 Let me ask Steve, you've testified in front of our committee previously, but it may have been at a point in time when we had some other members. But I don't think we have met in person, each of your colleagues who are here, so would it be helpful for us to introduce ourselves and then invite you to introduce yourself and your colleagues, why don't we do that. And again, I think picking up on the suggestion I'll start and then we'll go around, we'll go around the room as if we're in the room, which was how we all organize our mental, our mental picture of ourselves. I'm represented Bill Lippert from Heinsberg and chair of the house health care committee. And I'm going to turn to my right to the vice chair of our committee, let her introduce herself and then we'll go around the room and then we'll go back to Steve and have you introduce yourself and then invite your colleagues to introduce themselves as well as our and our staff before we go back to you Steve. Yeah, representative and down to you on from Northfield and also represent Berlin. I'm Peter read I live in brain tree represent Randolph Brookfield brain tree grandville in Roxbury. I think you're muted. Henry, I think you're muted. Sorry, I'm representative and Marie Christensen I live in Weathersfield and also represent Cavendish. Representative Lucy waters Waterville in Cambridge. Good morning. Representative David Murphy from Shaftesbury in Bennington County. Representative Brian Smith represent the towns of Derby Morgan Charleston Holland and Brownington Representative Marie Cordes from Addison County Lincoln Bristol Moncton and Starksboro and a nurse volunteer for the open door clinic that hasn't been there in a while. Hi, this is Brian China from Burlington Vermont, and I represent a part of the old North and and the most of the East District. On the improvement page, I'm calling from Newport, and I represent Newport Newport Center. Irisburg country and North Georgia. And I'm Lori Houghton and I represent as extension. Okay, how about Jen and Nolan would like to introduce yourselves and Dennis and Sean. Sure, I'm Jen Kirby I'm deputy chief counsel from the Office of Legislative Council. I'm with the joint fiscal office. My name is Dennis Martin and I'm the committee assistant. And Sean Island is joining us as our IT person this morning as well. So Steve, why don't we turn to you. Have you introduced yourself and then have your colleagues be introduced and then we'll proceed from there. All right, thank you, Mr Chair. My name is Steve Meyer I'm the executive director of Vermont's free and referral clinics. We were formerly known as the coal Vermont coalition of clinics for the uninsured, but for a variety of reasons. This year, I decided to start doing business as Vermont's free and referral clinics. And as that started in February, we're going to kick that off with our clinics day at the legislature in February, which was on the huge snow day so that didn't happen. So, but here we are, I'll tell a little bit more in a minute, but I'll let Heidi and others introduce themselves. Yes, just do a brief introductions and then when we come back around you can say more about your organizations as we come back around for testimony that work. My name is Heidi Soulis. I'm the executive director of the open door clinic in Middlebury. Okay, my name's Lynn Raymond Dempey. I'm the executive director of Valley Health Connections and Springfield tonight. Okay, welcome. And I'm Dana Michelovic. I'm the executive director of Good Neighbor Health Clinic and Red Logan dental clinic in White River Junction. Welcome to you all. So let me, let me try to start and tee this up. As we've been looking at, we're particularly interested in understanding what, what's being experienced throughout the state in healthcare around the COVID-19 pandemic and the pressures that it's putting on the healthcare system of Vermont. We have been hearing from representatives from hospitals will be this afternoon we'll be hearing from the FQHCs as well as at least representative of UVMMC and I'm sure we're hearing from other hospital representatives as well. As we thought about where there might be pressure points around the state and where there have always been some ways pressure points is the what I pardon me, but I still say the free clinics. So we'll work up to getting to know how to refer to you as your preferred name. But it is I think it's new to new to us. So we, we recognize that the role you play is an important role in our communities across the state. But I think it's important for us to understand what you're seeing in this cute time as well. So Steve, even though we didn't have a chance to hear from your folks because of the big snow day and then rescheduling just didn't work as well. This is our rescheduling in some ways, but but we'd like to focus on both understanding the nature of the work that you're doing generally but that's also focused on the COVID-19 pressures and experience. So I'm going to turn it over to you Steve and then have you work with your witnesses and I think we have some time. Great. Well, thank you again. Yeah, I'm just going to take two or three minutes and give a general overview of the work that we do around Vermont and I provided Demis with a general background document that I assume you have in front of you or could look up. I don't have a problem. I don't know if you allow me to share a screen but I could do that if that would be useful but I think rather than my suggestion would be not to focus so much on that but just just a couple of highlights. So you have a general sense of the work that the free clinics do around the state and then move right directly to the clinic directors and and how they're managing their work. So I'm going to start with COVID-19 free clinics in general, serve about 9000 Vermonters per year, a little bit less this last year. And the types of services we provide each clinic does things does a different array of services. Some of them do them slightly differently but among the things that the clinics provide are direct medical and dental care to uninsured and underinsured patients. One of the reasons we changed our name is that it was clinics coalition clinics for the uninsured we have found over the last several years that more and more of the people we serve are not necessarily uninsured so there's issues there we could discuss if you're interested but and we also provide referral services within a hospital or other networks our community networks. We provide a lot of sister services what used to be called navigation, we help people get connected into Medicaid and Vermont Health Connect and other private insurance. We provide help with lower costs or free medications in some cases. So, and I'm those are touching on the highlights you can see in our summary. Some of the other kinds of services and the numbers that go along with them. We have. We are celebrating and I put that word in quotation marks we are celebrating our 25th anniversary as a coalition this year. So you may be surprised to know that free clinics have been around this long. Most of the early years of the free clinics the people that set them up all did so with the hope and expectation that we would not be around 25 years later. And though here we are we continue to serve an increasing number of Vermonters each year. And the need for our services seems to it has changed over the years we do do different things some many different things and we did before but the need for our services continues to grow. For better and for worse perhaps. Anyway, I think I'll stop there. And I think the lineup we agreed on was that Dana are you prepared to go first, and then we'll hand it off to Lynn and Heidi will do cleanup. Thank you. Thank you all for inviting us to come and testify before you today. The good neighbor health clinic is one of five freestanding medical and dental clinics that is part of the nine member coalition of our network. Good neighbor operates with 24 licensed medical volunteers and 12 licensed dentists. And annually, these volunteers mentor over 50 medical and dental students. That's a big part of our operation is passing along the knowledge from the just maybe just retired generation to the generation that's coming through professional school at the moment. They provide 3000 medical and dental visits. What's really important for you to know is that all nine of our member organizations have very lean staffs. And in normal times, I think that's an asset. As we go through this unprecedented time, it is, it has become very much of a challenge. The freestanding clinics that provide care and typically we've seen patients in the offices have modified their business operations and we're providing care via phone, both to new and existing patients. Good neighbor is very fortunate in that we have an electronic medical record and we also have a nurse practitioner on staff. So, we were able to set up about two weeks ago to do our work remotely. And to talk with our patients were providing acute care triage for COVID-19 and billing prescriptions for those patients who rely on us for their primary care. Of note, I believe is that yesterday we received a notice from HRSA say, and they provide the malpractice liability insurance for all of our medical providers. And they have extended their coverage to telehealth. I will tell you that good neighbor has yet to figure out the protocol for telehealth. However, I was on a phone call with colleagues this morning and people's health and wellness and barriers ahead of the curve on that and they have. They're going to share with us the information on how they've done that our volunteer providers are mostly retired so they're in a high risk age group, and they would prefer to provide telehealth at this time. Currently, we know that we are deferring ER visits. And we also know that people are becoming those who live maybe precarious lives, maybe some who didn't are becoming unemployed, and we, we feel calm. And we say confident that's not really the right word, but we're expecting a surge in a demand for our services when we get a little bit on the other side of the current crisis and people who are unemployed and have their health insurance and reach out to the free clinics both for care and for assistance in enrolling in insurance plans. We've, we've shifted our entire business model as a result of COVID-19. We're working harder than ever to provide care for patients who call us. So, that's the extent of my testimony. I think we'll turn it over to Lynn. Thank you. Hi, my name is Lynn Raymond MP. I'm the executive director of Valley health connections, and we're referral free clinic program. So we provide referral directly into providers offices springfield medical care systems springfield hospital use their charity care programs to help people access care. We also do an awful lot of outreach and enrollment. Last year we served for monitors from 44 different towns. Mostly in the Windsor and Wyndham County area. And with our three, three and a quarter full time equivalent staff members. We served just under 1400 monitors last year on March 17 that became pretty clear that we needed to change the way we were doing business. And no longer continue the face to face services that we were providing, but we obviously still need to continue to provide those services to patients. So we have started working remotely. And the staff myself we've all worked very hard to come up with processes to do the outreach and enrollment to help patients get verification submitted whatever it is they need to do to get the help they need. And last and the month of March, even though half of that time, our doors were basically closed and we were just helping patients via phone email however else we could get old of them. We served actually more patients this March than we did last year with our doors wide open. So there continues to be a need we definitely can do this. But it's a constantly changing landscape, as I'm sure you know, one of the big things we did over the past week and a half was in reach to over 100 Vermonters in our database that we knew were not insured, contacting them to help them take a take advantage of the special enrollment period that's been open through Vermont Health Connect through April 17. So we felt that was really important. During our calls we actually were able to connect quite a few people so it's it's been a good exercise. Along with all the other stuff we're doing trying to get those calls done was really important. We actually had one patient who had sent in an application over a month ago to Vermont Health Connect. She had not received any correspondence. She contacted Vermont Health Connect on her behalf, found out that the issue was it was just laying there waiting for the her to do plan selection. Had we not done the call and followed up for her, her application would have closed after 60 days from being non responsive. And what we were able to do because we made that call was get her enrolled. She already had a number of medical bills that she had to pay, and she needed additional medical care so those calls are definitely worth it. We're also looking at doing some outreach to some of our older patients more more concerned about the isolation factor for them and checking in on and making sure they're okay and because of the database we have because we share it with the VCC it makes that that kind of contact and that kind of in reach possible. One of the, one of the other things that that's been happening and actually this was occurring prior to the start of the COVID-19 issue was Medicaid apps seem to be going really, really slowly in the system, trying to get people on I wasn't really quite sure what was going on we've been in close contact with our partners at diva, in particular with Victoria Jarvis who does the assistant program, letting us know that you know they're doing a lot of manual reviews, and they're not terminating people which is good, but that same manual process that's not terminating people is also slowing down the process to get people on. I've had two children waiting to get on Dr dinosaur is completed in March income verification scanned and received by for my health connect back in back in February excuse me was completed in February the verification was in in February. And now we're into April, and those two kids still are not on. I've made multiple calls on a regular basis. I just did another outreach yesterday to the actual sister program saying somebody's got to help me. So, you know, those kinds of issues are ongoing, they existed before COVID-19, and I think COVID-19 has just kind of exacerbated them in a system that's trying to do manual stuff. And any changes you make to the portal and the waiver my health connect does business kind of throws things into a tizzy and I think you're all well aware of that. So that's an ongoing issue. And the other things we found out just like a couple of days ago is the sister line is down because of the COVID-19 outbreak. So what you may not be aware of is we deal oftentimes with very complex issues related to getting people enrolled and insured. And so people wind up coming to us because they've tried to do it on their own but for some reason it's not happening and they need our help and assistance. And what we have is a special assistant line so and these are operators that are the sisters we have an assistant number they certify that we can speak on behalf of the patient. And they're also well trained well experienced operators because we're dealing with highly complex issues. The sister line is gone. So now the sister line at help me understand that more clearly because it's closed right now. It's closed right now to the COVID-19 outbreak they had to allocate their call center personnel all of them to the customer service line to deal with all of the contractors which I certainly understand because they're overwhelmed, but that leaves us without an important resource. So what that would mean is that in order for us to call that we could call that customer service line, but we would have to be with the patient and maybe wait on online maybe like a half hour, depending on how busy they are to just wait to talk to somebody. And the people on the regular customer service line have varying levels of knowledge when it comes to some of the complex issues we're dealing with lots of times we need to go to eligibility or I don't know if you've heard of tier two, tier three, tier four, when you have these issues so we deal with a lot of those. And that's not something most of the folks on the regular line are familiar with. So it's an issue we're working closely with diva with Victoria Jarvis we we met with them this morning just before coming here for the testimony. To talk to them about what we can do, trying to use an assistant inbox and maintain HIPAA privacy laws and trying to do it in some of these things have to be done very quickly because people need medications. We have people with psych issues and stuff who are just really struggling to get some of their meds because come up some because of some issues with their coverage. And so it's critical that a sister line is critical. And so we're that's that's an issue we're really working on. We also so for for our clinic in particular, we deal with a lot of people who are insured in 2019 4547% of our patients were above the Medicaid threshold, which means they were on like a qualified health plan. So with those folks now going through job changes job loss, all those things, there's a lot of income changes going on. The problem is when they're on a qualified health plan. And they're making an income change through for my health connect. If it didn't happen prior to March 15. That premium is not going to get changed for the next month. So they're going to owe the regular premium for for April. And then not until hopefully May 1 that premium amount will be changed. But the problem is, if with the backlog and the unemployment system and not getting those funds, and they don't have the income to pay the insurance premium. So with that amount, if that rides in arrears for 90 days, they're going to lose coverage, and they're not going to have an SCP because it's going to be done for non payment. So looking ahead, please, please keep your eyes on that situation. It's it's a concern of mine, particularly because we have so many people making income changes right now. And it, it's, you know, the portal just cannot respond as quickly as we need it to, to make the changes. So, and for some of these people, also trying to file for the unemployment claims, their social security numbers are not being recognized there, and they're having to call so it's not taking hours it's taking days for them to get through and even once they get through. The question is how much are they going to get when is it going to start I don't think we know I know there's a lot of issues regarding that. I know the legislature is working on them, but it does create a complex issue for our patients. Okay, well I also I want to say thank you for one of the questions I have on list of questions was the open enrollment period and hearing you talk about the in reach that you're doing is good to hear. Also, let me just throw it out there a question. Let's hear from your colleague and and if any of you who wish to comment about the open enrollment period plus the course there's ongoing difficulties as you indicated with even the change of circumstance around finances which is happening, which was triggers triggers enrollment changes as well. Let's hear from. Dana, let's hear from Dana and then we'll go back and open it up for questions from the committee. We heard from Dana behind. I'm sorry. And I would also like to say thank you for this important opportunity to speak with all of you. Much of my feedback really echoes my colleagues, Lynn and Dana. When I think very starkly about how this pandemic has affected us, it's changed entirely how we too are doing business and conducting services. We still have paper charts here at the clinic. And so that just gives you a feel that some of us still need to we actually have three people working here at the office and the rest of my staff is working from remotely home. And so when we're in close proximity to one another, we're wearing these and washing our hands a lot and doing a lot of social distancing none of us is sharing an office right now. Early on, we worked with our volunteer medical director, Dr. Lynn Larson to help us figure out how to navigate this unprecedented time, which every the word everyone is using. And so early on, we decided that we would also defer all kind of routine appointments and really add some clout to the triaging that our nurses do. So we have two nurses here who have been triaging all of our patient calls since we stopped providing our clinics per se, our in person clinics of which we hold 10 to 13 a month. And one thing you need to our clinic here is out of nearly 1000 unduplicated patients that we saw last year. A good third of them are our local Latino migrant farm workers. And so we have staffing and services in Spanish all of the time so Julia, our outreach nurse who speaks Spanish has been taking our cell phone. To cover all of our Spanish speaker calls and concerns and Jodi has been dealing with the rest of the population and our navigator Melanie is taking all of the navigation calls around health insurance. So, currently that's kind of how we're looking we're serving all of our people we're triaging. If there any suspected COVID calls, those are further triaged with Dr. Larson. And our backup plan is that if she gets overloaded she is a primary care provider in our community and a hospitalist. So burnout could become a real issue for them. We have a former medical director and another one of our volunteers who have stepped in and said they would be more than happy to help see patients triage calls etc. We're doing some telehealth visits. And Lynn has been doing those with Julia primarily thus far. So that's kind of how we're conducting our, our normal business. At this point in time. We have a lot of concerns around language access for Spanish speaking patients and I have been working with some of the people in incident command at Porter hospital to see if they would be open to and if it would be helpful for them to have a list of our interpreters. Should they get bombarded with or I think what we think, given the fact of how the migrant workers work and live, we expect that a cluster of people could come in to the hospital at a given time and overwhelm their limited language access capacity so we're working with them to try to support them and come up with creative ways where we could bring in remotely a trained interpreter to help with the Spanish speaking patients. We're also, this is kind of cool and I think not that I can claim to be a native or monitor but I want to show you this. As you have all heard and appreciate. We cannot get supplies and that's something that I think is really important to let you all know about we can't get thermometers we can't get hand sanitizer. Some of our local companies you probably you might have read about this kombucha, the Vermont soap company Appalachian distillery have been making special batches of hand sanitizer for a local hospital and we got eight gallons ourselves and so we're preparing some COVID boxes for outreach to our farms that will include hand sanitizer that we're putting in ketchup bottles from our local dollar store. We have masks, ibuprofen, some soap, and some patient education in Spanish for the migrant workers. Julia also did a mailing to farm owners a couple of weeks ago with that basic information to try to instill some of these safe safer practices for their workers. So those are some of the things that we're doing and how business is looking a little different than usual. And I think, again, to echo a lot of what Lynn said, we have real concerns I have real concerns, you know, a big piece of our work is to increase access to care and a number of different ways and one of those ways is to help people access health insurance. To help people become laid off unemployed. You know, our navigator, our navigators or our sisters are going to be swamped, and if the overarching system continues to be plagued with traffic and technical difficulties. It's going to be a mess. It's, it's already kind of messy and I don't mean to be critical but people needing to wait for days and weeks to get on to insurance is unsettling at best and horrible practice so I have concerns over time about people being laid off unemployed if they're lucky to go back to work lucky enough in six or 12 or however this last 18 weeks. It's conceivable that their insurance status will change again because now they're back on income and they won't qualify for the plan they're on and you just switch plans. So I, I am concerned about our system being able to accommodate all of all of this and access for our Vermont for Vermonters through this pandemic. And so I just wanted to read a story in conclusion that highlights this. And this was written by our navigator Melanie Clark, who was a superstar. And this shows you I think sometimes we take for granted that, you know, getting health insurance is like lickety-splickety and I think the people here today can attest to the fact that it can be a very cumbersome, cumbersome protracted process that takes a lot of knowledgeable people to help Vermonters with so. Sally is a young Vermonter who works for a local restaurant. I've helped her over the years update her Vermont Health Connect account whenever she's changed jobs or needed to complete Medicaid renewals. Just about a month ago Sally came in because she was finally making enough that she was no longer eligible for Medicaid and would have to pick a health insurance plan through Vermont Health Connect. She was both proud of the fact that she was now making a decent living, but extremely anxious about having to pick a health insurance plan. She had looked online and couldn't understand how the plans worked and what terms like out of pocket maximum deductible co-payment or co-insurance meant. This was a strange new world where she would now have to pay a monthly premium and still be expected to pay a portion of her own health care expenses. It made no sense and she was struggling to understand how this would impact her financially. Sally's feelings of anxiety and confusion aren't unique to her. There's a great deal of stress when transitioning from what is known to what is unknown. Just like we're all doing now. Most individuals who transition off for Medicaid for the first time feel the same way in these times when we are most vulnerable. A familiar face in a community community connection our sisters make all the difference in the world. Sally came into my office we updated her account and then went over insurance terms how plan how plans work and what subsidies are. We discussed the importance of updating income information how to make payments and next steps. We even talked about her budget to ensure she would be able to afford what she wanted. Although daunting at first understanding health insurance is much easier when explained with patients simple language and by using concrete examples. By the time she left the office she was empowered by her newly acquired knowledge grateful to support and proud that she'd moved into the next phase of her life where she could pay for her own health insurance. I'd like to say that Sally's story ended happily ever after but like many restaurant workers this isn't the case. Sally was laid off from her job a couple of weeks ago. Once again her future is unknown and she's anxious and stressed about what lay ahead. With all the uncertainty in her life. She said she felt relief knowing that at least a quick phone call to a familiar voice was all it was needed to figure out her health insurance and next steps. I think we're going to see an awful lot of that in the coming days. Okay. There's one other thing I just wanted to add and and Dana and Heidi talked about a little bit but when you only have three staff members. If one of them goes down with COVID-19. We're in big trouble. So that that's where it comes into play and it's very nerve wracking how we're going to continue to help and serve these people. It's more time consuming than ever right now because of the system we're trying to work in. But it's a huge concern. Thank you. And Heidi I think I was on mute when I was thanking the others, you and the others for joining us here today. I'd like to open it up to questions from our committee members and I see represent representative Rogers. Thank you. I have a few questions and I think I'll just lay them out there and then see if there's responses. The first is is more of kind of a question about about Medicaid enrollment, which is that I actually prior to this testimony today I had not been hearing from my constituents or others I'd been in contact with about issues of getting on Medicaid in a timely fashion. And I'm actually hearing about that. So I'm kind of curious to hear if this is a particular instance with a few particular families or a more systemic problem we should know about. That's one piece. Secondly, I was wondering if there are, if you're if the coalition is open to anybody who chooses to use the services or if there are particular if there's an application or qualifications of who is served by the coalition. And then my and then my third question was related to the work that's being done with migrant farm workers and whether there are legislative actions that you see as necessary. Or whether it was whether yeah whether there's legislative actions that you see as necessary. Let's open it up to any one of the witnesses to respond to represent Rogers series of questions to ask you to take turns and jump in. Since I brought up the timeliness of Medicaid approval I can, I can talk a little bit to that. It's been an ongoing issue, not just for magi Medicaid, which is for people under 65 and not disabled but also for green mountain care. There's a couple of different reasons like I said, since COVID-19 came into play, they're doing manual reviews to make sure that all the people who have a change in eligibility that they aren't throwing anybody off. So they don't want to take anybody off of Medicaid. So that slows the process right there. Then you also have people who may be going on for the first time. And there may be some pending issues those also have to be manually reviewed. And when you throw that all into a system that's already overtaxed because they've had a COVID-19 outbreak. It, it's a big deal. So, why it, I will tell you that on the case I spoke of there was no reason for that case to be languishing it's an ongoing issue of the different portals they have in the Medicaid system, and they don't talk to each other. And then there's a conflict like different addresses or slightly different spelling of a name or something like that. It creates a huge issue in the system and people don't get on and they can't access care because they're still not showing is active. That's been an ongoing issue for a long time and like I said now with COVID-19 and the manual processing thrown into the mix. I, it's definitely lengthening it and I know a lot of that is the system is just overtaxed. And I think I'd like to respond to the question about eligibility, income eligibility. So, good neighbor clinic runs a free medical clinic and a free dental clinic. And I joined the organization just six years ago, shortly after the Affordable Care Act was implemented. On the medical side is very clear that the patients who needed us had shifted slightly from people who were uninsured to people who are underinsured. And we made the decision in the medical clinic not to request that or require that people be under a certain income limit to receive services. The dental clinic had such an unrelenting demand for services that we felt it necessary to keep the 250% of the federal poverty level income eligibility. Now, here's what's really interesting. We still collect all the demographics and income information on all the patients. And we can say for sure that everybody at Red Logan is under 250% of federal poverty level. 98% of the people who use the medical clinic are under 300% of the poverty level. So, it hasn't really changed who's used the clinic it in fact just made it more welcoming I think. I'll just add quickly onto that to say that each of the clinics has a difference can have different policies about eligibility and so some continue to have some income eligibility requirements others don't. So it does vary a little bit clinic by clinic. And I would say representative Rogers said for us at open door. We are criterion is that one has to be at or below 300% of the federal poverty level. So for a family of one. That would mean that one could make $3,190 or less per month to qualify to see us. The vast majority probably 97% of our clients are uninsured versus underinsured. So there is that essential and we have some wiggle room. But that's our basic eligibility criterion. As far as legislation, and I'm going to call on Mari, who is one of our wonderful volunteers but you know, I, I'm not sure I can really answer this intelligently. I think if anything, I would love to see a day when our migrant workers are eligible for Vermont health connect and insurance in the state of Vermont health insurance. And with regard to getting through this pandemic and potential lost wages and things that they might be struggling with and in the non health care sector of their life, which is also part of our health. You know, I, I'm not, I'm not sure what might be a good solution. I know from seeing our patients in general or through what I've learned from Julia. Sometimes when people get ill, their employers will continue to pay them short term. Sometimes they're kicked off the farm there is a broad continuum of treatment and philosophies around what they can and and can't do or what they will or won't do and some of our farmers are very poor themselves. So, Mario, do you have anything to add to that. I agree with you 100%. I would like that universally anyone who lives in Vermont would be able to access health care. Period. And I if there is a way to get any kind of funding your clinics, and in particular to the migrant farm workers, I know Addison allies is a group that's raising funds to support migrant farm workers that might be out of work or might be might be ill. I think funding sources somehow during this this crisis would be immensely helpful. I did ask Vermont Community Foundation if it would be possible for them to award the Eric Rosendahl scholarship Eric was an organic farmer in Starksboro that died suddenly and there's a $5,000 scholarship I did ask if they might consider awarding that to the migrant farm workers. I haven't got one reply back I haven't heard more. I'd just like to add one other thing off of this topic representative Rogers but kind of big picture. You know when I think about us as our role or piece of a bigger part of a health care delivery system in Addison County, I think that one of the things that we can do and contribute to is especially at this time helping the hospital be able to focus their efforts and their energies on the on the COVID patients. And so I think our attempts at triaging and continuing to see our patients and triage them and use our best skills to either continue to send them to express care or the ED, but to hopefully, you know, to prevent unnecessary if you will visits to our ERs right now is another way that we're all making contributions within our network to the to the broader picture and supporting this horrible harrowing or deal. Can I ask, I see that I don't think Jen is with us still but Nolan is. Can I ask that our legislative council specifically provide us with any information about what the barriers, if there are federal barriers or barriers that exist. We can remove in Vermont in terms of access to any type of health coverage health insurance coverage for migrant workers or undocumented workers I have a sense that there are barriers that, but I would like us to understand as clearly as possible, if there's any barriers that we have control over that we can remove. So Nolan if you would pass that along to Jen as well. Okay, thank you. I see that we have number of other hands up and we're so I'm going to quickly keep moving through Brian, a representative. Yes. I have one question. If, if the time comes when you start losing some of your workforce due to illness. Will you have access to volunteers and resources from the medical reserve core for your clinics. I'll answer that many of our volunteers are active with the medical reserve core. I don't see us needing to go beyond the 24 physicians that we have actively as volunteers what we just need to do is set up that telehealth system. And, you know, each week we have a we have a new technological challenge so that's next. What Dana says at this time representative China. We have 170 volunteers and a huge cohort of those are interpreters but we have quite a number. And it's hard for me to imagine a number of them are retired and we have felt very protective of them at this time but at this point, I think we would be okay but every day is different. I agree with Dana that continuing to confront this new way of doing business and our, our paucity of technological resources and building upon those is probably where we need to put a greater effort. I have a couple of comments and questions and I'll just put them out there for you and you can respond appropriately. I notice in your annual report summary for 2019 from Barry to Burlington, North. We have no services whatsoever. But I'm assuming that those services are made up are made up by other agencies that are doing similar work to your, your, your agency. And we also have a number of migrant workers working at farms in the Northeast Kingdom as well. For your grant monies that you receive from the state I don't know how much money you receive from the state, but you do mention also that you receive $4.3 million of support from local hospitals. I would assume that those funds will probably hopefully not but probably will be maybe cut. I'm not sure due to this virus. I hope not but I just, I'd like to get your ideas on this. And then with additional funds that are coming from the feds through the UI funding and also this care program. Will that affect eligibility for patients that may otherwise be eligible for Medicaid. Thank you for your response. I'll just just quickly on the funding that we received the larger number that you quoted. I believe refers to in kind contributions from hospitals so those are donated space in some cases donated imaging services. Again, each clinic is different so but we do go through a process to value those donated services from hospitals so are some of the clinics do receive direct financial contributions from clinics but it's nowhere near that total amount of money. Receive a 1,000,000 total appropriation each year in the budget that supports that comes through the coalition comes through my organization and is distributed out to the clinics to support the work that they do. I think Lynn, Lynn might have. We were just talking this morning about your question I believe around do the will the unemployment benefits and such create problems be counted toward eligibility determinations I think the answer is we don't know yet. But Lynn may have more she wants to say about that. The unemployment will be counted towards their eligibility the question is, when are they going to know how much they're getting, and when they actually start collecting the check. Normally that's when we start counting it towards their eligibility for the health care programs. The stimulus part of it they're supposed, excuse me, economic incentive they're supposed to receive. My understanding is that will not count towards their income eligibility for the programs, but truthfully. There's no guidance out there on that yet so that's just based on googling and reading as much as I can. But, but that's the thing we're kind of at the bottom end of the chain sometimes when it comes to eligibility guidance. So it'd be nice to pick up the pace a little bit because we were seeing these patients firsthand. And do you expect that you're going to receive the same amount from the state of Vermont for your grant money that you did last year. And I jump in and just say that I don't think anybody has any idea what the state is going to be able to do the budget of last year was just basically put in a drawer by the Appropriations Committee and they're starting afresh. I don't say I don't think they're in any position to where and we're not in a position to say anything as well. I think it and the part of why we want to hear from these clinics is also it becomes a matter of advocacy on our part as well with our colleagues. Sorry to jump in that I just, I don't think there's any way to know. We were we were able to say we were included, low funded in the governor's proposed budget for whatever that's worth. Representative Cordes. Back to the conversation about migrant workers. The public charge, the federal public charge rule went into effect in February and one of the major public health concerns is for people that are afraid to go get medical help. Afraid of ice afraid of border patrol. What are we seeing Heidi can you talk about that in maybe an Edison County or Steve. I, I don't. Well, I should pull in Julia, actually, because I probably don't have enough information in my own head to answer you right now, Mari. I think that we're still getting a lot of calls from the migrant workers who we serve. I have sent several to express care and the ED in the last couple of weeks with things in terms of feeling a greater sense of isolation and fear with regard to the COVID-19. I can't adequately address that at the moment but we're happy to report in after we deliver some of these boxes. And, and I can also check with Julia and Naomi, our colleague in the northern tier of the state where the landscape is quite a bit different and much more threatening to migrant workers. If what she's seeing at this time. That would be great. Thanks, Heidi. Sure. I just wanted to say you bring up great points, delicate points, I think things that we think about when we're feeling really vulnerable. As we're responsible for fundraising at our clinics, but you know, for instance, the support we get from Porter Medical Center is rent free or lease free space. And they're very generous with another reporter office. And they're very generous to our patients in terms of lab and radiology services that they provide. And they also gifted us a small grant to help cover part of the cost of our navigator in the last two years. That I could see potentially going away if they start to suffer through all of this. I mean, who knows. We are respected by them and they would be very reluctant to, you know, not give us space any longer or not be able to serve our patients through radiology. We will see. And I would appreciate continued advocacy on all of your parts for us over the long haul. I know you'll probably all have to make very, very difficult decisions. As our entire state suffers on very new levels. But I think we're really important in the health care delivery system and do things nobody else really does. If I may, just a comment about migrant workers. I spoke to a local farm in our district and he was saying due to the coronavirus. He had not had too many recent visits by by ice personnel. And it's my understanding that they're pretty busy along the northern border. So, I don't know whether that eases some fears for some workers, but there's just one farm that I had spoken to yesterday. Thank you representative Christensen. And then after that representative Smith and then I think we're probably going to need to wind it up for the morning. I will first of all I want to thank you for everything you've done it's been a real eye opener to see the fire hose of things that are coming at you. But I was wondering, and you say you've thrown out new models and I know you're living just in the moment. But when you talk about triaging cases and keeping them from the ER. Is there ever a point. As I said you're living moment to moment at night you went, wow, that worked really good that we could take into the future with us. This is Dana I'll answer that. You know, we, all of us have a very, we have a lean staffing model and we have lean budgets. So, when I was approached by some of our volunteer physicians, a couple of years ago, and they suggested that I hire a nurse practitioner, instead of a RN to provide our patient case management. I kind of gulped because their pay scale is quite a bit higher than RN. At any rate, it took us over a year to fill the position, but we did it we have a wonderful nurse practitioner. And the beauty of that is, she can provide that level of triage patients who are calling herself herself. I mean, so they call comes in and then she calls them back from home right now. If I if, and someone asked you know what happens if our staff get sick. That's a huge worry for me, because if something happens to her. It means that our volunteers have to step in and then it's another layer of complexity. And he said our medical providers are reaching out to patients to and contacting them by phone, primarily. But, you know, it's a system that's put together. Elegantly, I will say it's an elegant system, and it's very simple. Not, but it doesn't have a lot of redundancy. It does to agree. I got it. It's hard. I'm trying to stay a step or two ahead in the planning but not 10 steps ahead. I know I know and at this point you're probably just living as I said moment to moment just keep on moving, you know, people so thank you for all that. Oh, I was just going to say to representative Christiansen. You know, our nurses have always triaged they do an impeccable job and have a lot of autonomy because we don't have an NP or an MD here during the week. And so I think it's more for us an extension of how we're doing business the nurses are taking the phone home at night, we're covering the phones on the weekends. And we typically haven't done that in the past. And we always have a consciousness about us to to do our best job of pointing patients where they need to go either coming to our clinic or going to express care and because we only have a clinic or two a week. There is always a dynamic for us that we can't see the patient because it's not clinic night or it's not going to be clinic night for five days. So we need to send them to the to express care so I think it's more, more of the same. And, but, but at a different level, and with a little more. I don't know, attention as all of this is unfolding and we're reevaluating every day. Do you have used telehealth in Springfield. So we're a referral clinic. So the SMCS providers do use telehealth, and they have screening processes in place. They have a drive up testing site in place. We're all coordinated with them so when we make a referral, or a patient calls us with possible symptoms the first thing we're going to do is refer them directly to that hotline through Springfield medical care systems to have them screen and and a termination made as to whether or not they need to be tested. They also have a walk in clinic there that so if somebody doesn't have a regular PCP. They have a walk in clinic there so somebody who just say they're from New York or something happens to need to get screened through a provider. There's that number there that we refer people to so they can they can call and get screen, but for us. We're not providing the care on site. So we're not providing any medical triage but we were referring them directly to the line that does. Okay, thank you. So bright representative Smith. I think this will be our last question for the morning. Thank you I'll be brief. I was listening about the conversation about trying to find funding, additional funding for the migrant workers. Are we talking about migrant workers with visas and green cards and we talk about illegal migrant workers. Well, vast majority of migrant workers who we serve representative Smith are, we don't ask about their documentation status we assume that they're undocumented. You know, the dairy industry, there isn't a legal means by which to come into this country and work on our dairy farms because they're considered year round employment. So there isn't a legal means by which for dairy workers to have papers and. So, so, well, if we found funding additional funding for migrant workers, and they were illegal you want to include them as well. Yes, in terms of health care. Absolutely. A lot of them are paying into our social security system and our government and, and they're, they're boosting our economy and part of our fabric so I would be an advocate for opening up health insurance to our dairy farm to our migrant workers who are on our dairy farms. Okay. I'll leave it at that. Thank you. You're welcome. Thank you. Well, I think, I think I'm going to bring us to a close for the morning. Thank you for each of the witnesses. Steve for helping to arrange this. It's, it's always important to hear what's happening on the front lines of your work. And it helps us think about what it is that we can do both in terms of the immediacy but also the longer term vision for access to health care for all of our monitors. So, thank you. Thank you very much. Thank you. Thank you. One of the things that we do suggest to so, yeah. So thank you, Steve. Thank you, Lynn Dana. Thank you. Heidi, thank you. Heidi, yes, thank you. Okay, so you guys welcome you to leave, leave our meeting for now. Thank you. Thank you. Thank you.