 Mike, the shirt here, from the Office of the Health Care Advocate. I have sat on the outside of this room for a great deal of testimony you've heard on this bill and have spent a good deal of time in the last couple weeks thinking about the challenge in front of you with this bill. And it is a little bit of a flashback of challenges I've seen at this table for many years. It strikes me that one of the challenges for me in my role as the health care advocate is that I sit sort of at times uncomfortably between two significant approaches about what do we do with our health care system. There is a part of me and a part of my office that comes from and holds an activist view of our systems broken and needs broad reform. But when somebody calls our office and says, I don't understand why I have such a big copay for something or isn't it unfair that just to use examples that have come before this table, that I keep getting these copays for my breast imaging. I thought that was supposed to be covered. The answer our system is broken needs to be reformed is not sufficient. We also need to live in the much more wonky health care wonky world of what adjustments do we need to make in the meantime. It feels to me like there's a real analogy here. I think the various versions of this bill fall on those generally in those camps. And I regularly have to in my role regularly have to push back on members of my staff who say we need to live in one camp. So I find myself as I come to this table with that very same thought that I don't find the, while I agree with the approach that the system is broken and needs very deep reform and should be publicly financed. Given the political landscape, I don't find it sufficient. I also don't find it sufficient. You've heard, I was paraded people who come before you and it strikes me that I had the thought as I was sitting down today that I was going to step on everyone's toes. So let me step on the other toes now. I also, you've heard a parade of people who have said, they're going to tell me this is unfair, but some version of we're on the job. We're making it work. We have a lot on our plates. Don't pile more on our plates. I don't find that argument sufficient either. You know, I know and love and support our FQACs and they provide a very important role in giving people access to care. And yesterday you heard some about the sliding scale that's available to people. Just as a reminder, the sliding scale is up to 200% of the federal poverty level. So an individual above $224,000 some income is above the sliding scale for the FQACs. When I look at the flow of cases that come to my office and when I search for, in my database, you know, just as a reminder, we get about 4,000 calls, cases a year, though our numbers are a bit up right now, by the way, because I'm working on my quarterly report. And I search for access to care, primary care. I see a whole set of people who are having challenges getting the care they need. And some of them show up as I couldn't afford the premium. So I don't have insurance and now I need primary care. And some of them show up and then there's a whole range of other possibilities as to why someone can't call our office and ask for help. And then I always need to say, again, I searched for 2017 for access to care, primary care and my database and I got 36 hits. I have no idea how to measure the relationship of the world, the universe of Vermonters who had such issues. What percent of them knew to call the healthcare advocates office and what percent of them did. Use your own judgment. I think all I can report back to you is today on the ground, Vermonters do have access to care, challenges in accessing primary care. What is on the landscape for access in the coming years? I don't know how to answer that question. I think there are substantial threats. I think Alan Ramsey did a pretty good job of, I agree with the predictions he made about threats to access, threats to our insurance marketplace. And then in my many thoughts that came to me as I listened to the various testimony, I also think it's really important to remind ourselves. The accountable care organization or approach, the accountable care approach, seeks to change the relationship between the payers and providers and change provider practices through adjustments there. And you've probably heard me say these very words before, but I need to keep saying them. I don't care what kind of new fancy relationships that are achieved there and how much they change behaviors of providers if people can't afford the access in the first place. So ultimately my message to the committee is, yes, there's a lot of interesting, hopeful things going on. Yes, we've built a great FQH clinic presence around our communities. And yes, there is some hopefulness in our approach with payment reform, with delivery reform through the ACO model, but I don't find it sufficient. And I don't know why ultimately it has to be one version or the other. I think there's an argument for continuing to move the ball, keep the ball on the field, continuing to focus on the viability and appropriateness of publicly financing health care while addressing and measuring the challenges we have in this case in accessing primary care. Again, I said I think it was 36 people called my office. How deep is the problem of accessing primary care? Are there questions there that a study committee could evaluate and give feedback to committees like this about action steps that could be taken separate from public funding? Or maybe before public financing, ideally. What is the out-of-pocket exposure and how does it limit access? Are there areas of the state where there are just not openings? Whether it's insufficient number of providers and many other questions I'm sure I can't even think of right now. So, for what it's worth, those are the thoughts that come to me as I come to sit at this table on this bill. I appreciate the way that you flushed out all the different angles. What's unclear to me is what you think we should do. So I'm wondering if you were on this committee, what would you do at this point? So very much. I find myself wondering if there's a meshing of the two versions of the bill available. And it might be that it's very hard to achieve that. But that's sort of generally what I'm saying to you, that I hope it's not an either or. I asked this also knowing your previous experience. Do you think there's any value to starting to save up money to finance future changes? Because we receive some letters and suggestions that we incorporate some elements into our bill around that. I don't know if you review everything we look at. But do you think there's any benefit to saving up money without a clear plan of what it's going to be used for? I think it would be very, I don't know about value. I think it would be very hard to do so. I think it would be very hard to do so. I'm going to leave it there. There are pressing needs today on the budget that the likes of me would come and say this needs to be spent on some need we have right now. Questions? I maybe will just say one more thought that's been on my mind for a long time. And that is one of the main reasons why I have always been a supporter of public financing is because, I wish Representative Donahue was here for this example, was because you don't believe we will ever really truly commit the resources to public health care, not population health care, but public until we're responsible for it. So the example I always give is, I think we say something like 6.7% of the population in this country has depression. And do we bring in each of those individuals to try and treat them? Yes, of course we do. But what's it going to take for us to attempt to do a different approach that says something more like, while our community is sick with depression, we need to reach out and treat our community in a different way to treat depression, for instance. And that's a very different approach than I think the term that's been said at this table a lot lately, population health, which is about the population in your plan and how to reach out to them in a different way. That's all good too, but I can't miss the opportunity to say, had we done Act 48, was it 48, 48, and been living under a single payer financing system, we would be debating at this table the actions that the state has to take to limit the cost. The state would in fact be an insurance company and would be saying no to people and people would be upset with that. So the concept of public financing doesn't fix all. It still costs too darn much. But it is my hope that it is moving that direction that frees us to some different thinking about where to make investments. Thank you. If you see finance, this will know if you will. Probably we're not entirely sure if it's posted or so. I posted it under, I posted the new one under today. Don't pull it up there. Okay. So let me just back up and say this is on me because I'm not here for a good part of yesterday in the way I hoped to be. So I did not have the opportunity to reach out and schedule ahead some of the folks that I would hope might be available for us this morning. And one of the things I did not do was to ask for the reason I was care board to be here to review the note which they provided to us. But I have asked Nolan who has reviewed the plan as it's, the S53 as it's coming out of the senate as well as had reviewed S53 as it was in the senate health welfare committee. And one in one need to ask Nolan if you would walk us through some analysis that looks at the various different aspects of the different versions of S53 and then depending if that makes sense then possibly to look at if it hasn't been incorporated to look at the latest information from the green on care board as well in terms of the dollar impact. So you can obviously that'd be great. Yep. For the record and all online while the joint fiscal office and I have incorporated the latest green on care board. Actually both of their estimates one for that has passed the senate and has passed senate health where senate health and welfare are both incorporated in my fiscal notes. So I can talk to what they said. I won't get into the why. If they can have the opportunity still to speak for themselves about that. So I won't get into too much detail because you've already had the walk through the bill. But as you know that as past the senate was directed to Green Mountain Care Board to convene a group of stakeholders to get into to do the planning and what I'm not going to tell you about. I'm going to highlight a few things. The second paragraph of my fiscal notes included tent language saying that this is the intent of the general assembly to provide sufficient resources. So the Green Mountain Care Board in fiscal year 2019 and 2020 to enable the board to carry out the duties set forth in this legislation. But the bill did not include an appropriation. There's two reasons why this language is in there. One was it passed the senate at the time and that big bill was announced by the bill. The second piece is that the Green Mountain Care Board did not provide had not provided an estimate of what. Let me reframe it. The senate as you know the past the senate health and welfare went to senate appropriations and they changed stuff. And then it passed. So the Green Mountain Care Board I think was probably caught a little off guard. And so they had not had the opportunity since they did not to weigh in on what they thought the costs would be. At that time there was no appropriations for those two reasons. So now we have it or sorry you have it. And so they had provided a document and I can go back and forth to their document line but essentially their document they put out said it was going to be about 590,000 to 770,000. And I break it out in here. You can see the contract costs are a piece of it and then the FTE costs. And I arrange it because between 90,000 and 808,000. I used to well raise it higher. I think your reference is to S53 not S175 is that correct? Yeah it's typo. I was writing. I don't know how Jen does it but I was writing madly writing fiscal notes for different legislation at the same time. And that's a skill that Jen clearly has because she writes way more legislation. If you're able to say this is that. Thank you I will. I'm sorry. I'll beat myself up a little bit later. We're talking in S53. The only thing I'm more surprised at the fact that Representative Donahue didn't catch it first. And it's only because she wasn't here. Because she's got to utilize. Well I'll get credit to Brian for catching that we're not in Manchester for a month as well and another letter that we got. Oh I have that in there too. A letter that so for people who aren't working in the room we received a letter that was printed to me as the chair and it addressed it to me at the State Capitol in Manchester for a month. So I hadn't noticed when I. Where are we? That's been correct. Thank you for the correction. I will fix that. So the costs from the Green Mountain Care Board are broken out into two pieces. One is estimated contract costs and estimated FTE costs. And it's over a two year period. And so you can see the contract costs change. But the FTE costs are ongoing. And there's two, there's a range because they weren't sure if they'd have to hire one or two people. So those are the costs that people had to close wages and benefits and all the costs that go in with hiring somebody. Okay so can I just make sure I do understand which we're talking about here in terms of the estimates. We're talking about S53 as past. The Senate. The Senate. Correct. Yes okay. And so what then what I did was I added up the column and I got the gross. And so the gross ranges for 19 is between 425 and 515. For 2020 it's between 165 and 225. Total over the two years is 590 to 770. So I broke it out. They didn't really have it broken out. I broke it out so you can see that if we were to pass this as past the Senate, the state total you would need between 170,000 to 206,000 for fiscal year 19. And then 66 to 102,000 because of billback. Okay so explain that to the people. So we have the gross cost and then the Green Mountain Care Board went back and they determined that these particular expenses do fit within their definitions of how they can utilize their billback. So that they would, that the state cost would be less. Now of course as we, you've all had been well versed on billback. When we billback we push those costs on to the industry. Okay. Maybe this is a question for the Green Mountain Care Board and obviously they don't understand billback as much as I should. But I thought the whole discussion we had this session was saying billback we're going to do a better job of making sure that we're billing back specifically the time that it takes to regulate the agencies. And that's my question about this. It doesn't seem like it fits that structure that we're going into. I think it fits well. I will defer to the Green Mountain Care Board but there's two pieces to that. There's the direct building and then the other piece which I forget. I don't have the piece. There's a piece for like direct services and then the rest of which they sort of split up between the industry. So I'm assuming that this fits within that second piece. Jen shaking her head yes. Good question. The revised billback piece here. Yes. And then this piece just sort of talks about those pieces. So to whom are we billing back in this instance? I'm trying to sort out. I'm going to call a friend here. Jennifer Cartey. Let's just say a council for the record. So the way the new billback language is set up is it has certain expenses, direct regulatory expenses being billed directly to the regulated entity and then for all other expenses of the board go through the billback formula. Which is 40% from state money, 60% from the industry broken out by hospitals, insurance companies, and the ACOs. So is that second category like what funds healthcare advocate? There's a separate billback progression in healthcare advocates statute. The difference with the current, the existing billback is that it says for certain regulatory expenses for rate review and for hospital budget review, those expenses get billed back in the, according to the formula and statute. What the new language says is expenses that are directly related to regulating a particular company related, particular entity, get billed back to that entity. All other expenses of the board are borne by the billback formula, which is 40% state, 60% industry. And then split up as described. Right. According to the formula. Right. And then with the additional, and then there's also a provision in the new one that has a minimum $150 payment from any regulated industry. And if what it cost to regulate that particular company was not $150, then whatever the difference was goes to reduce the amount that gets billed back for other board expenses under the formula for the non-state actors. Glad I could clear that up. Excellent. And then the other thing I add in here is that in the end of this paragraph, I said one to two limited service positions would also need to be created if you were to take the recommendation of how dream out care board assumes that they would do the research. So, and that's generally we do that in legislation as well when you have to create your positions. That's right. So, I'm just going to raise the question and we will be here for the dream out care board on this. Not for you in a new position, but having had the explanation about billback, I'm still somehow a little bit perplexed as to why the legislature directing the dream out care board to look at the issue of universal primary care. I guess I need to understand how that fits into the justification for billback to hospitals to carriers, et cetera. Why is the state not bearing the full cost? Why is the state not bearing the full cost? And that the state should be, if this is a study that the state, meaning us, is setting in motion and requiring a dream out care board. So, I have a question as to why we the state are not fully responsible for the cost rather than having those costs pushed back to carriers, hospitals, et cetera, through the billback formula. You might have to look at the language of the billback. For me, that's an unresolved issue. I'm not yet comfortable with the idea that billback is actually in play here. You could also be prescriptive and you could say something that, you know, or shall not use billback. Well, I understand what the consequences of all this are. The consequences are that it creates a much heavier, bigger lift for us in the legislature in terms of the appropriations impact. But nevertheless, I think I feel some responsibility to understand whether or not billback is the appropriate mechanism for something which we're setting in motion. We'll look at that later. They addressed that because I asked them. I pushed them. I said, well, how much of this is billback? How much is this federal? How much is this? And their lawyers came back and this was there. And just to clarify again for folks and for myself, we often say, well, this is a state portion. And the reason that it's a state portion versus some other entity is that there's a Medicaid match. That is not what we're, that there's no Medicaid match in play here. It's the billback formula in terms of state versus other dollars. Okay. The other thing I applied here is I said the fiscal note does not address any potential costs, offsets, savings, et cetera, and out years. Should the state move forward? I just wanted to address that because there's always a argument or discussion about does it cost more or does it save money? And I do not address that. Okay. So can you just scroll back to the first page and just let me look at the, let us look at the bottom line numbers. And so with, with the billback has reviewed by the, or analyzed by the BMI Care Board, we're looking at in terms of appropriations that are being required. The state totals only for FY19, which is where we are in the budget. We'd be looking at somewhere between 170,000, 206,000. In fact, for some, whatever reason, the billback was not seen as an appropriate mechanism for this. The dollars are in the gross total. Is that correct? Correct. For 25,000. So it really becomes closer to half a million dollars. For 25,000. I have a question. Yeah. That's further. We didn't let you get to the end of your memo. No one, but you later in the memo. Okay. Reference of 1115 waivers. And how the last paragraph. Yeah. And how the ACO might fund. Oh, forgive me. I do. So let me go through that. So that was part of the Senate. Okay. Yeah. That gets into how the Senate House of Welfare was looking at potentially funding. So yeah, that's a different issue. Okay. So that doesn't apply to the bill as passed by Senate appropriates the Senate. Yes. That applies to the bill that came out of Senate House of Welfare. And only because of one of the financing mechanisms they were thinking about using, which was the DSR payments. Great. Thank you. I guess I might have to move into Senate House. Well, if you have any more questions on this version, I'll let Chairman Lindberg. Are there other questions from committee members on that? So what we just looked at is, as passed the Senate. Yeah. And visit the discussions and people asking about it. Sometimes I have the habit of putting historical, sometimes I don't think it's just too many words. But in this case, I... Well, we as a committee have said we want to look at both. Yes. Which is why I added it. So as passed Senate House of Welfare, this bill was different. It required the Green Mountain Care Board to convene, facilitate and supervise a working group. It would have allowed the Senate Health and Welfare Committee, not you, to have a joke. To meet up to five times following the 2018 adjournment to provide guidance, receive updates. And initially the bill is passed just look at the legislative prudence. And this assumed that all five members would attend all five meetings. And this is what the legislative prudence, about $5,500, for the prudence. Then the board, what's today? So two days ago, one day ago, provided us with an update because based on the requests and the discussions around Senate Health, where they provided an additional estimate. And they say that for them to do this, it ranged from $740 to $830,000. Again, if you were to apply bill back, it would be between $300,000 and $330,000, roughly. That's not on their thing. I wrote it in, and I can jump to their thing real quick, if you like, or not. But basically of that, it's all one year. It's not over two years. Why don't I just pull up there for a little bit? Sure, if you're saying it's all one year. And then I'll come back to mine, and I can get to represent the prudence. Laurie, this is the wrong one. I need the other one. This one's from 4.2. Okay, what's the, this is the one I, I posted the one I just got from Susan. Oh, so there's Susan. So you have three amount of care board, and you have Susan. I think so. So we might want to combine them. I thought I could. Sorry. No, you're good. Maybe, maybe combine them, so it's not, or put them all under the green amount of care board. Okay. But maybe later, so we don't, thank you. So the estimate here, you can see under, so it's all one year. It's not a two year, it's a one year outcome. And so there's 650,000 for contracts, and then again the 90, 280 for an additional FTE. And that's where their combination is. Let's see, convene a working group, service and benefits, development. So they're saying 250,000 for that piece. And then I actually would let them speak to this 400,000. I don't quite understand it, based on how it's written here. But essentially their review of the Senate health and welfare bill, I'm assuming at their time, this is what their estimate is. Again, I'll let them speak to it. So to get to the representative, Brickland's question, part of the bill stated that to the extent permitted under the all payer ACO agreement, and under Vermont's, our Medicaid waiver, our global permit, up to 300,000 expenses incurred by the ACO to develop a draft operation model describing the committee version. That could be funded through delivery of reform payments. This is that piece with the delivery system of reform payments. As you recall, in the diva budget, there's $2.6 million going to one care for this delivery system of reform payments. And it's basically money to help them get their systems, their IT systems up and running to be able to measure and do all the pieces. And it's going out to the providers to sort of help them move on this area. And there was a sense that they could take some of that money, and instead of using it for the DSR payments, one care could use that in sort of helping with the under, of this piece. What became, a lot of information has come to light since then. One of which is that my two questions are issues that sort of flag on that are, one is that those $2.6 million are HIT funds. So, and it's not, it's coming out of the HIT fund. So my, and they are a mix of 90, 10, 60, 40. The second piece is that under the global commitment waiver, the recent agreement is that it was specific saying, yes, you can use this money for these kind of things, delivery system reform payments. If we were to take that $300,000 out and use it for this, it's not necessarily clear that we can actually get a federal match on that anymore. So you're taking away $300,000, but that may, it'd be 300,000 gross, and so you're going to 2.6, it just, you may not be able to match that money. So you're pulling out 300,000 gross, so. Questions whether that was 90, 10, or whether it was 60, 40 as well. Exactly. So the 2.6 is the grossed up amount. So if you take out 300,000 and 2.6 might not be 2.3, it might be something less. So, and that was all something that came to light afterwards. So I think that if the committee were interested in doing that piece, further exploration would be required. I don't know that this committee wants to use this money from that piece based on what you already recommended. So anyway, that's what that piece is about. Then it also creates the Universal Primary Care Fund and the Treasury, but again, it did not raise any specific revenues for this. Right. So that's the... I appreciate your walking us through that. I think I have to say honestly, for me it leaves to you with questions as to whether we have a sufficient analysis, fiscal analysis of what we have in front of us, but we need a version. It gives us a general sense of what the Greenback Care Board is anticipating as they are being assigned. We've worked in the Senate past version and it's a better understanding although there's, I think the issue around the 1115 waiver money is one that really does need to be understood because it sounds like you could have some significant impact. I want to play some of this back to you, Nolan, just to see if I've got it. The things I'm interested in here are comparing, depending on what this committee and what the House may or may not ultimately do, but comparing what the costs of these two proposals are because they're going to be very interesting across the hall, I suspect. What the Senate passed was a bill that they're presumably going to put in their budget that's going to come out next week. They passed legislation that will have a final cost to the state assuming that billback mechanism is available of somewhere in the $236,000, $308,000 range that in this year's budget, the Senate is going to put in their budget somewhere in the $170,000 to $206,000. Assuming that they say, yeah, the Green Mountain Care Board's estimates are reasonable. Okay, I get it. So they can put anything they want, but this is an estimate that suggests. Correct. Okay. What Senate Health and Welfare passed, in contrast, was something that the Green Mountain Care Board estimates. By the way, I'm sorry, I don't need to cut you off, but the Green Mountain Care Board hadn't went out this estimate when it passed the Senate. So there was no number when it passed the Senate, which is why it sort of... Right. So... The Senate chose to do it that way. Well, yeah, but they didn't know what the estimate was. So now they're... They were choosing to not know at that time what the estimate was when they passed it. Right. So that estimate is that it would cost... The Senate Health and Welfare bill would require somewhere in the neighborhood of $740,000 to $830,000. 300 of that potentially could be pulled out of already appropriated in the House budget. $300,000 that was linked into $2.6 million for the ACO, which was a technology funding under... Yeah, mostly implementation and delivery service reform. Okay. So potentially 300,000 of that might already be accounted for, but we'd be taking it away from something that's already in the House budget. Well, I think what it was is they had heard from Todd Moore, and I think it was more of, you can use all the 2.6 we give to OneCare. OneCare could take 300 of that and use it for this purpose instead. So we weren't pulling it out from giving it to the board. We were just saying, okay, you may use up to 300,000 of this 2.6 OneCare to work on this with us. That's my interpretation of that. Well, I guess what I was trying to get to is money that hasn't been accounted for in the budget yet. And the Senate Health and Welfare proposal is 748.30 less $300,000. No. Which is already in the budget. It's, well, 748.30 or 300 to 332, if you assume bill back, right, because that's the gross. And then the 300,000 is just already appropriated and just saying you may use this for this instead, which, again, I feel needs further exploration of whether they want it. If you were to move forward with that, I would recommend that we revisit that piece and understand it better. Then I may be clear with my question. What I'm trying to get to is how much would, if we, for example, out of this committee, recommended moving forward with a health and welfare type bill, what would we be asking appropriations to appropriate for FY19 relative to the numbers we see here if we are able to pass the Senate approved version of this bill. And it looks like we're asking the appropriations committee to appropriate about $200,000. Yeah. What's the health and welfare equivalent? I think the health and welfare equivalent would be the 748.30 or the 300 to 332 if you were to, that's the bill back. 748.30 is gross. If you assume that is bill backable. Yeah. Then the 300 to 332, in that case, in that conversation of whether you think bill back is appropriate, plus the per diem, and then the separate question is whether you, allow one care to use that 300,000 that were given for other purposes. We're not, that's to me, requires further research. But we're not taking it and putting it back in, per se anymore. You know what I mean? Yeah. So can I just say that? So I think along the lines of what you just asked me in terms of questions I found myself thinking earlier, could you do essentially a side by side? Yeah. The Senate has passed the Senate as passed Senate Health and Welfare so that we're looking at numbers, you know, whether applied bill backs applied or not applied, the gross dollars, et cetera, so that we have a side by side fiscal comparison. I think that's what we, so that we're not trying to. Chair, an appropriated funds versus new funding. Because somebody was already in the budget and one of those, correct? Well, I don't think there's anything that's appropriate. Nothing's appropriate. Because there's nothing in the House budget. You know, there's nothing in the House budget because we didn't have, we didn't have this proposal and the budget went to the Senate. So let me ask a separate question and I'm just skipping over your memory. Do you, as the, someone from the Joint Fiscal Office, can you share with us, or do you know what the Senate has put into their version of the budget with regard to S53? I don't know yet. Last sheet I had seen was sort of what their thinking was and then they had a tracking sheet which had placeholders of different things that the Senate had passed and then for the committee to sort of visit about whether they include that in the budget or not. So can you tell us at what point we will know at what point will we know what the Senate's actually doing in terms of proposing in their budget to address S53. I'd like to know that in terms of the timeframe for us to resolve what we're doing with regard to S53 and whether or not we will have that information or can't have that information prior to we, to us making a decision because what we decide in this committee has a direct impact on our appropriations process. We understand regardless that because of the constitutional requirement the budget starts in the house and we didn't have the budget or they didn't have the budget. There's this disjointedness but to the degree that we as a committee can know what the Senate's intentions are it might help inform to some degree what we choose to do. Yeah and I can check in with them because they've been taking testimony all week on their budget and whether it's their intent I'll ask about their intentions because whether it's in the bill or nothing is in the bill until it's all in the bill I guess so I will check in with Stephanie and the chair for appropriations to get a sense of what their thinking is on this and I'll report back to you. I have a question of the 300,000 on the health and welfare burden okay it goes from 740 to 840 but if you apply bill back that drops to 300 to 330. Yeah it's like 296 to 332 but the delivery system reform payments that go to one care cannot be used to counteract that 300,000 it could only be used for one care's portion of working through this system. Well let me refer in that you can use it for however you want you're the legislator so you can say we want to pull 300,000 out and put it here. The thing that I flag is the one is that it's coming out of HIT funds which you know you can do whatever you want with it but again those are monies that we've appropriated specifically for HIT stuff and two there are implications of pulling it out and giving its degree amount of care for it so if you look at my footnote at the bottom number two the governor's budget includes 2.6 million 941,000 of it is state for delivery system reform payments if that 300,000 is not matchable and you were to pull it out then you're only given 641,000 and then that grosses up to less than 2.6 because you're taking it away from the base that can be grossed up if it is matchable then you're only taking then you're leaving then the delivery system reform still has like 2.2 or 2.3 depending on different matching rates that's why I say we have to better understand you know canvass money I don't believe it was completely vetted it needs further vetting and I'm concerned that that money would not be able to I'm concerned about our ability to use global commitment funds specifically for that because that might be falling under more of an ANCO investment kind of thing of which we are pulling back on because of our agreement with the federal government on that one little just to go into the weeds a little bit further if you do look at primary care there would be a technology component and digital technology people could be part of the stakeholders in this group which they have radically with numbers the 90-10 I think is for specific pieces and so even of that 2.6 some with 90-10 some with 60-40 or whatever it all depends on what bucket it's what specific task like in that 2.6 there's a whole list of different tasks of how that money is being spent and so it has to meet certain criteria I don't know that this would because this is really for you know and the question is whether it's matchable we have to so if you were to do that I might not you can decide how you want it but using the DSR money might be problematic any other questions from all of them at this point thank you