 Good afternoon. This is the House, the afternoon meeting of the House Appropriations Committee on March 18th. We are delighted to welcome members of the House Health Care Committee to give us a walkthrough of their bill H4. I wrote it down wrong through H430. You're going to correct me when H430, which I'm calling the Dr. D Bell in my head and you will tell us about that. So, and representative, so we are joined here by Reps Houghton and Representative Black, as well as Ms. Carby. Carby, gosh, Jen, I know you. I know your name, Carby. I'm Ms. Carby from Ledge Council and Rep Black, you have not been in our committee before and so I would like us to really quickly just introduce ourselves to you. I'm sure you have met some of us, but just I have been in your committee. Never mind. Three times before. Observing. Never mind. We're not going to introduce ourselves to you. So thank you for joining us. And with that, we will turn this over to you for your presentation. Thank you. So having me today, I'm bringing before you H430, which is an expansion of eligibility for Dr. Dinosaur to all income eligible children and pregnant individuals residing in Vermont, regardless of their immigration status. The number of children and pregnant women in our state do not get necessary care because they do not have health insurance, and they do not have the money to pay for their medical costs out of pocket. Children struggle to obtain necessary vaccines and primary care, and pregnant women receive no prenatal care, and give birth in fear because they know that they will never be able to afford the cost of that care. While we do have clinics around the state that offer free care. Most of these do not provide care for children and none provide obstetrical care. They are also not available in all regions of our state. While all hospitals in Vermont offer patient assistance programs, many do not extend this benefit to individuals with an undocumented immigration status. These factors lead to care being sought in emergency rooms that cannot turn patients away and individuals are left with enormous bills that they could never even begin to repay. Also, I think it's really important to note that this uncompensated care further increases the tax cost shift in our health care system, and it's ultimately paid by commercial ratepayers. So under our current rules, there are many non citizen residents who can enroll in Dr. Dinosaur or other qualified health insurance plans. One of these non resident categories include those that have been granted asylum refugees trafficking victims and other humanitarian categories, but it's really important to note that they're that though the application and approval process can take quite some time, and while they're awaiting the approval, they are not eligible for Dr. Dinosaur. And due to the complexity of these many statuses, we do have people who are denied coverage when they actually are eligible, but a mistake has been made on their enrollments by simply extending coverage to all, regardless of the status. This simplifies the process and will lead to less denial errors. How many people do we think this affects due to the very nature that they're undocumented I only have estimates. These estimates are coming from UVM extension bridges to health and the Vermont immigrant assistance program at the Vermont law school. In our farm worker community, they have estimated that there are approximately 25 to 30 children who are accompanied by their parents who work on our farms. And then they also estimate an additional 20 unaccompanied youth under 18. And they are actually working in our dairy industry. The immigrant assistance program estimates that at most 50 children who are in those previously mentioned categories that I had that will eventually become eligible, but are not yet they estimate that there's 50 children. Diva has extrapolated out national data and they estimate that there are approximately 22 pregnancies per year in the state. I think it's really important to highlight that once a child has been born, that child becomes a citizen and therefore they automatically qualify for coverage. And since we know that prenatal and childhood access to care is an undisputed building block for a lifetime of better health. If we extend prenatal care and we could avoid just one premature birth, the cost of that premature child's care may possibly exceed the entire cost of this proposal. Many non-citizens in Vermont identify as people of color. And as we continue to address racial equity and health care on a statewide level, adopting these changes is a significant and straightforward step that we can take to decrease racial disparities in care. This proposal would provide a tremendous health benefit to a relatively small portion of our population. And most importantly, the committee on health care thinks that this is simply the just and equitable thing to do. And because of that, the vote on this bill in our committee was 10-01. I have a long list of supporters which I could rattle off if you want, or I could maybe toss this over to Jen Carby and she could do a walkthrough of the bill. Let's go to any questions. I'm not seeing any questions. Let's go to the bill. Thank you. Nice overview. Thank you. Thank you for the numbers. Good afternoon, Jennifer Carby, legislative council. Do you want me to put the language up on the screen or do you want to look at it yourselves? Members should have a copy of it. And I think I'm not seeing anybody say they wanted up on the screen. So we're good this way. Thank you. Okay, great. And should we start with the bill as introduced? Is that what you're looking to? We'll get that quickly and then we'll move to the change. Okay, great. So the bill as introduced really implements the policy change that representative Black went over so it would enact a new section in title 33 in our chapter dealing with Medicaid and other coverage for Dr. Dinosaur and specifically it would direct the agency of human services to provide coverage under Dr. Dinosaur to children and pregnant individuals who are undocumented immigrants, but who would otherwise be eligible for medical assistance from the state under the applicable provision of the Social Security Act that allows us to operate the Dr. Dinosaur program. Section two of the bill as introduced would appropriate $1.4 million in one time funds to the agency of human services in FY 22 to begin implementation of the Dr. Dinosaur expansion, including language appropriate outreach to the affected and healthcare provider communities. Section three would direct the agency of human services to include the full costs of expanding Dr. Dinosaur eligibility to undocumented immigrants, the undocumented children and pregnant individuals in the agency's FY 23 budget proposal. And then we have the effective dates with the FY 22 appropriation taking effect on July 1 of this year, the remainder taking effect on passage with the agency of human services making that expanded Dr. D coverage available, not later than July 1 2022. So that is the bill as introduced. And then with the potential amendments that this committee may offer, it would strike out sections 23 and four so it would keep that initial section that that would expand or direct the agency of human services to expand Dr. Dinosaur coverage to include pregnant individuals and children who are undocumented immigrants. But then the appropriation would still be in section two would still be 1.4 million and one time funds to the agency of human services in FY 22, but it would be for three different go toward three different purposes. First would be grants or reimbursements or both to healthcare providers for delivering healthcare services during that year to children and pregnant individuals who are undocumented immigrants. So grants or reimbursements kind of prospective or retrospective payments to providers for delivering care to that population. Second is grants to Vermont organizations that work with members of our undocumented immigrant community or members of the provider community to provide outreach and information around opportunities for children and pregnant individuals in Vermont for undocumented immigrants to access healthcare services at low or no cost in FY 22 and thereafter so kind of getting through this bridge year and into the doctor dinosaur expansion after that. And also the funds would be used would go toward implementing the technological and operational processes necessary for diva to administer the doctor dinosaur expansion beginning on July 1 2022. And then third, this is around the information about what the estimated costs will be this would have the agency of human services provide information on the estimated FY 23 costs of the doctor dinosaur eligibility expansion, beginning on July 1 2022 would provide information on estimated costs of that as part of their FY 23 budget presentation to this committee, the health care committee, and the Senate counterpart committees. And then we have the effective dates. Again section two with the FY 22 appropriation would take effect on July 1 of this year. It would take effect on passage and would require the agency of human services to make coverage available to undocumented immigrants under doctor dinosaur as set out in section one beginning on July 1 should say 2022 it says 2021 at the moment. 2022 subject to FY 23 appropriations for this purpose. Any questions for the presenters Jim representative Harrison. Yeah, thank you. Maybe this is, I don't know if this is a question for a representative black or a black carbie but is it envisioned here that once you're qualified you would get some kind of insurance card. As I would assume, most people probably have today from doctor dinosaur if they're on that program or from their private insurance carrier. Or is it further or is it and just envision you, you get pre care. You would receive a green mountain care card with your with your unique ID number on it and you would have doctor dinosaur coverage. As every other child with doctor dinosaur in the state has. Okay, that's what I thought I just wanted to clarify. Thank you. Are there other questions for members of the health care committee or our Ledge Council Dave. Thank you madam chair. So Jen in lay person speak here. What what we've done really with the amendment is we've given the amendment says give a chess, the $1.4 million to do outreach and that's to serve this population. And then it moves on and it directs diva and the agency to do a state plan amendment and bring back for consideration in FY 23 any kind of budget proposal. I think for the most part except the state plan amendment piece I don't think because this would be state only dollars I don't believe there would be a state plan amendment. Necessary, but otherwise yes it effectively creates kind of a bridge here and trying to provide more access to coverage and more information about access to cover it access to services and coverage for those services. And then it would provide you with the information for FY 22 and and potentially beyond but specifically the cost that would be in place in 20 FY 23, if you were to go ahead with the actual expansion. And in the first year it's one time money. In this first year for the right for this FY 22, the grants and reimbursements would be one time money. Okay, thank you. So, I kind of went down the same. I thought I understood what I thought Dave was saying. So it does not become in in the out years this cost does not kind of get subsumed into the diva. Instead there we will see a separate free standing line item for this cost is that how that will be managed how will we see this if we choose to accept the budget now years. I mean I expect it would be part of divas base funding the difference would be that there would be no expectation of federal match on this piece. Okay, thank you. And so the testimony was that there are sounds like is that there are about 100 children who we believe would be eligible for this and annually maybe 22 pregnancies that would be eligible for this. And the thought is that these individuals receive emergency care. Now, you know if you show up in a in an emergency department, you receive care they don't say, are you showing your health card or prove that you have insurance we have a wonderful system that takes care of people. And the thought is that this costs associated with actually providing insurance are less than those associated with potential the potential costs of emergency care. There's a speculation but that's the thought behind that. And, as well as kind of the obvious ongoing benefit of providing good health care coverage to children, so that they develop and are healthy and become good citizens in the state. That's kind of the effort behind this to to accomplish the reason we're considering this. Absolutely, absolutely that you know I mean just access to a pediatrician when your child is sick saves thousands of dollars instead of bringing them to an emergency room. Thank you committee so when when we received 430. It felt like it needed a bit more work, just in terms of getting the money out the door to the groups that needed this. I'm thinking of the of the effort that we put behind the stimulus equity grant checks that we provided last year. I think this committee and the body was proud to say yep we're taking care of this group of people. And we realized that you needed to do some additional sort of outreach work to make sure that folks in this community who are not normally connected to government services you need to figure out how to do some outreach there. And that's the genesis of some of this amendment that has been suggested and I'm assuming Dave, you would be suggesting that we amend that the House Appropriations Committee amend h430 with what Miss Kirby just walked us through. That would be my recommendation and I also wanted to take special pains to point out to our chair that in section two. It's very specific and that it does not list the name of the organization, whom the money will go to. I'm teachable. Sorry to the other member that's a little insight thing I guess. Anyways, I forgive me a little humor that very little human. Yes, that's my recommendation. Thank you. Representative Yacoboni is once again trying to score points in the committee. I try hard. Yeah. Okay. Um, any, any further questions. This is pretty straightforward and if the committee is ready is this something that we can act on and not have to come back and refresh ourselves with. Yeah, I think people are ready to go. Um, so, um, representative Yacoboni will you propose will you make a motion please. Yes, madam chair I would, I would move that we approve h430 as amended with the committee's recommendation substitute amendment for sections two and three. Um, would, would perhaps your first motion be that you that you move to amend age or 30. As provided in, I don't have a draft number on this but in the draft that is a before us. Yes, made it is that work for you. Um, I think it would work if I said move to amend h430 as provided by rep Yacoboni's language or something like that since we don't have a number on this language but to identify the language somehow. I need to draft it as an actual amendment for you. Okay, so maybe wait until we have, let's wait till we have that draft rather than from later. Yeah, I think it's a bit of a cut and paste but it's, this is just for discussion. Great. Thank you. Why don't we, we will set this aside. We'll wait till we have the, the, the amendment return to it. And all the credit for this work goes to the health care committee certainly not me. I want to thank him. Thank you committee members. Thank you very much representative black for your presentation and both reps black and Houghton and others in health care for your work helping us to amend this proposal. So, I think we should let you go we're going to probably move on to some other work when we get the amendment, we will do our work here and Dave will let you know what we're doing and we're trying to figure out how, when we're moving things. I don't have you on a list yet. So we'll let you know what's happening. Thank you very much. Thank you.