me, sometimes moving relocating is more of a, you know, it has to be, I would think it'd have to be a pretty poor situation to have someone leave, but I might be wrong too. How old are you at this point? So the one-year payback could end up being, pardon me? No, I'm just going to say how old are you? I'm just going to say that how old are you at this point in your career? You know, one or two years really isn't that much time when you're younger. It certainly is a lot different when you're older to pull up stakes and move, but when you're younger, it's a lot easier, particularly if you don't have a family and things like that. All I'm saying, and I agree with Representative Lipper, maybe we want to get somebody in to answer that question, but initially I remember it being more, we had it listed this way because we wanted to be more competitive with New England schools of medicine. Well, I'll reach out to Ahek on that and ask them to speak to that issue in particular. And as I'm looking at the other issues that are listed here, maybe ask them to also speak about the issue of adding the based on need, whether that's a key piece or not. Maybe that's a given. I mean, I don't know. I don't know. I mean, why would we give out a scholarship if you've already? Well, because we're trying to incentivize people. Yeah, I know. I know. That's actually the motivation, not just many scholarships are based on need, but the motivation here is to try to incentivize people to be in Vermont. So that might be kind of a contradiction to itself. Yeah. And are we good with the five versus the 10-year, or do we want to go with the 10-year, or the number of students up to 10, third and fourth year medical students? That was what the Senate had, whereas we had up to five. We had five and five, right? Yeah. I think the mix is more flexible. 10 would make it flexible, right? Yeah. You could have three and seven or seven and three. Yeah. So you'd like to go with the 10. Could I ask a question about that? I just didn't go with the 10. Was the 10 just for docs or was it for nurses too? So was it everybody or just? Just docs. We have medical students down. And so how does it get funded? We're giving them money. Does this money sit in an account until it gets taken? How does that work? That I don't. I can't swear as I know the answer to that. We have to ask the appropriations committee. Sometimes it sits in our account. Sometimes it sits in their account. I'm not sure, because it should only be available as it's used just from my point of view. So we don't really have an idea of how much is going to be sitting in this account waiting for these potentially 10 students a year. So that'll be 20 students over two years for third and fourth year students. I'm not sure how that influences what we're doing. I don't know. There's a lot that we need to pay for. That's all. I'm just worrying about money. No, no, no, no, no. Let me be clear. We need to commit this money. If we don't commit this money, this money will go away. That's what happened with the mental health scholarships. So I want to just, I'm just going to strongly weigh in that this we need to commit this money because otherwise, because we know there's anyway, that's my strong feeling. We've watched mental health money went from $5 million to $1.5 million because it sat there and it got used for other things. Brian, did you have something you wanted to say? Earlier, Art said, you asked, like, or you said something like the health care providers here, something about our perspective on the recruitment and retention or like what would make people leave or stay. And I remember us hearing testimony at some point from witnesses who talked about how it's what makes people stay is more than this credit. It's after you get them here, how do you, what do you, what is the state providing for quality of life that would make someone want to keep living here? And something I hear from young people who leave the state is they feel like we don't sometimes like when we argue about funding public education, they worry about the schools losing its quality. They worry about other other things like having access to amenities and people testified about this in our committee previously. But I just wanted to kind of bring that up because we did hear testimony about it and I do agree. And then the one little thing I would say is just from personal experience that when I came to Vermont, I was only going to stay here a year. I came here to do AmeriCorps and you get a $4,500 stipend to use towards education expenses. So I was like, it was worth working at poverty level wages for a year to get that stipend because I knew I could pay off a big chunk of my loans. And once I got here, there were aspects of the quality of life that I liked and the place where I worked offered me a job. And there might be people out there who are unhappy about that, but I stayed. So I just share that as an example because part of it is getting people in the door. And then the next part is how do you get people to stay? But it sounds like right now, we have money that we need to use to get people in the door. So maybe we should just do that. And then we should maybe spend some time over the summer working with other people in the community and other witnesses to plan for how to keep them here. What else do we need to do next? Like what do we need to do next to keep people in Vermont and make them want to stay here and raise families or contribute to our tax base or whatever. So that's my point. Good point. So I could also pose that question to the folks at AHEC. Representative Page, I have a question. In the list, I talked about Chittenden County being excluded. Is that what we're doing, excluding Chittenden County? Are there no rural parts to Chittenden County that maybe there's a rural hospital? Yes, but arch. I suppose you're right, Arch. But you know, Chittenden County being rural, give me a break. Well, I just throw it out there, you know, because it kind of goes to what Brian just said. You know, you stick a young person from a metropolitan area out and go pick some rural place. I see where you're going with this, but Chittenden County has no problems recruiting people. Oh, okay. Oh, that's fine. You know, I guess that would be my remark. Yeah, there's a risk of putting you in charge of this one, Woody. Are you afraid I'm going to sneak something in, Chair? I think it was a fine print. Everyone has to go to the Northeast Kingdom if they want anything. I offered to advocate for that, that they all must be in Newport within a five mile radius of Representative Page's house. Yes, well, thank you very much, Alyssa. I appreciate that, but I don't think it would be ethically right to do that stuff. So Woody, I'm just trying to see where we are. I think there's, can I walk through what I think I've heard? Yes, you may. Yeah. I think we've talked about, I'm going to try to reach out to AHEC, get them to come in and talk about the one year versus two year commitment and about the based on need language and possibly ask them about comment on what Brian Cina was saying, Representative Cina, about what are the things that can be done to encourage people to stay, but that goes beyond this bill or this language. We've agreed that we're going to stay with the general nursing language. We've agreed that we're not going to include Chittenden County as the eligible area, and that we're going to, I think we basically agreed that we're going to not include adding other specialties by the commissioner of health piece. I think the outstanding issues were, and I think these are probably stuff we could, a couple of them we could quickly agree on. I think to go with the Senate's language about strengthening primary care or the primary care specialty, that seems consistent with what we're talking about. Yeah, they didn't have that share. They just had to strengthen, they had just to strengthen workforce pipeline. I didn't know whether we wanted to Yeah, let's say primary care workforce pipeline, sure. I mean, I'm just going to try to see if we can't get through some of these. Then there's an issue which had to do with, we agreed on Chittenden County, but there's some language about not a practice not owned by an academic medical center, and there was some concern that that might eliminate some Dartmouth, like I think Representative Burroughs was representing that in your part of the world, there are practices that are actually under the Dartmouth extended orbit, if you will, and there's a little concern that that might, we don't, I don't think there was a sense of wanting to eliminate that, but I'm not quite sure how to thread that needle, other than take that language out. Because most of the, in fact, actually let me finish the thought, most of the practices that the academic medical center, which would be UVMMC, have are in Chittenden County, except for some in Addison County, or maybe in Washington County. So I think if that language about excluding the academic medical center is taken out, that actually allows for the border towns of a near Dartmouth to be included, and I think there was a general sense that they should be eligible. So we would want to remove not be owned by an academic medical center. And basically that combined with the Chittenden County, it excludes all of Chittenden County medical practices owned by UVMMC, but would allow Addison County or would allow, if they acquired something in Franklin County, which again become the rural areas, quasi rural areas. So we would say practice site must be in Vermont, the outside Chittenden County, and accept patients on Medicare and Medicaid. Yeah, I think we all liked that the other day. That was my sense, yeah. And there was some language that Jen was going to look into regarding service obligation for medical specialties and raised this issue. And speaking of Jen. And then there were a couple of other hands up, just so you notice. Okay. Do you want me to respond to this or do you want to do the other hands? Why don't we have you here? So why don't we go with you first? Sure. Jennifer Carby, Legislative Counsel. So as I was starting to compose an email to check in with AHIC, I realized that really the only thing that I think people were concerned about was that additional authority for the commissioner to add specialties in the future. So I think if we keep the existing language around primary care and the sort of sub specialties within primary care, I think we're addressing your interests and we'll just take out that piece allowing the commissioner to identify other specialties. And I think we just agreed on that. So I don't think there's additional, I don't think you need additional language. I think you just need to delete some language and your good shape for that. Thank you, Jen. Representative Black, do you have your hand up? Yeah, I just want to I guess go on record regardless of what anyone else thinks, but be not owned by an academic medical center. I vote that that stays. I don't believe there's a recruitment problem. Typically, the academic medical centers are the ones that are staffed and their clinics are in places that are higher populations, even if they are a bit more rural. And they, I think it's a disincentive for independent practices to open in more rural settings. I would be interested in a hex take on this as well. I'm aligned with you, Alyssa. So just, can I tell you the reason the logic for me was how to eliminate how to and maybe this is not an issue, but I heard Representative Barrows seeming to weigh in like, you know, if Dartmouth has practices across the river in Vermont and they're having trouble recruiting for those practices then to have the academic medical center language, unless we said, unless she says a Vermont academic medical center and then that makes it very specific. Or we should find out if Dartmouth is having problems recruiting for their clinics across the river. Well, okay. I thought I heard something from Representative Barrows about that. Well, she did raise it last week, I believe. Maybe we can hear from Representative Barrows. She is here. First of all, I don't believe that they're all owned by Dartmouth. I think they're just affiliated with Dartmouth just to make that clarification. But some of them are owned by Dartmouth. And I do think that Dartmouth is having a devilish time getting some of these ranks filled as I put in the chat that I've been on a waiting list for six months to get a primary care physician. There's a difference between going to somebody at Dartmouth where it's the revolving door of students versus having somebody actually placed in a clinic. But I don't, yeah, I think they have a fair amount of trouble and that's just totally anecdotal. I don't know. Maybe the AHA question or person should be asked that question too. Do you want to put that on the list? I've got it. Let's see who else is in the hopper here. Representative Goldman. Thank you. I think that there's a real problem recruiting primary care no matter where you are. I mean, maybe if you're sitting right in the middle of Chittenden County, but otherwise there's problems with primary care. I'm wondering about a designation. I think there's, and this is a question for AHEC about a rural underserved area where the expectation would be that the person, the recipient would go, would be committed to going to a rural underserved area. And I know that was a designation at some point in the past. I don't know if that's still an issue or if there's something equivalent, which I would want to hear about from AHEC, which would mean they would know that their commitment was to a rural area that was medically underserved. So that's what I would hope to see. We can ask that to AHEC, I guess. And finally, Representative Peterson. Yes, thank you. Representative Page, how does that read right now when it involves we're a person working their scholarship offers, basically what this is, where they're assigned? Did they choose where they go? And if they do, can that be changed? Do they get assigned to someplace at the state's bidding of where we need workers, where we need somebody? I mean, is that anywhere in the, could that be done, I guess? I mean, we're struggling with where to include or what to include or not include. Can we say, well, we have a real need here and that's where you're going to go? I think we need to find a way to balance trying to micromanage this and to actually create a structure in which it can be best utilized. And I think the same question came up like, well, what if someone's in a practice and they need to move? Can their scholarship change? Well, those are the kinds of things that come up with the practice procedures and rules. I don't think we can get into all that with statute. I mean, I think you really need to just have a, the goal is to create, create, appropriate money, create an incentive and turn it over and have them operate within the framework of that number one. The scholarship has scholarship, but it comes with a penalty if you don't fulfill the provision. And I think that's in there. And that's in the promissory note, et cetera, that the Senate added, which I think is good language. And then, but I think then the resolution in terms of what the service obligation is needs to get resolved. And then you, then we need to turn it over. There's a lot of aspects we can't speak out. Yep. Okay. So are there any other questions? Do we need to go over this again with, with Jen? I think we can do that offline. Okay. Yeah. I think we can. So what I, what I'd like to suggest is that I reach out to AHEK, try to get them into our committee tomorrow if at all possible. And either in the morning, late, later in the morning, or in the afternoon, if we have time after the floor. Sounds like a great plan. As if I know what you're talking about. Okay. I'm going to also suggest that I've asked Lori if she would take a role in trying to put together some language around the task force, affordability task force. So we, we had some committee discussion. We'll come back to that tomorrow some more. But if you have specific suggestions that follow up on what we talked about last week, we'd be in touch with Lori in particular. And if there's others who would like to help weigh in, be in touch with Lori around that. And, and again, it's, it's, it's partly frankly, it's, it's, I think we should be, we should prepare a recommendation for the Appropriations Committee, but we also need to understand they're in the midst of trying to negotiate both money and policy. And, but we'll have something prepared then that we can offer them. Hopefully we can bring that to closure shortly tomorrow too. Or the day after if that's it. I'm hopeful that we are working our way toward adjournment. And although hearing everything that was going to the Appropriations Committee today on the floor gave me pause. So, but things can suddenly speed up when, and when it's clear that we're going to be closing things down. I can bring a good report. Well, I can I'll wait. Okay. Okay. So I'm going to suggest I have my hand up there. Hello. Okay. Yes, please. I just wanted to ask quickly, having missed, I apologize for having to step out, but there had been an open question about the meaning of other specialties and whether it met within primary care or beyond. It's been resolved. Okay. Okay. Good enough. Seriously, we did. So I can just give the update from the rules committee that it is the intent. It is the intent to for our resolution that extends remote voting to end on the 22nd and not to have it like, well, you know, whenever. Can I ask a question about that? How does that affect a potential veto session? Oh, no, it's remote for veto also, but it ends and then it covers the veto. It's it's multi layered and I'd be happy to go through, through all the language that was just a quick update because of the chairs expressed hope for moving towards adjournment. Yeah. I don't think it's just the chair. I don't think so either, but you referenced it. So yeah, great. Okay. Great. Let's, let's call it a wrap for the day and we'll be back here. So I do want to say something tomorrow morning. I think the what I reached out to diva as well as to the green man care board about the rates filing for the unmerged markets, we were seeing press releases about it. And it's also important for us to be hearing from diva about their implementation and outreach. And as it turns out, it was suddenly there was other press releases I'm seeing about this. And so I think it's very important for us as the health care committee members to understand that as fully as we can. And so that's why we're going to spend some time with that tomorrow morning. Because it's going to fall to us in some ways to interpret it to our colleagues as well. Because I frankly think a lot of people, it's not registering as you know, there's a lot going on and people are focused elsewhere, but it's important for us to understand that. And so tomorrow morning, we'll be hearing from Kevin Mullen, the chair of the green man care board about the rate filings. We'll be hearing from diva about the implementation, the implementation they're having to go through for the enhanced subsidies for premiums, which should have a significant impact and the importance of outreach. Because if people don't know about what they can do, and that they might be better off by making some switches during this particular year, especially in light of the in light of the press releases that are saying individual premiums are going up. But in fact, it's not registering necessarily for people. These premiums are going up, but you are actually going to be, for most Vermonters, they're going to be not paying those premiums because of the enhanced federal subsidies. And they're actually going to have additional savings for a lot of Vermonters. I think we need to be able to get that message, both understand it and get that message out there. So I think it's important that we take some time with that tomorrow morning. Can I ask a question about that? We have a really robust comms committee and they're really good at what they do. Yeah, never mind. Yeah. Okay, so see you tomorrow morning. Before we go, Representative Black and Jennifer Carby, you want to hang around and we'll go over this and we'll just update you on, well, good idea. And I'll hang out with you as well, just so I make sure I understand it all. Great. Perfect. Good. And thank you. Thank you, Woody. Thank you, Alyssa, for Representative Black for helping us get to this point on this. And I'll reach out to Ahac.