 Thank you. We are back after break. It is about 10 58 on April 14th. So we are going to continue our testimony on s 120 s 132. And we have with us. Ina back us who's the director of health care reform from the AHS. We have a list of folks so we'll we'll keep moving right along and people who have already testified who are also listed for 132 will not. You know we won't we won't have you back. Because we've asked you to do all your testimony at once so I'm looking for. I don't see Ina. Oh, they're sure Ina back us is here. Ina, are you here. Good. All right, terrific. You're in the room. Thank you for being here and we'll listen to your testimony and again, for all folks who haven't been in the room until just recently. Let's provide what you can of your testimony in writing to Nelly, and we'll get it on our web page so we have everything together. So, welcome, go ahead, Ina. Thank you. Madam chair for the record my name is Ina back as I am the director of health care reform at the agency of human services. I'm going to take a first looking at as 120 and and the committee's discussion this morning with amongst yourself and with witnesses about your priorities regarding affordability of health care. An important context to consider for the for the for the work that is proposed within as 120. And as you may be familiar the American rescue plan act and has recently provided for some considerable and significant movement with regard to the cost of health care coverage. And that will be true for Vermonters are is considered at this time to be the largest reform package since the implementation and passage of the affordable care act in 2011. This greatly expands the ACA's premium assistance program for enrollees and qualified health plans through health insurance exchanges and will result in many millions of dollars of impacting individual health insurance purchasers in our state. So this law expand eligibility for premium tax credits that offset the cost of health insurance. It also reduces the amount of household income, known as the contribution limit that should be spent on health insurance. These are significant. These are significant federal level changes that are going to have an impact in Vermont very soon. These changes have an impact on the purchase and affordability of health insurance in our state. And in light of this change, legislation has been created to modify Vermont's marketplace. So that small businesses who are purchasing insurance can also benefit from reduced premiums after they're being after being decoupled from the individual market where there is going to be so significant of an influx of federal assistance for health care coverage. The impact of these policy changes is going to be very real, but it should be measured and monitored and considered in the constellation of other health care reform initiatives. And I think there are some important things to keep in mind regarding this change. First that Vermonters are going to be notified of these new subsidies this spring and will have the opportunity to apply for them as a discount on their monthly premiums beginning this summer. Those who are enrolled with Blue Cross are already receiving mailings as of Monday and those with MVP receiving mailings in the coming days. Small businesses that are decoupled from the individual market should also experience tangible reductions in the cost of health insurance premiums for the 2022 plan gear. Because these subsidies are available currently for 2022 and we need to monitor and understand the extent of the reductions, we need to remain nimble in the case that the subsidies are not extended beyond 2022. And we need to be very creative in how we think about these subsidies in terms of the overall picture of affordability for Vermonters, particularly if the subsidies do indeed remain beyond 2022, which there is quite a bit of speculation that these subsidies could be made permanent in the future, but they are here now and should be considered in the context of the work that the S-122 proposes with respect to affordability. Moving now to S-132 and the discussion that I've been following along with this morning, which has been of great interest. I first wanted to speak to the question that's been raised a couple of times regarding the requirements of the all-payer model agreement for there to be a proposal related to the integration of Medicaid services, specifically Medicaid long-term services, home and community-based services, and mental health and substance use disorder services that are not currently a part of the total cost of care or the financial target services for the model agreement. I want to be very clear that our federal agreement asks that the state submit a proposal for how these services could be integrated into financial target services for a next or subsequent model. That proposal does not, we're not required to propose that they are integrated. We need to consider the pros and cons of integration of those services, and we've also been asked to consider those pros and cons in tandem with considering the potential targets for a next agreement, which very well may change from the targets that we have today. It's an open question about how the next agreement will handle targets for healthcare costs growth. Again, I don't want it to be misconstrued that it is imminent and required that in a next agreement, these services, these Medicaid services are subject to the same financial targets that other services are subject to in the agreement today. It is in the hands of the state to propose something that is prudent, that is responsible, and that certainly supports our Medicaid services of this kind. Speaking at a high level about S-132, S-132 proposes quite a many and a different health policy interventions in a number of different arenas. My overall feedback with regard to that approach is that the approach is not necessarily consistent with our need to focus on implementing the all-payer model implementation improvement plan and improving our performance in our all-payer model agreement. We are working with our federal partners in Medicare, as you know, in a very specific and customized arrangement for the state of Vermont for Medicare to be a partner with us in transforming healthcare payment and delivery. And that partnership is important to maintain, that partnership is important for us to be able to evolve in future or subsequent agreements. We have seen a federal commitment to moving away from fee-for-service as we've discussed before, and we understand that the federal government will continue to push in this direction. And as other witnesses have really aptly noted, we're really poised at this time to be able to harness federal partnerships across Medicare and Medicaid to really maximize our state's flexibility to evolve and to approach payment and delivery system reform in the long term and in a way that will allow us the time necessary to do the work of transformation in the payment and delivery system arena. These models, like I said, in partnership with Medicare, we are in a position where we could potentially evolve how the state partners with Medicare. We need to maximize our performance in our current agreement so that we're in good standing in that partnership and so that we can focus on demonstrating results through this model. I also think it's important to note how significant our progress has already been in moving away from fee-for-service reimbursement through the all-payer model. While we want to improve and push ourselves further and more towards a fixed perspective payment aspect of our model, moving away from fee-for-service is a stepwise process. Payments that are attached to quality and value are considered value-based payment, even if those payments aren't a fixed perspective payment. And Vermont has made significant progress through our federal state agreement in adopting value-based payments. I think there's some important highlights to note about how we're performing in this agreement and why it's very important that we continue to have commitment to focus on the payment and delivery system work that is happening through this agreement and how we can advance in the future. More than 80% of Vermont's Medicaid enrollees for whom Medicaid is the primary payer are attributed to the ACO and aligned to a value-based payment model. And this includes fixed perspective payments. Vermont is only one of two states nationally that has a payment model that meets the healthcare learning action payment network criteria for being an advanced, the most advanced value-based payment model. So we have made headway here and we are well positioned to continue in this vein. Fixed perspective payments, as I said, are not synonymous with value-based payments. They're a mechanism that can be used in value-based payment models. Our improvement plan is very focused on advancing this mechanism. In particular, the Vermont all-payer model agreement in fact has no requirements in of itself for fixed perspective payments. Instead, the agreement requires that an ACO offer a value-based payment model that includes the possibility for shared savings if it achieves its goals related to quality of care or utilization. Vermont providers who are participating in the Medicare ACO program are currently rewarded by Medicare as participants in advanced alternative payment models. Consistent with that framework for moving away from fee-for-service, consistent with Medicare's program for quality payment, paying for values through Medicare, rather than paying fee-for-service. Again, we need to be able to focus our activities on continuing to push away from fee-for-service, broadening value-based payment models further. So we've made significant progress and including our broad group of stakeholders who are working very hard to implement this model. Healthcare transformation does not happen overnight, and we have had a global health pandemic that has sat in the middle of the implementation of the all-payer model. It has disrupted, as you know, all of our lives to some degree and has certainly disrupted what has been the ordinary way that the healthcare system works in terms of the delivery of healthcare services. We want to be able to focus for the remainder of this agreement on continuing to progress towards value-based payment and delivery system redesign and reform. I think it's important to note that, again, our federal partners have been committed to value-based payment along with Vermont for years now in spanning multiple federal administrations. The current federal administration is still settling into its leadership. The current federal administration still clearly is operating the Center for Medicare and Medicaid Innovation. There is speculation about what the priorities for our federal partners might be. Certainly, our federal partners, again, have been committed to payment and delivery system reform now spanning multiple administrations. There's a recent commentary. It's an opinion piece that comes from Donald Berwick that was published in the Journal of the American Medical Association, JAMA. This is an opinion piece, but it is setting a vision from a healthcare thought leader for CMS and CMMI, specifically the Center for Medicare and Medicaid Innovation. It's setting a future vision for that and making some pretty bold recommendations in this opinion piece. But the recommendations suggest that our state certainly is well positioned to work with Medicare in the future because of the progress we have made to date because we are so aggressively pursuing value-based payment. I'll just read a little bit of this recommendation now, one of the recommendations in the piece, so that you can have an understanding of where this opinion is landing in terms of CMS and CMMI's authority in particular. A recommendation from Donald Berwick says that CMMI should use its authority to scale the ACO model nationally by making it mandatory for all Medicare participating clinicians and hospitals. Clinicians, hospitals and payers find it difficult to operate in an ambiguous world, straddling payment for volume and value. Although voluntary participation has made evaluation of ACO difficult, the Medicare Payment Advisory Commission and others have concluded that different CMS ACO models during the last 15 years have consistently produced modest savings for CMS. CMS should gradually but steadily expand ACO adoption during the next five years until virtually all Medicare participating organizations and clinicians are operating within accountable care organizations. Advanced primary care practice models will be a natural core feature. Part of the expansion should include as much as feasible progressing to capitation of ACOs for total cost of care. I share this recommendation because Vermont is in a unique situation where we have the, we have a federal partner, we have a special agreement as a state where we can work flexibly with Medicare, and hopefully towards our goals as well as Medicare's own goals as Medicare moves to be perhaps perhaps more mandatory in how it sets out its payment and delivery system reform agenda. I think it will be critical that Vermont has an avenue for us to continue our work as a state, our work as a state that is customized and that is reflecting our state's unique characteristics, rather than only working within federal constructs, constructs that are prescribed and that are perhaps mandatory for us to operate within. We've been able to customize the ACO model to date here in Vermont in a way that meets the objectives of our state, you know, much more critically than if we were working with an off the shelf model. Okay, thank you, Ina. Any questions of clarification at this point. I'm feeling a little bit pressured, because we have six more folks and our time is getting limited but Senator Hardy you have a question go ahead. Thank you, Senator Lyons. There was a lot packed in there and we've heard a lot from, you know, over the last few weeks, I guess I would just disagree with a lot of what you just said, and am concerned to hear that you're tying so closely, the global commitment waiver renewal waiver with the continuation of the ACO model, given all of the concerns that we as legislators have heard about the ACO model, and I just, you know, we have struggled over the last few weeks about how we can provide some kind of guidance or input into the global commitment waiver renewal which is happening during the off session, and that I know you'll have a lead role in in in putting together, and I guess I'm just concerned and wanted to note that after hearing your testimony. And, but I also want to hear from the other people who are on our screen because they haven't had as much chance to speak to the committee. So we're, this, this testimony is specifically, specifically directed toward the two bills that we're looking at. And so we're going to continue with that. And we're hearing from folks who have asked to testify so that is important. The testimony was not specifically directed to the bill so that's why it brought up a lot more than that so that's why we'll let's we'll get the testimony on our webpage and we'll have our discussion. After we've heard all the testimony, it's, you know, everyone has this up has an opportunity. I'm going to turn to Corey Gossison and this is James are you together, providing testimony together or are you providing separate testimony. No, we can be on together. Okay, good. Yeah. And, and, you know, you know went through a lot of the pieces that I think we had to contribute to the conversation. So, I would like from listening to just make the comment that there's buckets. When it comes to health care that it seems like we are jumping back and forth between and it's and I think it's helpful when I think of the buckets to really get a handle my arms around what are we trying to accomplish here what problem are we trying to and if you'll be patient with me I won't take long but I'll just say there's health care financing, and then there's payment and delivery reform, and the financing is how much does your insurance cost or how much does gets paid into a health care system. I hear everyone regularly say how much health care costs because of the premiums the cost of out of pockets the inflation. You know, true statements that are, you know, problems we want a problem we want to solve. But on the other hand, then we talked about payment and delivery system and then like last week I was in and we were talking about how much gets paid for a certain difference and it's not enough and that the discrepancy between what we pay for health care and how we pay for health care is really the sort of separation I just like to raise and make and say that that's really in our minds where, you know, the Ina had a lot of the points I would have made about the Biden administration, the, you know, the future as a real pertains to health reform. A lot of the things we are doing are being held up in this federal environment as this is the, this is the way forward for health care. You know, that isn't to say that we don't need to pay attention to what the implementation of our efforts here on the payment and delivery side. Maybe I'll pause here and just say, on the, on the health care financing side, the American rescue plan has really a game changer of incredible magnitude, getting rid of the cliff there's a couple of little things the family glitch there's other pieces that are still to be determined discussed and and addressed, but in terms of financing this could be an incredible game changer. And I'll just say this we're in the process of implementing those changes so that Vermonters for at least on these two years and get access to those increased subsidies. And, you know, like Nina, like Ina said, if, if those were to continue. I mean we really have to think about how we, we talk with our, our Vermont businesses about providing health care coverage because that, you know, the level of support that would go into people's premium payments would be incredibly large and and so paying attention to the financing side executing as we are we we are, you know, diva is responsible for the implementation of the exchange effort so that is going to be something to really pay attention to the financing side so that a lot of this conversation though has been on that the reform side and, you know, I think we're looking at it like whether it's a success or failure today and that's really not how we look at it. We, for fear of being redundant with Enos testimony but it's really, we only have one story that is we know fee for service has inherent motivations and incentives for the provider community without any regard for what the cost of that service, you know the total cost comes together at the end of the day without any regard for that in terms of or any hate the term but it's just the most clear any skin in the game and that is what our effort at Medicaid I'm speaking for Medicaid not the whole all payer effort at Medicaid we have set the principle that we wanted to get away from fee for service and we wanted to produce a more aligned healthcare system. We have done that I mean we have moved in that direction, is it perfect. No one would ever say that and I would hope no one would ever say that about anything we're always about continuous improvements. Our third priority at diva for expansion and improvement and what we do we, we are continuously looking for improvements but I would assume healthcare reform is a similar. You know process in terms of in this and looking back it. It's always evolving so I would not say I'm struggling a little bit because I'm keep thinking of a few of the comments that were made in relation to our effort of getting away from fee for any prospective payments alignment. We want alignment care coordination is part of alignment a lot of what we pay for to the ACO as part of our purchase is for that care coordination and alignment. You know, the comments that you've heard, some of them are are close to the reality and some of them are pretty far off the reality I'll pick one comment I'll say I'll just tell you that the ACO is absolutely not trying to build its own cadre of care care coordinator or its own care coordination system that they're here to provide technical assistance training opportunities and care model implementation, and they have intentionally understanding where what we are in our state and that we've got a long history of care coordination spoke to the blueprint started in, in the middle eight 2000s. We've been very concerned about primary care and care coordination, the ACO is supposed to build on that and create even more standardization alignment intersection. And the, they have intentionally tried to build on that local and existing care coordination infrastructure that that exists in the state so I, I really understand the fear of that comes with someone else is in charge and it's not the legislature or it's not the green man care board for diva but you know it isn't quite true. It isn't quite true to say that they're trying to build their own independent system of care or that it's, you know, privately held I mean we, we are, we are in control of their contract and to say that they aren't the only possibility we just put out a renewal for an RFP for our Vermont generation Medicaid program, ACO program, any ACO can, can, and come into that and bid on that opportunity we have not have intentionally not built it for one provider or one entity alone, we have intentionally built it in a way that it gets what we want which is, then, movement away from fee for service, accountability for the dollars that are paid quality accountability, and risk accountability that risk is what is a difference from the fee for service right if, and we want to pay prospectively I want to pay prospectively because I want both our budget to be manageable, not the ups and downs and I want the providers to know they have money in order to provide the services to pay their people so you know I hope it doesn't sound like a lecture it's a little bit of like a defense of, we know what our principles are and we'll keep moving towards that if the game changes I mean the execution and implementation that we've been engaged in at diva was built on the agreement signed by the previous administration, Governor Scott evaluated that agreement. In this first month in office, we had a conversation and, and it made sense right trying to create alignment we've here we've heard from many providers saying look every insurance relationship seems to be different it creates requirements of differential agreements, so we said well let's try to get it together and I remind you that this is only what we're, I'm into my fifth year I guess as a as the commissioner of diva, but really I mean, this is just so the beginning of this process in my mind and I just say, you're not going to get any reform effort that is creates a situation we say oh three years later oh we're all done and I don't think anybody's expecting that so I'm just saying that, you know, where we see issues and where we see areas for improvement, we're all for making those areas better. I will say we do have our experiences and we have our reports on the Medicaid experience. The 19 report is the latest report so for year 19 that's the latest report we have don't don't forget I know you don't. It's all COVID all the time, but we even made adjustments in that and we've, we got the feedback that our agreements in 20 were were really important in keeping our healthcare system intact for Vermonters during a health pandemic. So, but just to get back to the 19 report quality was improved that that's in the report. We've seen that providers that get prospective payments, they, they, they spend less versus the estimated total cost of care, then providers that are paid fee for service. So, it's, we're getting this feedback you couldn't get that kind of data without actually implementing and seeing a system work. We would like to see if, and I'll just say this as I guess I'll close because I know you have time constraints to say this that even if the all pair model doesn't continue, I still believe in getting away from fee for service I still believe in in alignment, and I still believe that we need a provider based entity to lead that those contractual and those relationship efforts and that care coordination effort. It seems to me that in Vermont we want efficiency, but we want local control, we want, you know, everything to cost less but we don't want it to be to come with the kind of movement that really required to create the sorts of efficiency. I mean, if you could put everything in Medicaid control and we would spend, we would spend what we had to spend right we would have the state budget, anything you want Medicaid to spend less you get it in the budget. And then the that gets put out through the Medicaid program obviously that's a relationship between the state legislature and the governor's office but but you understand my point that like we can spend more, we just don't have necessarily more to spend always. And so, I would just say, we're, we're trying to reform the health care system by paying differently and hopefully it creates a better product for the, for the Vermonter that uses the system, and it creates on the line system that's better for the, for the providers I think that the one other comment that I heard was, you know, the, there's some entities that say the data models and the data pools that valuable to some providers. And that might be because those providers are on the frontline and they're the ones that might have the best information about what social determinants and be are really impacting a certain individual if those that information. Now I've heard some, some providers say all I do is feed information in and I think to myself, oh my gosh I think that's what I want. I think to know, or we or the system should want to know may not mean but that's what the system should know and so that when something, some acute, you know, episode happens that the provider that's dealing that is treating as all the information at their fingertips and so, you know, I think I'll stop there I know I really didn't talk about the bills, but those bills seem really geared towards this. And that's sort of theory of the case that we've been trying to implement. That's right. So, Cory, thank you and I think, and I'm, I'm, I'm thinking that you have, and Nisa are representing the same. If you had technical questions about the, you know, sections of the bill that, you know, that Nisa was really prepared to talk to those. Okay, what would help I think at this point is if you would please send your written testimony with specific comments on the two bills. So I think we're, we're moving into an area of discussion and we want to keep it at a level of talking about the bills. So, but I do. It's okay. So can I just say this though is like if we had specific comments I mean one of the issues I just think is really important the reason I sort of say all the about the effort is it. I kind of agree with a few of the, with your, the testimony earlier where, you know, a national system of health care would, would create a lot of efficiency in this country. There's no doubt about that but we don't have that and we have as a state and we've walked up to that precipice. And not this administration, a previous administration walked away from that understanding the complicated nature of it. So, you know, if we're in the sit in that situation where this is where we are. We should probably not and this is really to the bills center lines. We should probably not do things that makes it less likely we can implement and execute on what we're trying to implement execute right now. I'm going to ask, I'm going to ask that we move on, simply because we're running out of time and we've got, we've got about four other folks who need to testify. Senator Hardy quick question. Thank you madam chair commissioner. Thank you for your comments I just want to clarify something I don't think any of us are disagreeing with moving away from fee for service I think you have you and your team have provided any testimony about why we should do that and our progress in making that happen so I just want to be clear that, you know, my concerns are not about that. And that's good. That's perfect Senator Hardy. Right well, and I think that I think that you know that the reforms that you're talking about sort of generically or you know broadly are super important. My concern is that we hear a lot about payment and we hear a lot about providers and this is clearly a payment and provider based reform effort. And, and I want to know how can we fit patients into that model and I think that one of the things that we're trying to do with s120 is to really hear from patients and and and hear what they're experiencing, and how we can include them in the reform process so that we make sure that their experience is when they go to the doctor or if they can even get to the doctor are taken into consideration so it's not just about payments it's not just about providers that it's also about patients and so I just want to be clear about that and we're way off the bills now but that's that's really part of the intention of it. We understand that what you're saying and obviously I think that everyone wants to reduce costs for patients and to ensure primary care and prevention access and access for social services, and access to acute care when it's necessary so that is the goal. And so we're going to continue to hear from people who have our concerns. And I first want to say thank you, Commissioner Gossison for being here and for your input. I think we could have a lively dialogue going forward. Thank you. First over to Mark, Hagee, are you Mark? Are you here? Yep, there you are. Thank you for being here. And you're muted. Thank you. I think I have that down by now. I appreciate the opportunity to testify for the record. My name is Mark Hage. I'm the director of benefit programs at Vermont NEA. I am also a former public school teacher. I want to begin by testifying to S-132 and then I want to speak briefly to S-120 at the end of my remarks. In respect to S-132, I want to express my support with some very key measures in the bill first expanding access to primary care without cost sharing. Thank you. Primary care is fundamental to an affordable and equitable health care system and placing such care under a deductible or any kind of high out of pocket charge, which is often the case today, runs counter to providing cost effective value based care to every Vermont. In fact, I would urge the legislature to direct even broader measures in this regard by removing primary care from cost sharing altogether and to declare that the physician shortage in this field is an urgent public health problem that must be resolved. We also support health insurance coverage for hearing aids. This is an issue I hear about from my members every year. These devices, as you well know, are prohibitively expensive and their unaffordability has a profoundly negative effect on the lives of the hearing impaired. And for me, hearing aids like primary care also fall into the category of value based medical services and devices. And I would also urge that they not be subject to a high deductible or a high out of pocket charge. For hearing impaired students. I know the difference these devices make in their lives, not just to the quality of their lives, but as Patrick flood noted also to their health, and I also watched my father struggle with this issue. I also support the provision in the bill that calls for analyzing increases and health insurers administrative expenses over the most recent five year period, and how those increases compare against the consumer price. In respect to holding the accountable care organization were accountable and transparent. I say I find it deeply problematic, but a large hospital centric institution that does not deliver medical care, but is demanding more transparency and accountability from doctors who do must be compelled by law to turn over its financial agreements to the state auditor. An organization committed to the public interest should have done that, as a matter of course, but I'm very grateful that you are compelling it in this bill. More generally, I'm at a loss to understand how the bills provisions in respect to the ACO would dramatically alter the status quo to the benefit of Ramoners and our health care system. To serve the public interest in the truest sense the ACO would need to prove first, it is committed as its core mission to making health care accessible, affordable and equitable for all, and then be able to prove to us that that is actually happening. Respectfully, I see no evidence that indeed quite the opposite. The labor models, including school employees and their families are struggling mightily with the cost of health care and health insurance. The cost of the health care and health insurance systems continue to rise as the ACO continues to extend its reach and influence into the health care system. The health care systems finance and delivery system becomes increasingly more centralized under the umbrella of one ACL with or without changes called for an S 132 that this dynamic will inevitably drive up prices and exacerbate the unaffordability and the inequity of health care. Patrick flood mentioned other provisions in this bill related to contracts and fee schedules etc. In this flood I don't have any issues against all of us. However, I must say again, I can't see how these changes will bring us any closer to achieving the goals of Ramon's first principle of health. To ensure universal access to and coverage for high quality medically necessary health services for all for monitors systemic barriers such as cost must not prevent people from accessing necessary health care. And all verminers must receive affordable and appropriate health care at the appropriate time, and in the appropriate setting. Most for monitors have no idea what one care is, or what it does. I do understand that health insurance costs are hurting them, their families and their employers, and they see no relief in sight. According to a report from Vermont State auditor from 2013 to 2020 blue crosses premiums for individuals families and small businesses increased an average of 65.6%. While the median family income over the same period rose by just 18%. In 2018 household insurance survey reported that 36% of Vermont adults under the age of 65 were under insured. And when it comes to our uninsured population whose numbers are very likely risen during the pandemic. Their plate is not addressed by one care. To lead a lower cost and expand access to care, they got to go to the root of the problem. That's hospital costs, it's specialty care costs, prescription drug costs and administrative costs. And as a hospital based entity, one care's best interests are not served by fewer hospitalizations, less specialty care or lower administrative costs. For these reasons, I believe Vermont would be better served by transitioning out of the ACO by the end of 2020 to a model of health care delivery that is financed and regulated differently. And that this can be accomplished. I'm confident. Without sacrificing the quality or the coordination of health care, more specifically, both in current systems of care coordination and quality evaluation at the state level that existed before one care. Put it in the hands of public servants and direct that this critical work be done in partnership with the medical community. As Commissioner Gustafson noted, we have a long successful history of care coordination in the state of Vermont. These folks need more support and more funding. I'm thinking about a robust system of coordinators and home health in the agencies of aging in community mental health centers with sash and the blueprint for health and others. Again, they existed before one care. They're oriented toward community based and prevention oriented care. Let's give them more resources and support, so they can continue to do the good work that they know how to do. Additionally, I believe diva can go back to handling all Medicaid funds in the absence of an ACO the way it did before one care. Once again, I have to stress, taking decisive measures to rectify the shortage of primary care doctors and allocate the resources needed to strengthen primary care is essential. And I would also and Ed Paik when spoke very eloquently, I think to that public nexus of finance and regulation. I would urge us as a state to finance health care through a system of global budgeting that is fair, sustainable transparent and subject to public regulation. I would negotiate the all payer model to permit Vermont the flexibility to align standard billing practices and fees for Medicaid, Medicare and commercial insurance carriers, thus facilitating the transition the global budgeting and a fair price setting system. I would also urge the establishment of a prescription drug affordability board as Maryland has done to leverage the power of state government to control the prices of high cost medication. The pharmaceutical industry and PBMs. This is one of the most predatory corporate sectors in the economy, and they are leaching the life out of the health care system, and out of the lives of working people. And much more than systemic reform is going to be needed to ultimately overcome that problem, but I believe the steps we can take here in Vermont to address it immediately. And one of those is the establishment of a prescription drug affordability board and Maryland has showed us the way to do that. So I'll close my comments there and s 132. In respect to s 120, I want to say emphatically that from on any a very strongly supports this legislation. We've been in collaboration and conversation with a number of other organizations that feel the same way. We've not had an opportunity I believe to testify today. That would be rights and democracy AARP United Professions of Vermont and VP, all of us want to see this bill passed. And we want to see that conversation at the community level. We need an healthcare. What kind of reforms will actually make a difference to take place. My members really like this bill, and they want to be part of that. So thank you for having the chance to talk to you about both bills today. So, and please send us your testimony, send your testimony to Nellie. So we can have it so thank you madam. Yeah, appreciate it very much. And we do we have a long list of people wanting to testify and we're only hearing the beginning of the list today so Jessica Morrison is here from the Vermont workers center. We don't know that we're going to be able to get to both Susan Barrett and Ruby Baker, but we will, we will make every effort to put you on the agenda if we don't get to you today. Tomorrow we can add some time in at the end after we've had our done some work on our childcare bill so we'll we'll try to find that time Nellie. This is a heads up for you. Welcome, and thank you for being here so we will listen to your testimony. Hi, thanks for the opportunity to speak. Like you said I'm from Vermont worker center and you heard from Ellen and grace earlier on as 120 and I'm going to speak more to us 132 as to introduce myself I'm a worker center member and a nurse practitioner living in Burlington. So we got us 32 that it appears to attempt to address some of the problems with the all payer ACO model that have come to the attention of legislators over the years. And we actually have a more fundamental set of concerns about the model that this bill does not address. Our most fundamental concern is that the ACO model doesn't help people with the major barriers we face to access and for health care. And our case just said if you're uninsured, it doesn't do anything for you. Do you have a high deductible plan doesn't do anything for you either. And if your insurance doesn't cover something you need. It doesn't solve that problem. And it's not that it just that just it doesn't solve these problems well it said it can't because it's not designed to. And there's been a lot of talk today already about primary care and one care is supposed to increase access to primary care. However, we're actually seeing the opposite that small primary care practices have been increasingly shutting their doors, all over Vermont, over the past number of years and I'm actually one of those primary care providers that was driven out of practice by myself. And I can tell you how challenging it is to stay open and continue to provide care to people in your current system, no matter how committed you are. I became a nurse practitioner because I really wanted to help people with prevention and wellness, but the reality is the increased squeeze on primary care providers both financially and with administrative and documentation burdens just doesn't give the time to do this. And it's burning out more and more providers like me who are trying to give quality care in our communities. And I think we gave very high quality care at our practice and it was really heartbreaking to have to close because the system wasn't set up for us to thrive. And the ACO likes to say that have to be payment solution to this but I've seen the rates that they pay and I can tell you that the current race of their bank just would not even come close to covering our operating costs are allowed for spending more time with patients. ACOs are also based on the assumption that payment reform will somehow bring down the cost of health care. And I think we have to ask ourselves, has that happened in the years that we've had ACOs in Vermont. One cares and experiment has been going on for nine years now. And it really hasn't succeeded in making health care more accessible or affordable. And on top of this, Vermont ACO one care is one of many ways that UVM Medical Center and Dartmouth Hitchcock are advancing their monopolization of health care in the region. And we're supporting this effort with public money through the ACO. I can't expect that a private company is going to represent the best interests of people in Vermont, and monopolies are hardly the road towards affordability. You may be aware that in California currently the Attorney General has sued the Sutter Health Network for using its regional dominance to drive up health care costs. So really think we're headed in the wrong direction in terms of affordability with ACO model. And since the all pair while agreement was signed, Vermont has siphoned now billions of public mainly Medicare dollars into this private corporation and Medicaid is a public program that's been a life saver for so many people in our state. And it shouldn't be privatized. And in fact, we should be going in the opposite direction by making health care, a public good for for everyone. So to sum up, we, we don't think that saving the ACO model through some of the measures that are proposed in 132 is going to address the challenges we're facing and providing health care to Vermont residents. We need a totally different approach that ensures that everyone can get health care. We urge you to listen to the voices your constituents and seriously consider alternatives that can actually serve the health needs of our communities. And we think that as 120 isn't more in a position to to advance that. And we really urge you to have a public process around that to so that more voices can be heard. I'll leave it there, but thank you, Jessica. Thank you. That was very clear and helpful. And so, if you don't mind submitting your testimony for us. We'll have it on our web page. Thank you. All right, what I'm going to suggest now committee is that and I'm going to look to Susan Barrett. You are here and Ruby Baker, you both are here to testify. We only have a few minutes left today and and thank you chair Mullen also for being here and Elena Barubi of the team from the Greenland care board. I just want to say, when yesterday was a very difficult day for us with our inability to do appropriate scheduling. So, we are over scheduled, which is unfortunate doesn't always happen in this committee but it did today. What I want to suggest is that we, if, and I'm going to look to each of you Ruby, Susan, Kevin Elena is tomorrow morning late in the morning, a time when you may be able to come back in and zoom back in. I haven't been in your shoes before Madam chair I understand the predicament you're in and we'll make it work for whatever has to be done. Let's do that and I'll Nellie will reach out and try to ensure that there's sufficient time I'm trying to think that we'll need probably a half an hour to 40 minutes. We'll make that happen so that you all can provide your testimony and we'll, we would like to hear it without being rushed into two seconds. Okay, and I appreciate your understanding on that. No problem. All right, Ruby is that something that you can live with her. I'll see you tomorrow. Perfect. Thank you. And I know Kate Logan was also with us on zoom earlier. And so Nellie we might have you reach out to her as well and see if we can get her in. Okay. All right so committee tomorrow we're going to spend our time on each 171. It is absolutely imperative that we get that bill out as soon as possible. We'll be working on that. So take some time. As I said, when we first got on. I do have some language from Sarah Kenny which we may or may not include but I'll make sure that Jen Carby has it. If we can look at it. We'll put it up on the web page. I have Nellie put it on the web page and then if you have any specific recommendations for improvements to the bill, we can also look at that I think I have one, maybe two at the most. Okay, anything else. You know the struggle that's going on right now is some of it is a huge struggle in our healthcare environment. You know that act one that act 48 did declare healthcare as a public good. So it does exist in our. Our statutes that it is a public good. At the same time we don't want to lose that we do want to make it very available and affordable for patients but as we've heard from Jessica. It's very difficult right now in this financial climate that Corey Godfrey brought up without a pocket and premium costs it's very difficult for patients to pay for healthcare and then as we're hearing from our providers reimbursement is insufficient to keep them alive. So, this becomes a catch 22. And so how do we ensure that we have sufficient funds to support our providers and at the same time make the healthcare affordable for our patients. And the other, the other thread we're hearing, which is critically important is how do we link up our, our healthcare providers, our acute care our chronic care, our clinical providers with our social service agencies. The other thread that that thread, which is the, the consistency thread when you're a patient going from one place to another. That one sometimes isn't apparent to to patients so there's a lot going on and we'll just keep plugging away center comings. I've probably been here along with chair mullin. We've been through these battles before I spent five years, I think, trying to get pharmaceutical costs down in this state. So, we're hearing on one hand that the cost is too high for patients, and it is. But on the other hand, we're hearing that reimbursement is too low for doctors, especially primary care docs and I think you find that the more they depend on our Medicaid rates. The less affordable their practices are. And we do have one dominant hospital. But I think we also need to keep in mind as we talk about affordability and availability the models we used to look at where you're up in Canada. And in those countries, people pay 50% or more of their income in taxes. Americans have a very different attitude towards taxes. And that's a struggle we've had but that's how you socialize the cost that I may not need it today. But I sure will need it tomorrow. I just received my daughter's bill. Her bill from on state employees insurance, but her bill for probably four weeks was more than the average Monterey's annual income. That's, that's just what the cost is. And that's frightening. And I'm not sure how, how we get there, but we're not, we're not going to solve this on the cheap. That's where every plan that's come up before the cost has come in, and everybody has gone into sticker shock and the idea has been dropped it's happened twice before. And we just need to be cognizant of that as we embark again. Well said, Senator, I've been through it with you and with chair mullin as well. You have. But, you know, there's also hope for, for moving forward. And that's, that's what our goal is to continue to move forward and to make improvements along the way. Oh, it is 12 o'clock. And I'm going to have another meeting. So do I. So thank you all for being here. This has been an enriching morning. And I'll see you later. Nellie, we can go off YouTube. Thank you. Thank, thanks for being understanding.