 Okay. Well, your testimony on the first Senate 53. Yes. For the record, Dr. Deb Richter. Does this mean I have to I have to go through this, right? Okay Deb Richter, I'm a family physician practicing family medicine and addiction medicine in Vermont and also Chair Vermont Health here for all and I'm here on behalf of Vermont Health here for all. And I'd like to start off by reminding the committee that Senate Health and Welfare Policy Committee spent two years drafting the bill that was started down the path of eventually providing publicly funded primary care to all Vermonters. In that time, the Senate Health and Welfare Committee took testimony from hundreds of witnesses. It had initially 13 co-sponsors and three other confirmed votes that got to the floor. Senate Finance passed it without comment. And unfortunately, the majority of the Senate Appropriations Committee did not agree with the policy of public financing of health care. And Senator Tim Ash created the strike ball amendment you see before you in the revised version of S53. So the advocates are actually very confused about the purpose of the policy committee and the purpose of the money committees were confused. But we'd like to say that this revised version- In the Senate. Pardon? In the Senate. Yeah, yes, in the Senate. And so, yes, thank you very much, yes. In the Senate, we're very confused. So I don't know who can clear this up for us. It won't be us. Okay. It will not be us who are going to clarify what the Senate committees do and don't do. This revised version of S53 is passed by Senate. The Senate is nothing more than a study which will be shelved and will not lead us to meaningful reform. Vermont Health Care for All would like the original language restored and why? Because there are three main reasons, first of all, primary care is the most valuable sector in health care. Secondly, cost sharing and paid access. Third, importance of public funding of primary care is the only way to make it universal. And all of three of them were essentially eliminated in the revised version of S53. So primary care being the most valuable sector, the value of that is indisputable. In a nutshell, studies show that when primary care is available to a population, the outcomes are better. The health of the population is improved, system costs are lower, and quality of care is improved. Much of this is due to patients accessing care early on their disease, patients having continuity of care with a provider who specializes in them. And whom they have an established ongoing relationship with, and I have references that have been put on the website. It should be noted that primary care, while having great value, has a very reasonable price tag. Well, we will be spending $2.5 billion on hospitals this year. This, more than 6 billion in total in health care. Primary care is actually less than 6% of the total, and that's including mental health and substance abuse services. So we're getting really, in a sense, you can get great value for the money. The second point I want to make is, and again, some of these points will be elaborated by other witnesses, but the cost sharing, and that was in the form of it having no insurance, you're sharing all the cost if you have high co-pays and deductibles. But recognizing the value of primary care, Vermont Health Care for All endorses elimination of cost sharing for primary care, why? The original version sought to remove financial barriers to care by eliminating cost sharing for primary care, meaning no deductibles, co-pays, or direct payments. We feel the evidence shows the impede access to primary care. I'd like to mention that Dr. Elliot Fisher, I'm sure all of you are aware of who he is. He's the director of the Dartmouth Institute for Health Policy. And as the father of the ACO and all payer movement nationally, he has a similar concern in an exchange published in the New England Journal of Medicine. Commenting on the rise of cost sharing and deductibles, he stated, quote, By systems invest anew in primary care and care coordination, patients have a new incentive to avoid their doctors. Substantial or poorly targeted cost sharing could easily undermine these approaches. Numerous studies have shown that cost sharing is a blunt instrument, causing patients to cut back on both needed and wasteful care. ACO, the all payer movement in Vermont, does not eliminate cost sharing. I don't know if everyone is aware of that. I think they think we're paying doctors differently. But the patient comes to the ACO with significant cost sharing still in place. So they still have an incentive to avoid care. So if someone's uninsured prior to going to the ACO, they may enter care with diseases that were entirely preventable had they sought care earlier. Now there's a RAND study frequently quoted. It was done in 1970. It did conclude that when people are subjected to cost sharing, they use less care. It's true. It concluded that people use less unnecessary care, but they also use less necessary care. And the same is probably true today. We must ask ourselves, is this what we want when it comes to primary care? Do we want people to avoid primary care? Most of it is in the form of prevention of primary disease, secondary complications when someone already has a disease. And let's face it, the biggest experiment in cost sharing is with the uninsured. Who we know are two to three times more likely to die of the same disease as their insured counterparts. And I would say that primary care is where patients go to to determine what is necessary and unnecessary. We don't want to see them avoiding this care. My third point is the importance of the public funding of primary care, which again was put into question in the original version you had before you, of S53. But why do we need to publicly fund primary care and all health care eventually? It's the only thing that allows continuous coverage and prevents churning. What we see now is people, especially seasonal workers, they're on Medicaid, they're off Medicaid. I see them all the time. They come in when they have insurance and they don't come in when they don't. It allows continuity of care. It's also the fairness. I think it's principle 11 up there. The financing of health care in Vermont must be sufficient, fair, predictable, transparent, sustainable, and shared equitably. It's one of the principles that we are here to discuss. The other reason is it establishes primary care as a public good. Defining public good implies progressive financing. I'd like to add that this committee and the House passed a bill that would get us down the path of an individual mandate. The Supreme Court determined that the individual mandate is a tax. It's okay. We can do it. But it's an unfair regressive one. And poor people pay a much higher percentage. So I think we need to consider what we're considering it's okay to publicly finance when it comes to private insurance, but we don't have the same standard when it comes to people who are uninsured and these other things. And also why should it be universal? Again, the administrative costs are lower. And the other point that we never talk about is that we're paying the whole bill anyway. The $6 billion in health care, pick a pocket and see if you're left pocket in the form of insurance, your right pocket in the form of an out-of-pocket payment or taxes, we're paying the entire bill. So why not make it out there and determine it publicly what we want to pay for and what we don't want to pay for? And again, it prevents the churning. So those are the reasons that we want the original language restored. However, there is one section that we favor in the new bill that is striking out the money that comes from the ACO planning. And we want to give the Green Mountain Care Board the money to get this work done. We also favor the Green Mountain Care Board asking them to consider using excess hospital revenue. When we do get universal primary care, some of those funds to be put into the primary care fund to prevent people from being hospitalized. And I did include language about that. So that is pretty much a summary of my statement. Questions? Do you identify as a primary care physician? Do I identify as one? Yes. Do you, as a primary care physician, do you think it includes more than just medical services? Like should it also include chiropractic, for example, or other kinds of services? Yes. I think that when there is evidence that chiropractic care can help with certain conditions absolutely. It also, as I want to emphasize again, should include mental health and substance abuse services. Those are actually, it is by in statute in Vermont that those services are actually included in the definition of primary care. Yes. Those all should be integrated. I also believe that hard primary care are social determinants of health and that we need to look into that, but that is another issue we do. So would it be fair to say that universal primary care would be the universal preventive care? It would be a much broader conception of what we are providing people with. Yes. And I would add that there are countries that have done this, Costa Rica, which is should be an embarrassment to us, actually has a longer life expectancy and better outcomes because they do have universal primary care that does include the things that you mentioned. So I think that there are other countries that we can learn from that have done this. Spain is another one. And we found that people live longer if their costs are lower and outcomes are better. How do those countries finance their systems? They are all publicly financed. It is not to say that there is no private insurance, but it is usually for the extras. Most countries have some form of private insurance to cover some things. But public insurance is the majority of how they fund health care. Is it their tax system? Yes. Again, countries differ. Some it is a payroll tax. Some it is an income tax. They have various forms of taxes depending on the country. Am I correct in understanding that in terms of restoring the language that the Senate Health and Welfare Committee passed, which is what you are advocating for, that am I correct in understanding that they did not identify a financing source? That is correct. I just want to make sure that. So the money committee did not identify the money? Well, the Health and Welfare Committee didn't direct any specific way to finance it. Well, not to finance universal primary care, but to finance the operations plan. That is essentially the operations plan. I think that might be from Nicaragua. Michael from Nicaragua. They defined the money to start the operations plan as coming from the ACL planning money that was funded in part, I believe, by the state and the feds. So to take a portion of that. And then that is why it ended up in appropriations. What is the record? My name is Alan Ramsey. I am a family physician. I'm here to testify in support of the original S53 universal primary care bill that was commended and passed out of the Senate Health and Welfare Committee. Let me, just for those of you who don't know me, let me just make one minute and talk about my credentials. This is number one. I've been teaching and practicing family medicine for about 38 years. I consider myself an expert around defining the value that primary care brings to Vermonters. Number two, I practice and I'm the medical director of the People's Clinic in very Vermont. I consider myself an expert on the care of those who are uninsured or underinsured. Number three, most importantly, in my discussion today, I spent five years on the Green Mountain Care Board. I would argue and debate that I know more about the commercial health insurance model for financing health care services than any other physician in Vermont having spent five years regulating premiums for commercial health insurance plans both fathered and grandfathered in the Affordable Care Act. Those are my credentials. So what I'd like to do is walk you through my discussion here and I'm going to the second slide. I'm going to not spend a lot of time on it because I think you're going to hear from other presenters about why we implement universal primary care. We have a system already in place that will operationalize universal primary care. We have a health care regulatory authority that no other state has, Green Mountain Care Board. Our current reform initiatives do not in any way address access to health care for the uninsured, which are going to drive up costs any way you look at it. Okay? I'm not going to spend a lot of time on that. The second slide, I want to start with discussion about public financing of universal primary care and why it is so critical. We are going to see, you are all going to deal with escalating uninsured rates in the state of Vermont. I'm predicting in two years it will be 8 to 10 percent. I'm actually changing my prediction a little bit, thinking it will be more like 10 to 12 percent by 2020. In this state, 10 to 12 percent of Vermonters will have no health insurance. This silver loading is a brief step, but people are going to drop out of Vermont Health Connect when they see the premiums going up, and when there's no band aid. That's just the reality. People are not going to be enrolled in Medicaid because the enrollment and re-enrollment process is complicated and they just drop out. I see this at the People's Clinic every week. They say, oh, it's too complicated for me. I'll just go bare. Okay? So that's what we're facing. Lastly, the insurance model will never lead to universal access to health care. The insurance model. Because in the insurance model, there will always be winners and losers, and those that underwrite commercial insurance for health care will always be the winners. Those rates are always going to go up. That's the reality. Now, what does commercial health insurance do well? It indemnifies us. It makes good on things that happen to us that are bad. Universal primary care is not going to take away anybody's major medical health insurance. We're all going to need it. It's just going to give people access to preventive health services that reduce the likelihood of a major medical event. Commercial health insurance does really well in certain aspects. Not in primary care. That's my argument. Now, next slide. Do you wish to entertain questions along the way? Yes, absolutely. Just a quick question about, I think it was on the last slide about the uninsured rate. It's a pretty bold claim, 10 to 12%. Is that anecdotal? Is there actual real stuff behind that? Where are you getting that number from? I'm getting that number from... It's not actuarial. It's not even evidence-based. It is my own personal experience working for six years with the uninsured and seeing how it's not only the uninsured, I have people coming to the people's clinic with low value, these bronze healthcare plans that pay for nothing, that can't afford the deductible to get an MRI that their doctor or their urgent care center has recommended to them. So it is anecdotal. I may be wrong. I hope I'm wrong. I would love to be wrong. I'd love to see in 2020 that we're still at 5% or 6%. I just don't see that. Questions? All right, the basic principles in the original version of SPSP, they really have a lot to do with cost share. They really have a lot to do with what this bill can do to incentivize people to use the lowest cost services at the earliest point in their healthcare need. Not at the last point, not when that loan has gotten so big and so painful that you have to do something. It incentivizes that process by taking away the cost sharing burden. It lowers the cost, and basically we're lowering the growth in state healthcare costs by transitioning the delivery system to those to the best, the least intensive and most affordable level of care. The strikeout version does not respect these principles. It addresses the administrative burden that I face every single. I could tell you stories about prior authorization that you just won't believe. I can tell you one from yesterday, that you will not believe that I had to spend 30 minutes at the Vermont respite house, which we only take care of, dying patients, doing a prior authorization for Medicaid to get boost for a patient of my intimate, I mean boost is a high protein supplement who has a head and neck cancer that can't take anything else. You can't make that story up, okay? So, the next slide. Let's go on. I want to get through this because you've got a lot of testimony to hear. Appreciate it. Questions. Now we're at the original version of S53 was amended to assure operational and financial protections. For those of you who remember, this is the mirror of what I call the Mullen amendments when we passed Act 48. We had to do these things before we could actually implement the program, okay? And the Greenland care board, the first year that I was on the board, we thought about how are we going to achieve the goals of the Mullen amendments? Now these are a set of amendments that follow along that same course. It has established, it has to provide specific regulatory authority, allows for a phase in period. We're not doing this overnight. It establishes a set of conditions that are met including stable and adequate financing and would establish targets for a total primary care spend rate. Now I want to talk about that in the next slide. In the original bill, we talked about working groups. In the strikeout bill, we talked about stakeholders, okay? I want to tell you the difference between a working group and stakeholders. I want to make sure we're talking about the same using the same references. Right. You're talking about the original bill. You're not talking about the bills introduced. Right. The original bill says a working group. The strikeout bill says a stakeholder group. I'm trying, I simply want you to clarify which bill you're talking about when you say, because in fact, if I'm correct, maybe I'm wrong, the bill is introduced, the bill is passed by Senate Health and Welfare, and the bill is passed by the Senate coming out. And you heard, and you have meetings of both bills on Friday. We did. Okay, good. But I'm just, when you refer to which. All right. Let me refer to the Senate Health and Welfare bill which establishes a working group. All right. I like that. No, I'm fine. I'm just, I'm just trying to clarify. I'm just referring to the strikeout bill passed by the Senate which talks about a stakeholder group. Yeah, the strike all amendments. Yeah, the strike all amendments. One of the things in the italics there are that the Greenmount Care Board would convene a stakeholder group. Now, I have a lot of experience with stakeholder groups and the Greenmount Care Board because I convened one when you passed the bill to develop a prior authorization pilot program. Four years ago, five years ago. Okay. It began as a stakeholder group and nothing got done for six or seven months because stakeholders have a stake in things and the insurers had a big stake in changing the prior authorization rule. Okay. Finally, I said, okay, if we can't do anything, I'll go back to the legislature and they'll give me some guidance. And they'll, now we became a working group. When I said that, we became a working group. We passed a pilot around prior authorization. Now, you guys are the stakeholders here. We don't need a stakeholder group. You are elected to do this work. You are the stakeholders that represent Vermonters. A working group is a group that is convened in the original Senate health and welfare bill to actually do the work to operationalize universal primary care. So, there was a big difference. I don't think people understand. There's a big difference between saying those two things in two different bills. A financing plan. Now, there was no mention in the Senate passed strikeout bill of a primary care spend rate, which would be an essential component to financing universal primary care. Where every entity, whether you're an ACO, hospital and insurer, says we spend this percent on primary care and we will increase that percent a certain amount to achieve the goals of universal primary care. That's primary care spending. Ask one care. What does their primary care spend rate? They don't know. The Green Round Care Board right now is working on that process. They will do that work. So, a financing plan has to include a primary care defined primary care spend rate and a primary care trust fund. And there is model legislation about how that could be done. Remember, this is six to seven percent of the total spend in the state. Six to seven percent of the total spend of six billion dollars goes to primary care. It's totally inadequate, but until we define it and start regulating it, we won't achieve any goals. I think you're going to hear about the Rhode Island Small State Financial Evidence to support a universal primary care program where they actually, in 2010, required commercial health insurers to increase their allocation to primary care by one percent a year for five years. My understanding of the debate in the legislature when that law was passed is, as you expect, commercial insurers felt the sky would fall if we had to do that. If we had to regulate to increase in primary care spending. But what we found after five years is increasing that primary care, commercial rate primary care spend by one percent a year led to an eighteen percent drop in total spending. In that five year period. In that five year period. And I think the commercial insurers now, they're continuing that program and they're very enthusiastic. I don't know, we don't have final report in the last four years, but they're quite enthusiastic. And that's a small state that took this legislative approach in 2010. Quite a couple of questions. Right. Was there a reason that the dropped eighteen percent? I mean, you're saying this is, we did this and this happened. I mean, is there... Well, it's either utilization or price structure. Utilization times prices cost. It is unlikely that utilization went down in a small state like Rhode Island. They don't have a huge population. They didn't have a delivery system like we have. I suspect that it led to the commercial insurers looking at how they set their prices and paid their... No studying. We don't know that detail. Just checking. Thank you. This one. Okay. Right. I have two questions I think. One is, do you happen to know the population of Rhode Island? It's twice. Yeah, it's about a million, too. Okay. And do you know how many commercial insurers are involved in the system in Rhode Island? No, I don't. I know in Vermont there's a lot, but we have like two major ones, but I mean there are a lot, because there's all these other, all these plans for... They have an insurance commission. Okay. But it doesn't have quite the authority in that degree not to care about this. I know that much about Rhode Island. I'd be curious to learn more about this, not necessarily from you, but I don't know if there's other witnesses that could see. Yes, we are going to hear other witnesses that are going to talk about this. Okay. From Rhode Island. I believe. Yes. I don't know. This morning. Do, can we estimate in the next slide potential universal primary care savings? There is no actuarial way to estimate this amount. Okay. So all we can say is one, all we can say is could we, by increasing the primary care spend rate from 6% to 7% to 10%, could we reduce the total primary, total health care spend in the state? If we took the total spend, which is around $6 billion, a 10% reduction, I've mentioned it would be $51 million, a 10% reduction would be $513 million a year. If we took just the hospital expenditures, just the total hospital spending, and we increased that spend rate to 10%, I went through the same numbers with the economic adults. And I will say that the accountable care organization model, which is basically dominating our health care reform landscape right now, has not shown meaningful health care savings. You all must know that. You probably know that. In the Medicare shared savings program. We hope they will. We hope they'll stay within a 3.5%, 3.5% to the all clear model. We hope. It's going to be a big stretch. Next slide. And we're almost done. The Senate strikeout version, S53, it's not meaningful legislation. It is not meaningful legislation compared to what came out of the policy and primary two year policy debate that occurred in Senate health and welfare. It proposes a study of the feasibility. That's exactly what we have done for two years in the Senate, is we've established the feasibility of universal primary care. It suggests private insurance income sensitized cost sharing will increase utilization of primary care services. This is an extraordinary statement to someone who has looked at how premiums are established in the commercial health insurance market for five years. This would drive premiums up for all of us without any hope. And if you don't think they're going to be it's a trouble now. Wait till they get, wait till the projected premiums are presented to the Green Mountain Care Board in six weeks with a flu epidemic, okay, with risk insurance, with risk corridors gone. I mean fasten your seat belts in terms of premiums. And now we're talking about insurance income sensitized cost sharing. I mean from someone that's looked at premium increases for five years I'm very concerned about that kind of proposal. Again, we talked about insurance models of health care coverage have never led to universal access. Convenes a group of interest stakeholders. We talked about the difference between stakeholders in the strikeout version and what a true working group would do. And those stakeholders already are doing well in the health care system. Has anybody looked at the results of the actual results of the hospital budgets from 2017? The Green Mountain Care Board is struggling in developing proposals as we speak for how to deal with the revenue excesses that have been declared in the actual budget for 2017. Those who oppose, next slide. Those who oppose, either oppose or do not support the original S53 bill. First it was the Appropriations Committee. I sat through that two-hour session but only 20 minutes. 20 minutes were spent on the Senate Health and Welfare bill with minimal actual discussion about appropriations. This was the Appropriations Committee striking out a bill adding language at the last minute. And I was there to hear about appropriations. Not about striking out meaningful policy that came out of a policy committee that took testimony from the public. Yes. You're clearly making the case that you don't support what happened in the Senate. This is inclusion. I think we can stick away to the fact that we don't need to... Stick away to the fact that you don't support that. What I would like to ask is, and you do support what the Senate Health and Welfare Committee did, if the legislature stakeholders, as you indicated, if the stakeholders conclude not to support what the Senate Health and Welfare Committee did, is it your view that it's important to not go forward with what the Senate passed? Or is that... We need to cut to the chase here and say, okay, we got it. You're disappointed. You're upset. The Senate Health and Welfare Committee took a step in the direction, perhaps not fully in the direction that you wished it had. We haven't really talked about that, but at this point, that's become somehow the gold standard. And what you're hoping and what Dr. Richter indicated, we should try to reestablish here in order to try to move this process forward in the manner that you really believe strongly should happen. But absent that, I would ask you to comment on whether you think there's anything that you're going forward with what the Senate has passed or should we do nothing at this point? Or should we do something else? Because right now it's set up as a binary choice of either or. And, of course, you know in this building it's not either or. But I do want to ask you about the or because you're making a strong case for what the Senate Health and Welfare Committee did and frankly I don't know, I could not tell you what this group of stakeholders will choose to do. But we will be trying hard over the next period of days because we don't have weeks and weeks, we have days to sort through some of this and it would be helpful to me to have a sense from you and from Dr. Richter who I meant to ask the same question pretty previously and I would still like to. Can I answer that? I'm here to represent my family colleagues throughout the state, particularly in the rural areas of the state, particularly in those that have been so burdened in the last six or seven years by measures by performance standards, by utilization control, by prior authorization, I'm here to represent primarily to represent them. In that sense I would support any effort to keep this alive. I would like to move it from hospice to at least to some sort of palliative care I would like to achieve that so my answer is that I'm here to speak for the Vermont Chapter of the American Academy of Family Physicians of which I'm a delegate to the National Conference or the Social Calendar I would have to say give us anything that we can say to my colleagues we're doing the best we can we're not going to let this hospice die, we're going to keep it alive a little longer on the other hand I would like to say to you with a set of credentials that I had hoped would establish a little more debate around policy that was my hope I appreciate that at some point I'd like Dr. Richard to give a way as well because I think that is a fair one it's just a brief statement if we're using the patient analogy this patient using patient analogies and in my view this version the patient has braved it they're on life support but they're not alive and this has no chance to be anything meaningful it just I believe gives legislators a feeling that they did something about primary care and it's the frustrations of Romaners every time that we end up with another study that ends up getting shelved I think it's better off dying if that's the case so you'll need to consult with your medical colleagues for around the patient situation we have ethics to be I'm going to drop that analogy I think it's helpful to a point Brian I really want to run with the analogy and say that I would love to restore the chromosomes and bring the patient completely back to their prime but that being said curious you witnessed what happened in appropriations from your perspective why did this change occur what happened I'm not representing that I'm not a politician by any sense you've heard me today I think that there was my sense is that there was a preconceived decision even knowing the majority of senators committed to voting yes affirmative on the original Senate health and welfare bill I think there was a decision made even before it got to appropriations that that was not in the best interest of Romaners that's the best I can say okay lastly well those who oppose you can read through this again I will just say finally that we have a workforce crisis we have done nothing nothing substantially to address the primary care workforce crisis there's no evidence that this would address that crisis but there's no evidence that it wouldn't anyone has argued the universal primary care nobody has argued or effectively contested that universal primary care could be a way to attract primary care physicians and more students into primary care careers we have some evidence from Dartmouth medical school I have some evidence from the national AAFP congress that it would unless we address that crisis we will have primary care in five years again another prediction I don't have evidence on this based on my experience for 38 years we will receive our primary care in the next 5 to 10 years at urgent health at retail clinics or on the internet unless we address this primary care and mental health crisis I think the legislature spent a lot of time into the mental health crisis that's great but it's broader than that so in no testimony has disputed universal primary care is incompatible with our current health care reform efforts the accountable care is an all-care waiver there's no one that's that has contested that it is incompatible with what we're already doing that's all I can say I'm concerned in terms of our time I'm just taking some of the time as well but are there immediate questions then word force is something that we deal with in our community so I have an interest in this would it be possible to get a copy of this survey of the survey I can send it to you we actually did a UBM survey too we tried to collate the two and let me try to get that together I'll send it to you I think Dr. Ramsey I think I think you have more experience and knowledge on the whole financial complexity than a lot of our businesses because of your time on the Green Man Care Board and you know we have a RAM report that really drilled down into where the dollars are all flowing and roughly 30 percent is through net federal inflow not just Medicaid but all sorts of net so have you looked at or how much have you looked at how the complexities of the federal inflow would align into working out this model without losing any of that 30 percent of our care we're getting subsidized by the rest of the country right now 30 percent of the cost well that's a great question Medicaid again is a program if you have full Medicaid coverage you have first dollar coverage for your primary care services Medicare is different and there are many of your Medicare constituents that are concerned about this bill because they've paid into Medicare and now they feel like if there's any general fund allocation I'm going to pay into it for something that I may or may not benefit from you know that's a reality many and we'd have to deal with that reality as we looked at the total financing plan so we've got the Medicaid we've got the Medicare I think that we would have to work fairly closely with CMMI to establish this process through our all payer waiver I'm not talking about Medicare or Medicaid I'm talking about all of the vast other federal inflow of dollars and how we ensure that we don't lose any of that if it's paying 30 percent of our bill right now again and that is one of the things that led to one of the amendments during the Senate health and welfare debate is that we would have to not diminish the flow of dollar federal dollars into the state in any way okay that involves tax benefits tax benefits there is a house savings account house savings account don't worry about that there are health resource accounts owned by the companies but we don't have any of those in Vermont so there's a lot so I'm not sure I did not organize the witness list so I'm going to turn to Lori to help me understand is Herb Olsen, Herve are you on the line is Michael Fine on the line I'm on the line okay do you why don't we turn to you and hear from you since you're on the line and if Herb Olsen is he expected to join the conference at some point okay why don't we hear from Dr. Fine and I'm going to open it up to you to make comment we don't have a specific set of questions for you but obviously you're looking to comment on the bill as it's coming from the Senate and also the Rhode Island right well I'm assuming that I'm assuming that's because why don't you start by identifying yourself for our record introducing yourself to the committee and then sharing some brief comments only because of our time but we are interested in hearing from you great thank you I'll be if I can Mr. Chair and members of the committee it's a great honor to be here however it's just going to be before you I'm sitting in San Wanda and I'm glad we're doing a work in Spanish so that I can better work with the members of the population can you try to speak up some for our it's going to be if you can over speak if you will to speak more loudly than you think is comfortable it might help us and we'll kind of coach you along with because right now I don't think most people can hear okay that's significantly better that's significantly better thank you great I'm I was the director of the Rhode Island Department of Health between 2011 and 2015 I'm a family physician I'm now the chief health strategist for the city of Central Falls Rhode Island and the clinical and population health officer for Blackstone Valley Community Health Care a large community health center in Blackstone Valley in the northern part of Rhode Island together the city and Blackstone Valley Health Care are building the first neighborhood health station in the United States where we will provide surgeon care, primary care dental behavior, behavioral health care oral health, physical therapy and the EMS for the entire population of the city of Central Falls to help get at some of the same issues that universal primary care will get at in Vermont and I'm really here to testify mostly about universal primary care I really don't have specific information about the various versions of the bills when we talk about universal primary care there are really two challenges that we're hoping to solve the first is to improve population health and the second is to reduce cost to improve population health we really need to include everyone in prevention now in Rhode Island 55% of people get primary care people have access to health insurance but only about 55% of people actually use that health insurance for primary care and of those 50 to 70% or less get the recommended preventive activities that they need in order to maintain their health as individuals and that together represents a significant public health failure because that means we're bringing prevention only to 25 to 35 or 40% of the population as a whole prevention becomes meaningful when we include everyone and we have so far as the state of Rhode Island and as a nation fails to be able to do that when most of the population gets prevention we get the biggest effect from a population and the other major challenge that we look to address is in fact the challenge of cost as you've heard about already the real challenge on the cost side is that we don't really have a healthcare system and we don't have ways to help people understand how to get the kind of care they need in the time that they need in a way that's most cost effective so many people use emergency departments that don't need them many people get hospitalized many people use EMS when they didn't need EMS in Rhode Island 50% of all emergency department utilization is what's called primary care it could have been taken care of in a primary care situation and the difference in the cost of each of those visits is astronomical a single primary care visit for a relatively routine medical problem might cost as much $150 you take the same problem to an emergency department and the cost becomes $5,000 to $10,000 or more and that's if the person didn't get admitted to the hospital in Rhode Island 10 to 20% of all hospital admissions are likely unnecessary or could have been addressed in a primary care environment and 70% of all emergency medical services are for problems that could have been addressed in a primary care office and the problem that we all face again is that most people don't have access to primary care in the communities in which they live and the way they know how to use them and so they go to the default opportunity which is EMS emergency departments and that whole process generates huge cost and some of you I'm sure know as a nation we estimate this 30 to 50% of all our costs are unnecessary which means that as a nation we spend at something like a trillion dollars a year that we didn't need to spend and that's why we consistently rank in terms of cost we spend twice as much as the average of the other industrialized nations in the world and our outcomes are relatively poor we talked for a moment about the Rhode Island experience which I had the opportunity to be pretty involved with I think you've heard the basic numbers the Rhode Island primary care spent work has been reasonably effective but it is not effective enough because the authority the regulatory authority of the health insurance commissioner extends only to people involved in commercial health insurance clients and in Rhode Island 44% of people with private insurance are enrolled through the risk of process so that we actually have the health insurance commissioner as a head jurisdiction over the bulk of the population of the state even so we've seen real change in the character and effectiveness of our primary care delivery system since the health insurance commissioner increased the primary care spend from what was then 5% to what is now about 11% but part of the reason we're working on our own primary care trust legislation which is modeled on the same legislation that's before you is to make sure we find a way to extend that process and include the entire population of the state so that not only the spend improves but also to give us the opportunity to continue to work on the delivery system itself we want to make sure that every community has access to a primary care practice that's open from morning till midnight and open on the weekends and for us the primary care trust is the way to do that and I'm actually going to be testifying before our house and senate committees over the next couple of weeks as soon as I come home to help people take this through. Let me pause and open for questions. So can I just, this is representative Lippert the chair this is helpful to put in context because to be honest with you it's not entirely clear what the Rhode Island experience is what you've done in Rhode Island is to increase the spend on primary care but in the commercial for the commercial carriers but you've not yet achieved or you've not achieved public financing of primary care for all persons in Rhode Island that's something that's still on the agenda but in I understand, okay but in increasing the spend for primary care what you're testifying to us did Dr. Ramsey earlier but given that your direct experience is that there has been a significant drop in total spending and I don't want to put words in your mouth. Yeah, I I'm not looking at exactly the same number sector that he is but we have certainly seen a drop in spending for the Medicare population which is the spending, the population where the opportunities come up the greatest because that's where the cost is raised and seeing a real change in what the delivery system looks like we've seen primary care physicians do a little better financially we've had a lot less trouble recruiting and we've seen many expanded opportunities for people to get primary care connected to urgent care on nights and weekends and that's where this is going to benefit us long term and that's why we keep trying to develop this sector. Can I interrupt just for a minute and say that this is helpful for me in terms of trying to clarify how to move forward here and what testimony is going to be helpful or not helpful it occurs to me that the testimony that I'm hearing from you is in the direction of making the case for the value of primary care I would personally stipulate I don't need testimony about that personally but I don't know that other committee members may as the chair I'm sitting here thinking what is the testimony that we need at this point to make decisions about how to move forward and so I'm just going to name that and at some point I'm going to turn to our committee to try to articulate what are the questions that we as a committee need testimony on that we need to help us resolve the questions for some of us Can I just respond a little bit I'm not really trying to testify about the value of primary care that's what I maybe misunderstood generally well understood what I'm really testifying about is the value of making primary care universal what we have seen is lost mountains of evidence about the value of primary care but we haven't had much public care discussion about the importance of bringing that to the entire population both from a public health in fact from public health for public health reasons and also for cost reasons we have allowed the marketing character of our system or the marketing or the character of our market to to kind of marginate the primary care process instead of putting it in the center of what we do from a public policy perspective and I think the universal primary care and the primary care trust legislation is there to make sure that we get to including the entire population because when we do that that's when we get the value of primary care from a public health and cost perspective we don't make universal and we don't work hard to make the universal its advantages will stay theoretical by the job of public policy I think to take those theoretical advantages and make them real thank you and I appreciate the distinction you're making and I would just so you have a sense I perhaps misspoke when I said the value of primary care I was taking the value of universally accessible primary care I think representative she has a question I have a question you mentioned you've talked about the connection between primary care and urgent care and about how people having greater access save money and I'm curious where does mental health fit into that in Rhode Island like our primary care providers is that increased access to primary care also addressing mental health challenges we are doing everything we can to integrate mental health into the primary care process and as the neighborhood health patient I talked about has those two areas completely integrated so that we have mental health workers working shoulder to shoulder with primary care clinicians seeing patients every day and we've developed a technology of warm handoff and we make sure that everybody can present to a primary care clinician with a mental behavioral issue or a substance use disorder issue get those issues addressed at the time of the primary care visit now that hasn't become universal in Rhode Island yet but with that number of folks who are working on it and many of our community health centers have achieved full integration already that's the direction that we're going from my perspective that's the direction we must go if we're going to be effective at helping people change behavior the behaviors they need to change to create the best health outcomes and it's also the only way we're going to be able to begin to control costs and begin to dial back the very difficult problems that we face with substance use disorder and opiative health steps how does I'm sorry I'm curious about the in Vermont we have a backlog in our emergency rooms of people needing mental health services and there's a lot of factors involved but it's common here for people to be sent to the emergency room when they're in a crisis in Rhode Island is it any different do people go to the ER can they come to the urgent care I'm curious like in terms of crisis level where the universal access to primary care might be helping or might not make a difference it's usually different and I'm going to speak with a little pride about now that I'm hearing about how things are in Vermont we all our primary care all our community health centers who are in many of our primary care practices are ready to deal with mental health issues when they present in addition we have two large mental health organizations that have really developed capacity for immediate response so that when someone presents to the emergency department a mental health crisis they are met at the emergency department of the mental health clinician and that mental health clinician initiates treatment right away they really got a number of layers of sophisticated mental health address so that these two areas are now functioning together we don't see them as separate we see them as one on the same I think I wanted to try to represent Brighlyn who has a question and then we're here are any final comments from Dr. Fein Dr. Fein this is Tim Brighlyn a question I have in terms of the road that Rhode Island has gone down with requiring commercial insurers to increase the proportion of medical costs allocated to primary care by one percent a year I'm trying to picture what that looks like what actually happens to to drive that result and what are the things that either the primary care system or commercial insurers are doing to achieve a higher percentage of costs being directed at primary care services that's a great question the initial driver was our health insurance commissioner one of the few dedicated health insurance commissioners in the United States that also have a pure health insurance commissioner and as the health insurance commissioner wrote his regulation he involved the commercial insurers in the process made clear what the targets were and then created a reporting antibiotic process making sure that what was counted was also made clear to insurers and the way insurers directed was they directed in a number of different ways first they began to participate much more actively in a multi-payer patient-centered medical home process which brought small-capacity payments to primary care practices through case management in the multi-payer patient-centered medical home process so they now more than 50% of our primary care practices participate in that practice and in that process that's been a major step and that required specific investment by health insurers in that per person per month payment for care management which was done just before they participated as well in the electronic as the shared record system they hasn't worked as well as we hoped but we tried to make sure that at least electronic information through health information exchange was available to everyone and then they obviously had the opportunity to look at their own peace schedule and see whether there are opportunities to improve reimbursement itself and you're targeted as many people across the country get targeted we're targeted moving to a more value-based payment system trying to develop more towards payment towards future service part of the rationale behind our primary care trust legislation is to move that process along because it's been going way too slow we think that we really need to get to get primary care capital and another discussion but when you do that it saves 20 to 40% off the top because of the cost of analysis it's been iterative with reporting and oversight and lots of communication making sure that there really was and stated at the table so I want to play some of that back to you in layman's terms because I think I understand most of what you said but it sounds like what you have done regularly in Rhode Island is kind of direct the supply side of the equation in terms of what what primary care services you mentioned medical homes are available what are being supplied to Rhode Island patients you only mentioned a little bit in terms of kind of the demand side in terms of for example pricing of primary care services one of the things we're considering here in universal care is they would be costless to consumers which would make those services more available so that this is addressing to some extent more of the demand side making it easier for people to access care from a pricing perspective I can't tell you what you thought a lot about the demand side our focus has been developing the primary care delivery system and making sure it's both available and responsive and using the regulatory process to encourage change and that works because everybody has to play on the same level playing field that level in the playing field I think has been a pretty important part of what we've done on what you call on the supply side but I you know I can't tell you I know what changing the demand side would do but I can't see that making access through the demand side better and to me that seems like a real opportunity because remember what I said before and I don't know if the number is on or not but 55% of people in Rhode Island who take best health insurance don't only 55% of people with the best health insurance have a regular use primary care so part of our challenge has been to make sure they're primary care practices for people to go to but incentivizing people to get there seems like an important part of the equation thank you I think if you have a final comment or perhaps those are your final comments I think we need to stop for now but I appreciate your participating because it opens our eyes to hear some of what other another small state in New England is doing to address some of the issues of primary care no comment thank you for considering this legislation and working so hard on the public policy which is really important to figure out how to create a health care system for the United States affordable something we haven't yet thank you thank you let me just check and see if Pearl Bolson has joined the conference call in the meantime Pearl are you on the conference call I think what we're going to do is to turn to Dr. Deppie and hear from her and then we'll see whether we can circle back and connect with Pearl Bolson at some other point do you want to prime or Tim can you help make sure that's off because otherwise I don't know if you want to stay on excuse me he's not going to do sorry good morning I'm Dr. Susan Deppie I practice psychiatry in Colchester in private practice I have a small practice let me open since that reminds me that cavitation will not work in a small practice because I have a tiny practice and one or two very difficult people with a lot of time could really upset the so something like hourly being paid hourly which is practically what I'm doing in private practice anyway or something else might be a better mechanism for that perhaps salaries or whatever I want to affirm what Drs. Richter and Ramsey said I think it's incredibly important I have Dr. Ramsey feet however I think my longest pre-certification for somebody to get them into the hospital took me about two hours on the phone with someone and they were suggesting ridiculous things that were 20 years out of date I think we need to make it publicly funded and make it extremely streamlined mental health and substance abuse as you guys well know and I appreciate representative Brian's comments is a key piece of that and will help you save money because there's a cost shift when you don't provide mental health and substance abuse as well just another comment before I get to my major couple of points with respect to Medicare I still have people who have primary Medicare is primary and they have a commercial secondary and they're still paying deductibles at the beginning of the year and they still have co-payments so don't assume that if somebody has a secondary commercial policy they're getting a good deal in psychiatry they often do not the I would echo what Deb and Alan said in terms of going back to the health and welfare version and having that work group be really knowledgeable about what it's like in the trenches including patients and especially physicians, psychiatrists primary care physicians Dr. Ramsey's comment about the burdensome administrative piece is incredibly important and I think has been a big piece of why people in primary care and psychiatry have retired or given up on trying to deal with insurance many of us many of my colleagues don't take commercial insurance even Medicare and Medicaid I do but this isn't about money or taxes this is an investment as Dr. Ramsey said and I think we're already spending the money we need to think of it that way do we want to be intelligent about how we're spending Vermonters money I think there's your answer for people who say we don't have the money well if we don't spend the money to invest we're spending it anyway and in a very foolish way it's prevention treatment reducing suffering which is a huge value for Vermonters I think for each other other costs and tax burdens I suspect would drop under universal primary care although I am not a financial analyst but how could your school town and state employee costs or Medicaid or corrections costs not drop if you are providing service at the cheapest point or as early as possible we already have the data on primary care doing that so it's going to affect other taxes in a positive way if insurers are not covering primary care their premiums are going to go down they have to go down they have to be regulated down to avoid becoming another burdensome insurance this can't be just another insurance that's layered on top it really needs to be a comprehensive this is how we pay primary care and we have to make a little juggling for Medicare or whatever we can't include but it needs to include as much of the insurance system as possible including hopefully Medicaid which I don't find that hard to deal with frankly compared to Medicare and God save us Medicare D programs at the precincts are ridiculous so universal primary care has to really cover everything that's normally done in our offices and in the community perhaps nursing homes or however they want to do it for primary care all of those settings that are not hospital based or not intensive you know mid level services like in psychiatry where you have a day program or something would not necessarily be covered but it needs to cover everything we do so that the billing is sleek it's less hassle for the clinicians and you know it would work better exceptions have to be extremely rare or you're going to lose the administrative efficiency of having a publicly funded system the primary care and psychiatry private practice workforces are collapsing we have largely had troubles with low reimbursement and the massive administration burdens we were attacked by managed care in the 1990s before primary care was and it was quite egregious one of my colleagues has uncovered a report that indicates that in the 1990s or since managed care started started around 1990 when I entered practice that the proportion the percent of the total paid to psychiatry dropped 50% in those first few years I think about a decade I don't have the study in front of me but 50% bang devalued that was a fairly shall we say unwise uninvestment so we are people are I have a colleague who's retiring he gets he's beginning a thousand referrals a year taking very few of them wonderful psychiatrists he now has 140 patients he has to refer somewhere he sees some fairly complex stuff as I do you know where are they going to go there are so few of us in private practice compared to when I started here in 1990 it's unbelievable or in the 80s actually I moved to Burlington there were tons of psychiatrists so and of course child psychiatry you guys have probably heard has been extremely painful because just aren't your resources so it has to be minimal administrative burden let people do their jobs bump the reimbursement so it's commensurate with the rest of the system because it still isn't and more clinicians would want to practice here more psychiatrists would want to practice here as well as primary care docs back when we passed the single payer bill we had something like over 200 this is not psychiatry but over 200 medical students and physicians who said they would like to move to Vermont if we passed it well we passed it but then we didn't actualize it so people would want to come if the system is a decent system to work under we just have to keep it streamlined and you can't be measuring everything to death as Dr. Ramsey said so if it's done right it would be in our clinical workforce that was pretty much that Alan did come back to that comment and I think that's really important so that's what I had I'd be happy to take any questions I can from the private practice psychiatry trenches Questions for Dr. Debbie I've got a general question it's not necessarily directed at you we brought out some of the administrative challenges that you currently face and it's a broad question I've been hearing other people talk to as well which is is this system that you're envisioning one that is fee-for-service so the payer ultimately pays you for the work you do with patients and it's going to be on an as-seen basis or do you see this evolving to a some sort of quantitative thing my own opinion is that fee-for-service isn't a bad thing in private practice psychiatry in primary care psychiatry it would be fine I mean it's hard to get a patient to sign up for $2,000 worth of therapy they don't want or don't need I think most of us I don't think there's a lot of abuse of say sending people for procedures that they don't need I usually don't write for my own CT scans anyway I usually work for my primary care docs to get an MRI or CT or something so I think fee-for-service would work fine I think for many people who work more hours than I do because I'm very part-time with a lot of other things going on for folks that work more hours if they wanted to be on salary or whatever there could be a number of mechanisms I don't think it needs to be capitated because capitation has the risk of really cranking down on being able to do what the patient needs and in a small practice the numbers just don't work Thank you Thank you very much We're going to continue to we have a number of witnesses that tried to get to still this morning Ken and again I'm going to pull our attention to the bill before us from the senate as well as the bill that came out of the senate and so welcome you to comment on the road without care board or if there's any perspective you wish to offer as it's included or not included in each bill for the record Kevin Mullinger of the road without care board with me is Gene Stetter our business manager I would say there's much to talk about we can combine it to those constraints to make a bigger picture I don't think we're when you say bigger picture we could spend we will be spending months around issues of health care generally but this is really focused on out of the bill that's coming to us from the senate and S53 and the bill that came out of the senate health welfare I think that's really what this committee needs I do want to take the opportunity though to address this senator we've had this conversation in the past in this committee but it's about workforce I still feel like people are not addressing the key issue of working with higher education to turn out more primary care practitioners and I just want to update this committee that the head of the nurses union Deb Snell has reached out to the university and is trying to create a workforce summit on the nursing shortage but that same thing has to occur on the primary care shortage as well and as I've testified in the past we really have it wrong in the US we have twice as many specialists as we have primary care the rest of the world has it the other way and they're getting better results at a more affordable cost I'm not quite as optimistic as everyone else that just because you pass a bill that primary care practitioners are going to come here and if you take a look at most of the analysis that's been done the most direct correlation to where they end up practicing is where they went to school and where they did their residency so I just hope somebody doesn't forget the workforce piece as this moves along as far as the two different versions whichever version you pass you're going to have to recognize a few things number one that we're going to need the resources and I know that Gene worked with Nolan and I think you already have that going on do they have it? I've posted it you can just be fresh and timing unlike other agencies of government or other businesses that agree about care board probably the busiest time of the year is the summertime because we're dealing with possible budgets and rates and everything else and I'm not sure that the timing is the best as far as in October deadline and so resources timing those are the big issues for us at the care board we'll do whatever you tell us to do okay so we have not had a chance to review the fiscal note in the committee at this point but can you comment on the resources because as passed by the senate it simply says resources as available for the green amount of care board to do its work it's the intent of the general assembly to provide sufficient resources and we're getting mixed signals because some senators are saying don't worry we're going to make sure you have the resources and others are saying well you could just do it so I've got to tell you that as the administrator of the green amount of care board I can't just do it that's part of the testimony that we need to hear of course because everyone is confusing but we budget by constitution as a starting house so we passed a budget I guess my assumption is maybe a wrong assumption that since the senate has sent this bill to us that their version of the budget as passed will include resources for the green amount of care board but what I'm hearing you say is that there may be those in the senate who believe that there are sufficient resources within the green amount of care board that it doesn't require additional appropriation so just as you saw that great divide over what this bill should be in the senate there's that same divide about what resources would be necessary to do the work so I just want to put that out there Jean do you want to talk about the spread yeah I'd be happy to so what we did was we worked you'll need to talk closer to the mic or it won't be recorded press you could pull a chair up or Dr. Richter you could switch over just for the moment or something swap chairs and Jean could pull a chair up closer to the microphone because otherwise it does not get recorded so for the record for the record Jean Stetter business manager at the green mountain care board what we did in looking at costs was we broke it out from the senate as passed by section because there's kind of clear delineation by section and the first we have a document I did not bring I'm sorry I did not bring it forward I can actually review what you're referring to yeah so thank you I mean that's online right now we'll refresh that's Nolan's fist yeah that's Nolan's fist yeah that was so high a document from the green mountain care board from the joint fist office yes I apologize So, in working through this, Section 1 from the Senate As-Past references a universal coverage for our primary care report in that that takes it through, the report takes it through, and is, we estimate contrast expenses to be about $110,000 for that, and again I will get you the note on that. That specifically talks about the specific services that would be defined, and there were two previous UPC studies, and what we looked at the parts for the specific report, what we did was we looked at the parts that were different from the two previous studies, and so one difference was if Vermont can achieve universal primary care through health insurance, and then we also looked at how to update a model that, from Wakely, that came from one of the existing reports, so we'll get how to make coverage for primary care services affordable, and those together, we estimated, would cost about $110,000 in contract services, and then also for FTE staff would be the equivalent of one to two FTEs working on that, which fully loaded would be roughly in the ballpark of 90,000 persons for working on that, so that's the first part to cover the report, and then moving forward and thinking about the draft operational plan, because it seems like there's a clear pivot point that Section 2, the universal coverage for primary care draft operational plan will only go into place if everyone agrees on Section 1, so I tried to pull them out discreetly. The biggest lift on the operational plan part is determining if it is a feasible, and then the benefits to Vermont residents outweigh the estimated financial cost, so that's putting together the operational plan. We estimated about $300,000 for a contract expense for that draft operational plan, and then the subsequent work is that there's going to be the draft operational plan that goes to ATROC in October of 19th, and then in January of 20th, it would be the final draft to your committee, House Appropriations, Senate Appropriations, Senate Health and the Welfare and Senate Finance. So for that, we also included one to two FTEs, and the tricky part with timing is the contracts are discreet, you know, in terms of discreet number. When it gets to staffing requirements, because it's spreading over a longer period, then assuming that someone would be needed to help support and answer questions about the operational plan throughout the legislative session, we included another one to two FTE there. So the total cost range would be, if you'll serve on the, the total cost range would be contracts and FTEs in the range of about $590,000 to about $770,000 total if you assume the whole contract cost plus the FTE range as our estimate right now. For the entirety of the two FTEs? For the entirety of section one and section two. FASED over two fiscal years. Yes, yes. Again, I want to be clear with the assumption that even though the report is due in January of 20, 2020, that our assumption was that there would be three amount of care board staff needed to respond to questions throughout the legislative session. So what I'm taking from your testimony from Kevin's testimony is that number one, resources would be required. Yes. That there's not sufficient resource within the current funding of the Green Mount Care Board for staffing their consultants to do the report or to do the work necessary. Yes. And the range is over two fiscal years. Yes. And in this fiscal year, the range is around $170,000, I'm looking at $10,000 as well, $107,206,000 in fiscal year, in state dollars, right? And that assumes that there would be matching dollars. That assumes. Is it a billback? Is it a billback? So, if I may, I have two additional thoughts on that when you're ready. Can I just? Go ahead. I sent your email gene to Lori. Okay. I'm posting it. Okay. So it should be up. The thing that you're looking at, that's. I'm posting it now. It'll take a minute or two and then fresh. And I may have to do something else. Okay. So the one thing I want to make crystal clear is that we can't take our focus off the implementation of the all payer model and so that the resources have to be there. And I do want to say that I did disagree with one of the earlier witnesses that it is possible for capitation to play a role in this, in that if you take a look at what's being done in the all payer model, they are putting more resources to primary care. And they're trying to make administration simplification occur. So they're making changes to prior off and things like that. And so it can occur in the capitation model as well. It doesn't have to be fee-reserved. So what I'd like to suggest just in terms of our time and our process is that we take your memo of what you, the numbers and no one's fiscal note and not try to dive into that in any specific detail right now. I think we will be able to come back to that. Okay. What I'm wanting to do is to kind of do the, get a broad understanding of the percentage of care board's needs and their perspective. And number one, you're testifying additional resources would be necessary. Absolutely. Under ASPAS by the Senate. And more resources under the ASPAS by the Senate than the Senate Health and Welfare. And what I wanted to get to then as well is what your views are on the resources or work of the involvement of the Greenbelt care board has passed by the Senate Health and Welfare. So to be clear, the Greenbelt care board hasn't taken a position. I understand that. I doubt that you will. Right. And we wouldn't. No, I understand that. Right. So. But have you. But as far as our workload, it's definitely heavier under the second version. And is there an estimate of need in terms of ASPAS by the Senate Health and Welfare Committee? Did you ever? I went, Susan Merritt executive director Greenbelt care board has passed by the Senate Health and Welfare. They are written out to be fiscal need. There was a stakeholder group that we could. So what I'm trying to establish is that, okay, so under the Senate Health, because we're correct, what we really have here today in part is that we have in front of us the bills passed by the Senate. And that's what you're testifying to in terms of there is a need for resources. And you've given us an estimate of the range of resources in our joint fiscal offices given us. Those resources would be essential for your testimony in order to implement ASPAS by the Senate. Correct. In the, we've had numbers of witnesses today and many communications saying please reinstate the language of the Senate health and welfare bill. I understand you're not taking a position on that. But my hope is to try to establish what would be needed in terms of resources for the Greenbelt care board in that version. And what I'm hearing from Susan Merritt as the executive director is that the testimony was that there would not need to be additional resources. We could absorb that work in the Senate health and welfare version of the bill. Okay, so that's helpful. And surprising to me. It seems like a fairly intense process over the next nine months to establish a platform off of which universal primary care could go forward. And so, that's good news. To clarify, I understood the first Senate health and welfare bill to be, for our responsibilities, was to bring in the stakeholders and talk, it was by state and the ACO and utilize their expertise to provide input on how to go forward. But in my opinion in assessing both of these bills, the second bill, the appropriations bill, was a much heavier burden. And we should make this very clear. And if we're not on the same page, we should clarify that. This is the time. Yeah. Yeah. The Senate health and welfare version put much more burden on AHS. Right. Yeah. And on the ACO. Yeah. Right. No, I understand. There's a significant difference in role and responsibility in the second version of the past past. So they've moved a lot of responsibilities to the United Care Board. So I would like to ask Kevin as the chair of the United Care Board to comment on something that has come up. And frankly, I think a question that has kind of just lingered for me or for some others in the debate and discussion around this. We're currently in the midst of a major effort with the accountable care organization model, the all-paying model. What care is the ACO at this point? And a question, a comment was made earlier by one of the previous witnesses that did not appear to be any conflict between continuing to move forward with the all-paying model implementation and initiating implementation of a universal primary care or possibly universal publicly funded primary care either. That the two are not in conflict with each other and that they could both initiatives could move forward simultaneously. I'm interested from the green light care boards vantage point how you see that in terms of trying to move several initiatives forward simultaneously or whether there's to just give me a sense. My concern would be that if people have this hope that in a few short years there's going to be this great new system that's going to compensate them much better than how they're working today, that they may not be as willing to join in an ACO and that there may be some stickiness to that. I don't think that there's a true conflict between the two, but I do think that there could be complications. So I wonder if we could delve into that a little bit more in terms of potential conflict or not. I'm specifically looking at whatever the future financial modeling, how the dollars would flow between what the effort is with the all-payer model in ACO and what might be, and it's not defined yet, but what might be the dollar flow for universal primary care. So I think one of the things that you can look to is just look to the current experience that we're seeing in that, for example, an area where I live, Rutland, is not participating in the ACO because the FQHC has the vast, vast majority of primary care practitioners and because they are able to get better compensation in that model than they could if they were in private practice, they really have put the roadblocks on that whole county joining the ACO. And so no matter what it is, there's always going to be what's in it for me, what's best for me, just human nature. And so there could be that problem. Okay. I mean that's helpful background. It's not quite what I was trying to get at and maybe I can't at this point articulate it well enough yet. But I'm not thinking about participation as much as where is the money coming in from and how is it being distributed. Does that get much more complicated or can that... It would all depend on how the universal primary care system was designed and that's the unknown and so it's pretty hard to hypothesize on it. So can I just bookmark that issue, the relationship of the continuing implementation of the ACO and potential implementation of universal primary care as something which I would ask and welcome you and others at the Green Mount Care Board to be thinking about and perhaps offering us some more specific comment if that's possible even as we move forward with our deliberations over the next period of days. Because I think there is... The design of the whole system is really the key and if you take a look at it, first of all you have to define what primary care is. But then when you start to get into it like when I go see my doctor, he's one of the few doctors that will still draw blood out of you and is that covered? Things like that. So it just gets complicated as you start to figure out what is, what isn't and those are things that are going to have to be figured out and that's why it's going to take resources to do that. I think what would be helpful for me is if there was some ability to say, well, if the basic model were this, for instance, if the basic model were as past Senate health and welfare and the money was going into a fund and so forth versus if the basic model was supporting... But the bill as past the Senate had the possibility of different models and it may not be possible even, but as you were saying, without knowing how the system was set up, you can't really compare but I'm just wondering if you said, well, hypothetically, if it was sort of this way versus this way, it might be easier for those to both work together financially or it might be more difficult. It's possible, but to the extent that we're non-careable members could chew on that a little bit to help guide us within the next couple of days. It would be really helpful. We have our own timeframe as you well know. Well, at least you invited us on the test flight. We did have a pleasure here. So I'm just going to lay on the table one of the questions that I had and I'll just name it for myself that this is not making a judgment about the value of universal access to primary care or even the value of universal access for publicly funded primary care. But the state of Vermont has made a decision to commit to a systems change with the accountable care organization, the all-payer model. And we are being asked to add to that a significant change in the healthcare system of Vermont for implementing, moving toward implementing some version of universal primary care. The question is whether it's publicly financed or not publicly financed, but the Senate bill and the Senate Health and Welfare bill both at least aim in the direction of universal access to primary care. And I have to honestly say there is, even if you share that goal, there is the question of how much systems change can be managed at the same time. And I'm not talking about specific dollars, I'm not talking about, I'm just talking globally when you're trying to move a system in a new direction, how much systems change can be implemented and absorbed at the same time. I'm going to be very clear, I'm not saying that's my concern and I'm opposed to this. I think there needs to be acknowledgement of that issue and that's a challenge. You know, we just have to look at what transpired since the passage of Act 48 to see that really you have to focus on a couple of things at a time and you can't take on the whole world. And when people ask me why did Act 48 fail, I say because we tried to do too much being pushed by the Federal Affordable Care Act in the exchange and because we weren't ready to actually do the exchange properly, then we lost the faith of the citizenry for government to do anything right. And so I worry about that, we should actually get some things done right and then progressively move towards a better system rather than trying to take on too much at a time. I'm not saying that this is too much of a time, but I'm just saying it's a real concern. I have a question for you around money. When Dr. Ramsey and Dr. Fine talked about the 1% increase to primary care, were you in the room with that? No. They thought that by increasing... This is a Rhode Island. I'm sorry, Dr. Fine is from Rhode Island and Dr. Allen Ramsey is part of us. Just a little. They both were indicating that in Rhode Island, they increased the spend towards primary care for the entire state. They had 18%, 18% decreasing costs just by doing that. Doing a couple of things. It was 1% per year over a period of time. 1% isn't going to cut it. It was over four or five years. Over four or five years. They saw a fairly decent decrease in costs by doing that. Do you see Vermont being able to do something about whether it's 1% or increasing it to 2% towards the costs and how that would play out? Well, I think that the fact that what we have approved in the ACL budget does pay a little bit more and does try to decrease administrative simplification is a clear indication that, yes, we have the rebound care board and, yes, the people at Montecare, Vermont, our ACL, believe that it is important to funnel more resources to primary care because it's going to be a better investment in the system. And we in the state government have tried to do that over the years. I mean, this isn't something new. I mean, when we've done increases in Medicaid reimbursement, we've tried to target that towards primary care. I hear that there is concern about taking on too much at once and how we've made a commitment to go in a certain direction and that layering too many things at once might be a burden that seems like too often in our civilization where we're focused on immediate short-term fixes to problems and we lose sight of a long-term vision or goals. So I am curious how might universal primary care be integrated into existing health care reform efforts? How might we frame it as being coordinated and expansion upon that versus something extra? Because you mentioned earlier, Marie went like this and you were like, they're not incompatible. And so I'm curious if you could say more how you might see this being integrated into what's going on instead of being just something extra. So again, I would hope that if universal primary care was implemented that it would be done in such a way that it would be compatible with our move towards population health. And that would be what I would see the two of them working together. If it's not done in that way, then we're going to have something going to fail. We're not going to reach our skill targets with the federal government on that agreement if it's not done in a complementary way. Back in the 1980s, when we had a whole thing at that time in CHU before we came out of AHC, they had a big push saying that everything was going to go towards the primary care. It was going to be all outpatient services and hospitals were going to decrease in size. And we realized that didn't really happen. And it's somewhat just the reverse of that and we've lost a lot of primary care. Exactly. And we've gotten more into the hospital. But by having the focus go back to primary care, we would be taking more money from the hospital because we're trying to make it so that people wouldn't have to go into the hospital. We're trying to treat them at the service in their own backyard basically. So a number of hospitals are already committed to trying to shift resources away. If you take a look at the leadership that Dr. Brum set has been exhibiting on the all-payer model, there's an acknowledgement that the right way to do things is to treat patients in the proper setting. And the hope is that they don't have to actually get into a hospital setting. So I think the hospitals are willing to work on this collaboratively. And the fact that so many primary care practices are now owned by hospitals they're going to have skin in the game no matter how it plays out. Do you think by increasing, you know, that they're providing to the primary care provider of a piece of the pie that they are right now, increasing that for help? Well, when you push on one side of the bubble, the balloon, the other side is going to pop out and there will be pressures. But if it's done right, and again, it's all in the implementation, if it's done right, and the dollars that are invested in primary care reduce the dollars that are spent elsewhere in the system, then it'll work. But there's no guarantees. Well, it's a goal. Yeah. Thank you. Thank you, Kevin. Thank you. Susan and others. I'm reaching him. Reaching him. Reaching him. Reaching him. Reaching him. Reaching him. Reaching him. Of course. I'm going to ask to hear from Michael Costa from Diva next. Mr. Chairman, thank you, Michael Costa, Deputy Commissioner, Department of Public Health Access. Thank you for giving me the opportunity to testify on S53. I just wanted to raise a couple of points from the administration's perspective on this bill. And as we've done throughout our testimony this morning, there have been references to both S53 as passed by the Senate Health and Welfare Committee. So I hope you agree with the possible comment. I think we're going to... My plan, if it's helpful to the committee, is to start with the overall concept, you know, that the administration testified at length in the Senate Health and Welfare about its point of view on the concept of universal primary care. That's fine. And I want to tie right into that with some of the really good questions that were coming out of the committee a minute ago. Certainly, this is not about... Let's start with what it's not about and then we'll get to what it's about. It's not about whether it's a good idea to invest in primary care. I think there's broad agreement that investing in primary care and having the delivery system be more coordinated is a good thing. I think the state's efforts around healthcare generally and with the ACS program specifically are an acknowledgement that primary care is central to our hypothesis about how reform is supposed to work. So it's not really about what, it's about how. And what I think I heard the committee talking about a second ago is that you have both a policy issue and an operational issue. In my mind, the policy issue, going back to some testimony I did earlier this year, is what problem are you trying to solve? And from the administration's point of view, I read the documents and agreements that the state has signed with the federal government. It's a 1115 Medicaid waiver and it's all-pair model of ACO agreement is that the problem we're trying to solve is that we pay too much for healthcare and we do not have high quality well-coordinated care. And so we're trying to integrate healthcare system and community service system to deliver better quality care and more reasonable price. The problem we're not trying to solve is getting to the last mile of insurance coverage or changing who pays into the system. Because my own personal hypothesis delivered with some experience in creating a universal publicly financed healthcare system is that until you get the cost of care under control, it is very hard to move dollars into a publicly financed system. Because to the extent the expense of that system grows more rapidly than your tax base, you're going to have a real sustainability problem. Separately, beyond the policy issue, there's a pure operational issue. Simply, how much statewide change can you reasonably manage at any one given time? For me, I worry about a lack of alignment between universal primary care and the other statewide healthcare reform that we're presently engaged in. The most clear path with the ACO model as always, I say the same thing. I promise to work hard on the ACO model. The administration promises to be transparent on the ACO model. I do not know if it will succeed. We're engaged in a multi-year effort to determine whether it has merit and whether it will succeed. I think we'll know at some point in the future. I think universal primary care is a totally different project that has a non-trivial amount of complexity. And so I think to take on a totally separate second statewide reform effort, we'll put both projects at risk for uncertain benefit. And I say that not as just an opinion, but as someone who has put time in as both a contributor and a reader of the two separate reports on universal primary care that have been delivered to this legislature. The two separate reports run 181 pages total, and they list lots of excellent questions that to my mind have not yet been answered. Specifically, the 2015 report on universal primary care bucketed questions into five broad categories. What is the public financing plan? What's the economic impact of that financing plan? What are the legal and waiver challenges facing the state government implementing a plan? How do you operationalize that plan, including what I think are really vaccine coordination of benefit issues? Because potentially you have every Vermonter with two insurance cards in their pocket and insurers and providers and then how would this plan design work with health savings accounts? The administration's view of the law right now is that ERISA and federal law make universal primary care and health savings accounts incompatible. I know other people have different opinions, but I don't think they work together. I think we use it as an example of just how disruptive this could be to people's present insurance relationships. Lastly, just to make quite clear, the public finance plan requires new taxes. I think the Governor has been very clear on his position on new taxes and fees and so it's hard to see a situation where the administration would ever support that aspect of universal primary care. Lastly, I commingled health savings accounts in ERISA together and I did not intend to do that. Health savings accounts are just a separate sort of legal problem where we don't believe you can have if you have a health savings account it means you don't have other types of insurance and that we have examples of both of this either being offered as an insurance plan or just some sort of public good. For example, there's an example of the federal government if you have tricare or veteran VA insurance or Native American insurance the federal government does not permit you to have an HSA so we're just worried about this disrupting that relationship. Like any public pay finance statewide health care effort that involves how people pay in and get coverage there's the legal barrier of ERISA which just basically says you can't compel employers to carve out primary care insurance services from their self-insured plans so employers who continue to carry primary care coverage and employees in those plans could end up paying twice or just really run into this coordination of benefits project and so like anything like this you'd end up taxing some people in businesses for a plan that they don't want, they don't need because they're offering similar coverage I think each of those issues sort of big picture issues has a huge layer of complexity underneath the first two studies trying to get at those questions I think it did a fair job of illuminating those questions but it did not provide answers so to me it's to have a third effort at this either in the way the original health and welfare bill imagined or in the past version imagines is really a third by the dapple with very few other questions actually answered and so for me that brings me all the way back to the operational issue how much reform can you responsibly manage and part of the reason why the administration opposed both the concept and the bill in the senate was that we think the concept is fairly fraught and an operational issue is just not clear how we can do both and both while running the Medicaid program while doing complex IT projects with the state is historically struggling with like integrated eligibility in our MLIS system and it's just really hard to see how these things are working together so if that would be a happy to answer the committee's questions I would just say that from a policy operational conceptual issue or from a policy operational perspective the administration just does not support an effort to afford to enforce the primary care as a major health care reform initiative but in no way diminishes our support for primary care as part of health care reform can I ask for one clarification and then we'll play some questions that just be clear that the administration position is not based solely on a proposal for universal publicly financed primary care what I hear you saying is that you're the administration's position at this point in time is to not initiate further study analysis or to develop an operational plan for the implementation of universal primary care whether publicly financed or financed in another manner yes but I want to highlight the phrase you used at this present point in time I have not seen language see us supporting it doesn't mean that someone can come up with an idea that might be interesting but I have not in any of the discussions over the past two years on universal primary care the legislature seen anything that the administration could support and we're really focused on the present agreement as we have with the federal government to answer your question directly yes it's the opposition of both the concept I really do want to make sure I understand everyone understands it's not just the concept of universal primary care but further exploration of it as well further exploration of it at this time whether or not that operationally includes public finance that adds another layer of opposition from what I'm hearing your testimony that complexity very much Mr. Chairman what I want to be really careful about and I'm not trying to be too cute by half we support the goal the administration supports the goal of everybody having health insurance and I think the administration's position on the individual mandate bill that came through this committee shows our support for the concept of having everybody having coverage and so nothing about this bill changes that support however we go between one how where we're not supported in universal primary care as the mechanism to ensure that universal coverage that we are open for other discussion of other avenues that might get us the universal coverage and again without trying to just reiterate that that position is not based on the possibility that it might be publicly financed but it's broader than that there's another layer of concern or opposition I would say about the public financing proposal but you're putting that aside the administration is taking a position at this point in time that to try to undertake a further study or implementation of universal primary care regardless of the financing I appreciate your question and it helps me to clarify my comments because I think there are three levels of concern and objection there is obviously a public finance concern the governor does not support new taxes and this implies eventually new taxes separate from them there is a policy objection that we don't support universal primary care as a concept because we think there are other ways to focus our health care time and effort separate from that there's an operational issue that further discussion of this resources discussion and implementation of health care reform that we don't think is appropriate given the path the state is on so thank you for helping me separate those I'm just trying to make sure that we don't lead with a misunderstanding of where the concern and opposition is coming from and again let me just be clear my clarified questions is not necessarily reflection at all but I think it's important for us to understand the situation so I have two questions one thing I want to start with is just thank you for being so clear about your opposition and giving us specific reasons because we don't always get that from people who say they oppose things so at least for the record you gave really clear reasons one of those reasons have to do with the concept of not wanting to raise new taxes and I'm curious if you could help me understand what the difference is between raising someone's taxes to cover their health care and removing their cost subsidies or removing other public assistance which ultimately increases a fee that a person is going to have to pay because we've been hearing no new fees, no new taxes but then we're asked to make policy decisions that are going to increase the actual cost of people which is increasing their fees so can you help me understand that discrepancy between the policy statement of no new taxes, no new fees but then recommendations that actually cost people of Vermont more to access their health care in this year's budget yeah I have a question if I may represent a work form like the specific out to the general what are the problems with the affordability that we worry about in a publicly financed health care system is sort of the end of employer based tax subsidies and once you make something tax based employer based you lose those tax subsidies and make it more expensive and so that's beyond sort of the general administrative general goal of the administration to avoid new taxes or fees particular to this bill there is sort of a tax argument embedded in it that by making something publicly financed you're potentially making it more expensive because of the current tax treatment of health care now working to the general I certainly understand the tension in your argument which is because I hear you saying let's have an argument let's have a discussion about affordability because you're saying hey no new taxes and fees but the argument being we want to keep Vermont affordable yet there are some policy decisions of the budget that have the potential to cost for monitors more money and so for this one we want to make sure that we're doing the best job that we can on both sides of the fence one in what direct taxes and fees we levy because they obviously cost for monitors money and so that's part of the objection here on the other side of the fence I think as commissioner Gusterson testified in our budget presentation Diva's budget presentation we are constantly reviewing what level of support we might offer our most vulnerable and so I think with the Vermont premium assistance and cost-sharing reductions our cost-sharing reduction proposal rather it's not that we didn't think that those folks could use help paying for health care expenses which are substantial it's we're making the best of difficult alternatives given limited public funds and so I think two things can be equally true you want to try to keep tax and fee burdens low for people but sometimes you have to make hard policy decisions about who can be the recipient of public funds when you have a whole more need than you have resources can I ask my second so I heard you say that it's a goal to have universal coverage and I guess my question is what about everybody having the ability to use that coverage because we can force people to purchase a product from a corporation that provides a service but if people can't afford to use that service that they're being forced to purchase then we're levy another fee by forcing them to purchase this thing that they can't even use which then backfires cause us money so I'm struggling with this concept of we want to provide universal coverage but also make things more affordable and take care of the most vulnerable I think that's an outstanding question and it all goes back to what problem are you trying to solve and what order are you trying to solve them and I think the administration I thought this would be at least my own is that you will not be able to make sufficient progress on access and affordability and universal coverage in health care until ongoing regular health care costs are more in line with economic growth and wage growth and so our point of view is let's take care of cost containment quality first if you get those things under control then you can focus on affordability and access would you like to be able to do everything at the same time? Yes I sat through the chairman's testimony thinking in a world of we live in a resource limited world if we didn't then it might be interesting to pursue several different avenues of statewide reform at the same time but we live in a world of restrained time and resources so we have to make strategic decisions about what goes first and the administration's view is that payment and delivery system reform is the precondition for working on the types of issues that you've raised so what if what if is a good question to ask someone about this but I'm working on my question so I actually have this thing here this is not asking the right question I feel excited about that I never expect this to be easy so I'm just thinking what if we invest years in this new philosophy or policy approach that we believe we're gonna by reforming the way we pay providers and organize healthcare we're going to reduce cost but we're not doing that in a vacuum there's also other policy decisions that are making healthcare less affordable for people so it's almost like we're creating the conditions to manufacture lower cost by denying people what they need and then if that's going to be used to justify a system change you ask what the problem is well I think the problem could be to reduce cost but I think the greater problem is how do we take care of the people and I'm kind of struggling with how why we can't be thinking about both at the same time why does it have to be either we reduce cost or we just spend all these limited public funds and raise taxes and milk people dry I don't think it has to be either or I think you're right it's both and because for us if you look at our Medicaid for DBA and AHS if you look at our Medicaid waiver if you look at our accountable care organization agreement if you look at our all-payer model agreement federal government there are access measures right if we are if there's any indication that we're saving money by denying care then the model doesn't work and so but it's about we're having a conversation with universal primary care about what is your strategic direction and your strategic investment in statewide healthcare reform and so you never want to do that at the expense of access but you do have to you know you have a limited amount of time and resources to engage in statewide reform and so I think we're merely saying that that focus should be on the all-payer model but there are safeguards in there because both Medicaid and the state legislature and CMS all care about access and that's the thing where we're obviously looking for very clearly in any healthcare reform innovation if you're saving money through reducing access you're doing it wrong and it needs to stop and so we have no indication of that we feel like we have appropriate safeguards there so using your words and saying that you're unsure whether or not the all-payer model the ACO model is going to work and be able to do what it says it's going to do don't you think that we should have something else for working on in the meantime so that should it fail we have something to put immediately to shore up the healthcare system so that we have that access to primary healthcare immediately and whether or not we phase it in as the all-payer model because certainly we're not going to be able to do all this work this session maybe we will but if we can't then we have time to do that phasing in and getting this work done I don't think we should drop this question representative and I would say a few things one, I try to be much like you have said in this committee and watch people make promises they can't keep and so my number one goal is not to do that so I try to be really honest with people about whether the ACO based reform is going to work or not and clear answers I don't know and when I talk about it to my own leadership and administration I say look we can mitigate risk but we can't eliminate risk and so if you're going to engage in any reform that's a natural question which is okay so what's plan B and for me the need for a plan B does not eliminate our strong viewpoint of what the problem is we're trying to solve so if you believe the problem you're trying to solve is payment delivery system reform that makes quality higher and costs more sustainable our first plan is to try to use value-based payments for an ACO to get out of paying for volume and start paying for value and so I think if the ACO did not work you'd be partnering for example with providers directly like the hospital association hospitals and saying hey there are things that we need to work on payment delivery system reform can we partner directly rather than using the ACO as an intermediary and so I think for when you're talking I still if the ACO model does not achieve all its goals until I receive sort of more evidence and data I still think the problem we're trying to solve is payment delivery system reform and you'd have to show me evidence and data representative done that says there's something about universal coverage generally and universal primary care coverage specifically that makes me change my mind on what problem we're trying to solve before plan B involved a universally publicly financed system of care so I guess I might ask you would you agree but that access to the care is the primary in order to get that value you're looking for from the care to have that reform so if they don't have access to the care we might have value for 50% of Vermont because they're able to access the care but the rest of Vermont doesn't have that value and is not getting the kind of care that we at least myself and I know other people on the committee want for all Vermonters that's my concern yes payment reform is part of it but I think that initially we need to ensure that all Vermonters have access to care because that drives the care costs down in the long run and so I think that's the primary push that I would see thank you that let's hopefully hear that a couple things I'm thinking about is when I listen to your questions is there a difference between access and coverage because they're not 100% the same thing so I want to think more about that obviously I think people the whole goals to get Vermonters the care they need when they need it to get the right thing at the right time so we don't disagree on that I just you know I try to work through the other side of the equation if I could get if the state government it's not I by any means if the state government could get 100% of Vermonters coverage today and access today but those the delivery system quality is not higher and the costs are not controlled then we have set up a situation where you either need to raise taxes annually or hollow out other programs to pay for it and that's to trade off that I don't think we're anxious to make I think it's hard this conversation is hard because representative Dunn I don't disagree with any of the goals committee members talked about they're all valuable as well how you spend your time focus and I think if I may just I think we'll need to wrap this up shortly but I appreciate your allowing members to ask these questions I think they're key I think what I'm hearing from representative Dunn in part and I think part of the case is being made for universal primary care is that there's an ironic right there's a you're saying we need to lower the costs and have payment reform before we pursue the other and I hear the case being made that until and unless we get everyone access to primary care we will not achieve a reduction in cost to the entirety of the system that in fact there's a missing there's a logic to your logic but there's a missing piece that if in fact the compelling argument that's being put forward for universal primary care is that when implemented universal primary care will in fact reduce by having both quality access to all our monitors for primary care at no barrier and then in fact we will up we will move the intervention earlier for many many for monitors in their medical care and that will result in the actual entirety of the system reducing the demand for health care yes but that and absent that all the other health care reform skips over the fact that there are people who may have insurance but can access care or may have may not have insurance and still are dependent on a system where they have to go to a free care or other things so I think that's what I hear is a compelling different scenario yes but that brings us squarely back to the operational question because with the ACO based system I can test the return on investment of more investment in primary care today with the actual delivery system to test the return on investment of universal primary care I have to build an infrastructure I have to create a publicly financed system and I have to give every monitor a card I have to figure out what the issues are possibly you're going to the one that you know you oppose well I can regardless of how it's set up it's a very firm point Mr. Chairman but regardless of how it's set up I know I'm in the midst of testing one of those now my hypothesis is that boosting primary care and supporting primary care has that much quality return on investment and cash return on investment I can make an argument that we can take resources from the system today and cover that last mile of people that are uninsured or have trouble accessing care regardless of that card in their wallet with universal primary care we have to make a huge upfront investment to figure out how it works before testing that model and so I think that's part of why the administration supports the former and is very concerned about the latter very firm thank you for your ability to be articulate in your position thank you you're welcome so I think let's hear from two final witnesses for this morning and then we'll be coming back to this clearly later but let's first hear from Dan Barlow let me just say in our putting together our witness list we've been trying to hear from both advocates and those who may have positions of concern so it's a mix of we'll hear from the hospital association next and then we'll finish for the morning you have a few printed copies of my testimony okay has it been posted it's also posted okay great thank you for the record Dan Barlow I'm the public policy manager with Vermont businesses for social responsibility I would like to initially start off talking a little bit about BBSR's history with healthcare because I think that informs our support for universal primary care and it really ties in our concerns that the employer based oh thank you that's going to be a lot easier our employer based healthcare system is failing both employers and those who get their healthcare through that so BBSR is a statewide business organization we've been around since 1990 we have 650 members across the state our businesses adhere to what we call the triple bottom line approach to business that's people, planet and prosperity they often find that when they're they're good stewards of the environment and they take care of their workforce that makes them a more successful business healthcare reform was actually the first policy paper that BBSR put together in the early 1990s I cannot claim to be part of that because I was in middle school at the time but that document although it's been revised over the years the values in that document continue to inform BBSR's policies around healthcare and you know our stool our value stool around healthcare has four legs first we want a system that covers everyone you know no one's out so all Vermonters or all residents of the United States if we're talking about a national system would have healthcare we think we need to cut the unnecessary waste and spending from our system we think we have to cut the tie between a person's health insurance and their job and we think we have to fund this system fairly sustainably possibly through taxation if that's one of the only options so you know I want to go back to talking about cutting that tie between insurance and the job I think a lot of people realize that we have this sort of Frankenstein healthcare system that's been designed and built on to itself over the years and the employer sponsored health insurance system really dates back to the Second World War and that there are government controls over uninsured employees so employers were looking for non-wage ways to attract employees and health insurance became a big part of that and I think a lot of us do you know when we ask what's a good job health insurance, employer sponsored health insurance is an essential part of what we also consider a good job over the years for VBSR businesses we quickly realize that the cost of the system is unsustainable and it's holding that economic development in Vermont and the example I often like to use is Don Mayer who owns Small Dog Electronics one of the VBSR founders when he started in business 25 years ago he could insure an employee and their whole family for $1500 a year and today that cost to him is $15,000 he yes and that's why it's no longer just the family you know so he's had to reduce his own coverage over the years and so he's paying about $7 an hour minimum wage for each employee just for healthcare and this impacts every decision he makes from how much he offers as a wage to if he expands his business, hires more expands benefits so this is really weighing down on him and it's interesting Don is also someone who's also a big supporter of raising the minimum wage and he's kind of struggling with how he can raise his own minimum wage over the next few years because he thinks that's important and the burden of the healthcare costs that are weighing down on him as a business leader so and I have hundreds of stories just like Don from VBSR memberships is struggling with the sense that the employer sponsored health insurance system is kind of a ball and chain on the ankle of them as business leaders right now so other drawbacks of the employer sponsored health insurance system is that it limits business entrepreneurship and mobility between jobs you know a lot of people are not going to gamble with their health with their own health if they want to become the next Ben and Jerry's and you know form a new company it also has high administrative costs for businesses providing the benefit you have business after business duplicating their efforts to administer this benefit to their own employees and the system we have still large segments of the population remain uncovered additionally you know it's you know for whether or not you have health insurance it's kind of haphazard maybe you get it through your employment maybe you get it through a spouses employment maybe you're on you know public benefits system and so it creates a system where the businesses that are paying for employee health insurance are at a competitive disadvantage in the market because they know they're competing against other businesses that are not offering that benefit to their employees and maybe their employees are on a state system so we're all supporting them with our tax dollars in some ways just ask if you are open to taking questions along or if you would ask that question whatever the committee prefers I'd be happy to take questions now I just have a question about I totally agree that we should decouple health insurance from jobs just make sense as we move to the gay account that being said I don't see how the universal primary care does that because it's only a small piece of the larger so how do you envision that split happening when theoretically you still have a lot of the major medical benefits that there's no current vehicle to decouple so I think maybe Chairman I should have said let's save questions for the end of my testimony I apologize that's a great question you can hold that question I really appreciate it we do want to get to the presentation so that his question can be answered and that we have one more witness I will make it a very swift here additionally we have fewer and fewer people covered through health insurance through their job today I dug up some recent numbers I was looking for more recent numbers and I couldn't find them back in 2012 7,000 for monitors who got health insurance through their job today it's estimated about 285,000 so like everything very few things just fall apart in one day this is the slow drip of the system falling away it's not a bridge that will collapse but it's a bridge that has pieces falling off every day so VBSR was a big supporter of single payer health care under the previous governor my members were pretty disappointed for many reasons that ran into several walls although we do really appreciate the work of this committee the senate committee and the legislature as a whole around this area I think one of the things that this is reflected in testimony today one of the learned lessons here was that it's difficult to do system wide reforms in one big chunk because one of the reasons in addition to many other reasons that effort did fall apart so to your point representative the universal primary care bill will not cut that tie between an employee and their job with the health insurance what it will do is put us on the path to a system that we hope will do that we think this is the manageable first chunk to larger system wide reforms so we think that this is the path to larger health care reform if we can show that this is successful that this investment in primary care can not only cover everyone but also reduced reduced costs long term you know that would be the path forward that we would choose you know so this is a manageable piece of the health care system to focus on we know that access to primary care is the foundation of every successful health care system across the world and what also actually gets us excited about this is this would provide a benefit to every Vermont or almost every Vermont or depending on how it's all formed a lot of the times around health care actions in the legislature you know go after that declining that smaller and smaller pool of people who don't have health insurance and we like the idea of pushing forward a proposal that every Vermont or can benefit from so that gets us really excited as well so we do see this as the first step towards larger system care and you know I know the chairman will ask you know about which bill we prefer the initial senate health and welfare one or the bill that passed the senate we did prefer the original committee bill and felt that that more firmly puts us on the path to universal health care brings all the necessary stakeholders the table relies on their expertise and the bill that passed the senate we appreciate that effort but we found that a little lackluster so I have a question to follow the first bend to the question but I guess your question is going to address in the course of what you've shared Anne-Marie do you think this is feasible on a statewide level as opposed to a national level and you know it's not stated in a wealthy state I appreciate that question and when we talk about that members that comes up all the time you know quite frankly it's clear we have no leadership on this issue in Washington DC right now in fact everything that they're doing seems to be taking healthcare backwards so we feel that you know Vermont has been a successful leader in many areas and that's why we think this deserves further study before we move forward before we pull a trigger on something so the chair does want to ask you more about your interest in the two versions you were disappointed with what happened we don't have the words in your mouth I believe you indicated that you were more supportive or you were supportive of the Senate health and welfare version let me put a point on it if in fact all that could move forward in this session was the past as past the Senate version what is your membership position on that you know I'm not suggesting that's the only choice but I do think it's important for us to have a sense of how other people are viewing the choices which in fact we do need to make is that worse than doing that we've heard different version yeah I wouldn't say it's worse than doing nothing but it's not a present I can bring home to my members at the end of the session that they'd be very excited about opening up so it's better than nothing but we were really optimistic about the Senate committee version I appreciate your sharing that point articulating that point thank you any other questions for Deanna so you have 650 members is that businesses? a handful of non-profits are members and we have a handful of individuals who like the organization they'll join but the vast majority are businesses so what is the total number of actual consumers who are people who are connected through their business do you know what I mean how many employees last I checked our businesses employ about 5% of the workforce in Vermont and we have businesses in every part of the state and everything from large corporations like Ben and Jerry is owned by a country corporation all the way down to people who have no employees and they're making value-added food products in their kitchen thank you appreciate it let's turn to Devin sorry this is Devin Green from the Vermont social health system I like going by the one name thing it's like Medana Devin we will try our best to use the right towel Devin Green Vermont association of hospitals and health systems thank you very much for having me come in today to talk about the universal primary care bill before I go into that I did want to step back and just provide a little bit more detail about what's going on with the all-pair model effort and how it coincides with what's happening under or what's proposed under universal primary care I just want to emphasize that this is a huge culture shift for the provider community this now referring to the all-pair model what I'm trying to say is this is a huge healthcare reform that's happening it's not flashy you don't get a card necessarily a lot of it is happening behind the scenes and it's how it should be because it's between your provider and yourself and it's more changing the culture and making a healthier culture we want it to sort of be in natural progression for people to not feel a jarring change but that being said this is a big undertaking and it requires engagement at the provider the provider patient the community hospital and at the regional level so developing relationships at all levels to make that culture shape change and that takes a lot of resources hospitals are doing this work already Northwestern Medical Center is doing Rise Vermont it's community to battle childhood obesity Northwestern Vermont Regional Hospital is working with its community and its community providers to find innovative ways to deal with the mental health crisis and Southwestern Vermont Medical Center is doing community development to help bring jobs to the community and sort of get at those social determinants of health issues this shift is already under way and it is a massive but most importantly what's happening under all of this is an emphasis on primary care so in 2018 hospitals through the ACO are investing $14 million in primary care that includes the blueprint community health teams with which Dr. Fine said was hugely important for providing primary care for people it includes that PMPM payment to primary care providers and other incentives yes so there is this shift towards supporting primary care and hospitals are doing the bulk of that through the ACO they're providing that funding so when we look at universal primary care to what Representative Tino was asking or I forget who you were asking but where does this coincide I would say use a scalpel not an axe so the whole point of the all-pair model is to get people come in through their primary care providers so we want as many people in having a primary care provider as possible we want that incentive so what you could do is look at who is not able to have access and incentivize those folks or put a system in place to help those folks reach their primary care provider instead of developing a whole new system which could put strain on the current health care reform that's already happening I think there is I think the strained resources issue is real I think the people who would be working on universal primary care at least under the original senate health and welfare bill would be the ACO and FQHCs and so those are people who are also trying to implement the all-pair model at this time as well so I think that will cause a strain on the current health care reform effort but I think one thing that they'll already be doing is trying to get people into primary care and trying to target people who don't currently have access to primary care and once you have that data you know if you have proposals and systems in place to get people into primary care and get them access the ones who currently don't have it that's when you can sort of mind the data to show the cost effectiveness and put it out on a broader scale sometime down the road the other thing that I think was mentioned is that well one other thing that I wanted to say in terms of all this health care reform is that the other side of the all-pair model is on the Green Mountain Care Board and limiting budgets and the oversight of hospital budgets so right now hospitals are funding the reform effort under the all-pair model at the same time the Green Mountain Care Board is looking at their budgets and saying reduce your budgets reduce your budgets so they are in this place of having to both invest for transformation and also reduce their spending so they are going forward with that they think this is the right thing to do for health care in Vermont to move from services to actual health for Vermonters because it's the best thing to do with Vermonters but it does create attention and a difficulty and setting up some whole new reform process sort of sends the message of yeah we're not really we're not really invested in what you're doing over here we're going to do this new thing over here with universal primary care so again it would just be helpful to have those things aligned and the other thing that came up earlier I believe by Dr. Deb Richter was the potential to use excess hospital revenue for the funding mechanism for going further down the road on universal primary care I do see a couple issues with that that I spoke about in senate health and welfare one is that you're essentially betting against health care reform so you're saying either hospitals don't come in on budget so you can fund something or you say they come in budget or and universal primary care is not getting funded so it creates this weird sort of incentives when it comes to funding health care reform through a health care reform process there are legal issues with it as well in terms of the way it was set up in senate health and welfare was that the green mountain care board could decide the amount that would be that could be seen as a tax which raises non-delegation issues because the legislature would be leaving it to the green mountain care board to essentially impose a tax on a hospital there's an issue around it being a provider tax so your taxing hospitals it would look like a provider tax we already have this sort of 6% presented cap that that would go on top of and then in addition there's an issue because provider tax must be done uniformly and so if you're taking different amounts of money from different hospitals that's not a uniform tax literally any other funding source would be eligible for potentially eligible for a Medicaid match but not if you tax hospitals differently or necessarily do it this way and you know again I would just say we've made a lot of progress in the current health care reform efforts that we're doing and I think hospitals would really appreciate the support of their public partners in going through this effort even if you know you took $5 from the hospital budgeting process it would send a message of okay we set up this regulatory for hospitals to be under we set up this health care reform effort that we want you to do but now we're going to come in a couple years down the road and change things a little bit and be unpredictable and I think it would really demoralize hospitals when they are really stepping up at this time to try to implement health care reform. So it would be more resilient and not so demoralized by such an event and I think we can count on that and I look forward to it but I hear your concern expressed in the committee in your question. Yes so something you said thinking so if we were to assume and presumptively assume that the evidence is that one of the best return on investment in terms of primary care leading to savings and access being a fundamental piece of access which for as you pointed out might be a subset of folks who have very high co-pays through the coverage they have for but getting affordable access to primary care for those folks you were saying as opposed to a big system so what if for example we said okay you invested 14 million in primary care last year maybe that 14 million should be going directly to subsidizing co-pays for the people who cannot currently access primary care rather than the investments that are targeted under the way the ADCO model was functioning if it was a redirection is that a potential way of getting it the same thing that we're all trying to get at well then because the 14 million didn't work or I mean would you want to do that when it sued if the analysis is that would work better at achieving the goal that it might be a better investment if we say right now we can't come up with other money we don't want to take more money from the hospitals to do other stuff but what if we took the same money that's being invested that said would this might be a better investment in terms of you know cost containment because getting these folks who aren't getting access to primary care and primary care would be the best short term specific way of cost containment yeah I mean I think that would create a tension between the primary care providers and the patients and I would certainly leave that up to Todd Moore to answer that question but yeah I guess I would worry about that tension but just thinking out of the box sorry back in your box and I just want to be I need to respond to what you said Representative Looper about hospitals and the demoralization I'm not saying they couldn't afford a $5 thing I'm just saying that the message it sends is you know this is all a voluntary thing that sort of works against their best interest sending a message of we don't necessarily just support would be appreciated I appreciate it with the hospital system what the hospitals of Vermont are doing and participating in this don't mean to suggest anything otherwise it just seems a little I'll just dial back my comment I just think that the hospitals would be so easily demoralized was more than I would anticipate the hospital I think we should so let's stop there we've heard a lot of testimony this morning and appreciate your participating and others and the committee as everyone knows has a short timeframe to make a series of important decisions and we have other bills that we're going to turn to later this afternoon tomorrow but we will just so people know part of our significant focus that we're going to next week which will probably be very close to the end of what we're going to be able to do as a committee so thank you thank you dad