 All right we are live. All right good morning everyone it is August 26th this is the Senate Health and Welfare Committee it's a as Senator McCormick said it's a brisk morning a transition from what we've had in the month of August and July it was pretty hot. Today we're just we're going to look at some bills that have come to us from the house one of which we've taken significant testimony on that's H 663 the act relating to expanding access to contraception and I think as presented to us in the house was a bill that prevents unwanted pregnancy. So Jen do you want to remind us where we are with that bill and I know and then Debbie I think you wanted to add some comments. Sure good morning Jennifer Carby legislative council so we had walked through as the chair said we've gone through H 663 as it came over from the house and you were going to be and I can't recall if you actually got an opportunity to consider some language from the senate education committee that would add some additional provisions on school wellness and provision of menstrual hygiene products. So I think that amendment is also posted if that's something that you wanted to look at or if you wanted to have Senator Ingram set that up first. Why don't we do that why Senator Ingram why don't you give us a heads up on what the amendment is and then maybe Jen you can walk it through on the screen with us. Sure. Great thank you. Yeah so education had been working on a miscellaneous bill that it looks like is not going to move on the education side so we had requested to add a couple of pieces. One is about school wellness programs in general and then having an advisory council on wellness but wellness has been looked at primarily as sort of nutrition and you know PE kinds of things but this would actually add especially in light of you know the impact of COVID a more comprehensive idea about wellness and it includes actually consulting the director of trauma prevention and resilience development and the substance misuse prevention oversight and advisory council to create kind of more comprehensive wellness programs so that's one part of it and then the other part is this was originally a standalone bill actually introduced by our very own chair Senator Lyons about making menstrual hygiene products available equitably to all female students at no cost and basically this fits in quite well with the section on contraceptives because it's the same sort of principle that the school nurse would make decisions at each local school about how best to make available feminine hygiene products in the same way that the contraceptives would be available in the other bill so that's basically the two things that senate education would request that we would kind of include in this in this bill okay um so any questions for senator Ingram all right so Jen can you share your screen and and walk us through that proposed amendment yes just one last question was this fully supported by senate education yes absolutely totally and enthusiastically okay thanks okay so you should be able to see my screen yep and this this is the language and we put it together i'd put it together back in early june so you will notice on this bill and the same theme will come up with the others that we're looking at today when we get to the effective date section we'll need to make some changes because we have effective dates that reflect a july first 2020 effective date that's already passed so we'll need to pick another date but this is the amendment so it would just strike out section 11 the effective dates of the bill as it came over from the house but not make any other changes to the substance there and then as senator Ingram had highlighted this is the first group of sections is on school wellness it amends the definition of wellness program in an existing statute um to first tie into the definition of comprehensive health education which is um which is addressed a bit in the underlying bill um so a wellness program is a program that includes comprehensive health education as well as fitness and nutrition um it has the secretary and it takes out a requirement that there be approval of the state board the secretary establishes this advisory council on wellness and comprehensive health that would include at least three members with expertise in health services health education or health policy it would have the members serving without compensation and eliminates language on receiving actual expenses um the council will assist the agency to plan coordinate and encourage wellness and comprehensive health programs and public schools and this would add a requirement that it meet not less than twice a year subsection c adds in addition to agencies and councils working on childhood wellness that the secretary would also collaborate with other officials and then it adds in a specific reference to the director of trauma prevention and resilience development and the substance misuse prevention oversight and advisory council um and then make some terminology changes and eliminates language on creating a process for schools to share with the health department information about height and weight of students in kindergarten although i think you may have heard testimony that that some of this information um may be getting provided in or collected in other ways section 12 would specify that honor before january 15th the agency of education and collaboration with the advisory council and wellness and comprehensive health that council we just talked about must update and distribute to school districts a model wellness program policy using that expanded definition of wellness program that we looked at that must be in compliance with all relevant state and federal laws and reflect nationally accepted best practices for comprehensive health education and school wellness policies such as guidance from the centers for disease control and preventions whole school whole community whole child model so those are the two sections on wellness programs and then section 13 would add a new statutory section on menstrual hygiene products starts out by saying that by enacting the statute the general assembly intends to ensure that a female student attending a public school or an approved independent school has access to menstrual hygiene products at no cost and without the embarrassment of having to request them then requires a school district and an approved independent school to make menstrual hygiene products available at no cost and a majority of gender neutral bathrooms and bathrooms designated for females that are generally used by females in any of grades five through 12 in each school within the district or under the jurisdiction of the board of the independent school it would have the school district or independent school in consultation with the school nurse who provides services to that school determine which of the gender neutral bathrooms and bathrooms designated for females to stock with menstrual hygiene products and which brands to use and it specifies that the school districts and approved independent schools would bear the cost of supplying the menstrual hygiene products and that they may seek grants or partner with a nonprofit or community-based organization to fulfill the obligation then it goes back in and does some effective dates so for the most part it it and said what is now subsection a it pulls in effective dates from the the underlying bill uh it has section 13 take effect on july 1st 2020 which of course we we need to revisit um and would have school districts and approved independent schools comply with the requirements of that section for the 2021-22 school year so not this school year but the next school year and thereafter the remainder takes effect on july 1st 2020 again we should review this and that is the end of the amendment so just uh can we stick with the effective dates for just a minute sure so sections 178 those are referred to access to contraception so those actually refer to and this is a piece we should um revisit as well those relate to pharmacist prescribing of self-administered hormonal contraceptives and as you recall there was some overlap with what was happening in the opr bill which as i understand is now in uh well i don't remember where it is it was in finance um okay so there needs to at some point there needs to be um some decisions made more broadly about what is going to pass this year in the way of pharmacist prescribing so if the opr bill goes through it does almost all of what this bill does the only difference is just the section one of this bill addresses um health insurance coverage for contraceptives when they are prescribed by a pharmacist so it pulls in that concept of the um the pharmacist prescribing that's not i don't believe in the opr bill because it's more on the insurance side but the pharmacist prescribing itself is in the opr bill so if the opr bill is going through then you don't need and in fact it's confusing and a little bit um internally conflicting to have these provisions as well okay um well so opr we'll have to hear from um senator comings about the opr bill and where it may be out it is out okay hello it's out yeah we did that i'll give you your there you go i will double check but no it's out because we had two of them um yes i will look right now i had things got things got put on other bills but they're all out to the best of my knowledge i think that's probably true so yes it isn't it is in the house now thank you okay and which committee is it in is it's in the government operations committee it's a it's all part of the larger opr bill all right um i i guess who um the question is then what do we do given the where it is i would like to have us move this bill forward as much as possible and i'm thinking that given that we're adding this proposal amendment it will require some consideration on the part of the house human services committee and i i don't know that they've actually um taken testimony on this and i'm looking at teresa and dan representative noise and representative wood i don't know if you've take looked at this proposal at all for the amendment that senator ingerman gen we're talking about oh should have we raised our hands or how do we do that no no go ahead i have a very small group okay uh yeah i don't i don't believe that we have seen this language no and i have not walked through it with them okay so um and so i think what we might do is to have language that's as close as we can to whatever opr is i'm not uncomfortable with what we do have right now um i hate to send another problem over to representative pew but i don't think it's a big problem i think it's a matter of coordination so right and we had when i'd worked on this bill with the with the human services committee back in the spring um they were aware of the potential for conflict and it seemed too early in the process to be trying to to resolve that so i don't think it will be a surprise to them that this issue needs to be addressed okay but i just made myself a note to follow up with the chair oh thank you excellent uh why don't we do this why don't we leave this bill for now and then senator ingerman go ahead so i just wanted a small point should we um should we change the title of the bill too can we do that we certainly can change the title we also should should look at what date um just so you know so far i've been mostly changing july 1st effective dates to be november 1st um just it seems like it's about as far out as you usually have from the end of the session to allow time for the governor to sign the bill and for it to become an act before that effective date has passed so if that works for you i will i can change the july 1st 2020 dates to november 1st 2020 dates okay and senator mccormick yeah this might be a question for senator ingram more but i just uh i just want to verify that this is not on the hygiene issues this is not already the case i want to make sure we're not it's not testimony you took test on that this is not already the case that's right yeah i'm surprised i'm surprised that i mean uh yeah um well it there you know there might be machines in some like high school bathrooms but like generally they don't work and and they cost them and they still going to cost money and it seems like such obvious common sense okay and we talked to school nurses and yep thank you okay so unless i hear an senator comings okay i just has anyone talked to the schools i'm just thinking of everything the schools are dealing with now um stores don't have dressing rooms i don't you know it has anyone asked them if this is something they can deal with at this point well we took testimony earlier in in the year and everybody felt it was a very minimal sort of requirement um i mean i guess it is true we haven't you know education didn't go back and talk to them since you know very recently um i i don't i do need to clarify the the um menstrual hygiene requirement product requirement is for next school year but the contraceptive requirement in the underlying bill would apply to this year so that's really the so i think senator comings question is relevant um but it applies more to the the provision of contra of condoms than to menstrual hygiene okay yeah that all right that's probably not a big stretch okay okay okay with that then all right so the november date works for the first part of the bill okay so why don't we then uh hold this hold this aside and we'll come back to it um as soon as we can on our agenda i think we're probably ready to have a um short discussion and vote on the bill once we see the dates in place and once we hear back um jan you're going to talk with representative pew so that will be very helpful yes i'm i will follow up with her and i'll copy you so that excellent everyone is part of the same conversation excellent thank you okay that's good um amazing what you remember when you actually get back to trying to remember uh thanks me now uh it's all coming back to me now i know it's great it's good uh i know i know all i know all of walley cleaver's friends names that's scary senator that's scary all right well let's move on to um the older vermonters act and i think before we go through the bill we should ask uh representative noise and representative wood of human services to introduce the bill to us and thank you for being with us this morning well thank you so much senator thank you senator thanks for having us yes we are um delighted and extremely appreciative of um your committee's taking up this bill um this is uh something that's been in the works now for over two years and dan will talk a little bit more about the process that we use to get here uh h6 11 we really felt in the house that this was an important bill prior to coveted and uh the current pandemic has uh shown with a huge magnifying glass how incredibly important this bill is right now and into the future um we we see that there is significant improvement needed across state government not just in the department of disabilities aging and independent living um we can see as an example the um emergency response center after encountering um you know some spread of the disease in long-term care facilities realized uh pretty quickly luckily here in vermont that they needed a different approach for older vermonters who were vulnerable and a different approach than the general population approach and that wasn't evident that hadn't been planned for in that way and so um this bill really talks about all of state government and our communities it's not just the department of disabilities aging and independent living um it also talks about uh promoting healthy aging and for people to stay independent as long as possible those are things that we want to strive for here in vermont and we do a good job at it um but we can always improve on those areas um the other thing that i did want to point out is that um there are a couple of features of this bill um that are uh critical frankly um and one of those features uh is the development and the study by the division of rate setting of the methodology that we currently use to pay our private providers and as as you probably well know um they during this pandemic they have been uh particularly uh hurt they're they're mostly small they're mostly um you know organizations that rely to a great extent on volunteers as well as as uh paid staff and uh for instance in rotland and in um central vermont uh two of our adult day centers have already closed uh having succumbed to the financial impacts of the pandemic um those are vital services that help keep vermonters at home with their families for as long as possible and avoiding you know more costly out of home care and so we have long struggled in our state to understand uh or to address the issues facing that group of providers and uh the to their credit the division of rate setting is undertaking numerous studies across the agency of human services and um this bill would add this group of providers to their list and um they have testified we we did because of the pandemic we did put out the date required for the reporting back we pushed that out a little bit um in the bill that passed the house and um so they are ready willing and able to do that um the other thing that this bill does is to include a study committee to examine the issue of self-neglect in older vermonters uh it's an issue that crops its head up on a periodic basis and frankly we don't really have a lot in state statute um dealing with it and it's a complicated issue it's extremely complicated issue uh and um so with that um there's a group formed um to pick up essentially where the last group left off because there was a previous group a few years back um and it puts that requirement for a report back to us um it pushes that out a little bit um but that is is a critical piece of this as well the other main reporting piece is the division of licensing and protection um for those of you who were here a few years back um you may recall that they had been sued the department had been sued because of um I I think essentially it was the ability um of the staff at the time to uh investigate sufficient number of complaints and the substantiation rates and all all that kind of stuff there was a settlement agreed to um that required certain reporting um that uh reporting in statute was in session law and was not in uh in the green books and so what you will see in here about reporting of adult abuse is something that the department is currently doing um but we felt that it was important enough that it should be in state law so um with that what I am going to do is to turn it over to Dan to tell you a little bit about the process that we have um gone through to get to the point where we are yeah good morning and thank you um thanks for having us here today and thanks for taking up 611 it's glad to see it's um moving here so uh yeah we started this in 2018 um we passed the bill the um older Vermont study group to help draft this kind of the the blueprint for creating this legislation and we met for 30 of us met for like 18 months um and really went through all of um what what is what does successful aging look like in Vermont and what do we need to do uh within state government to make sure we have a comprehensive system of services and supports for older Vermonters to age um uh have the ability to age with dignity respect and independence so um we had everybody had a seat at the table it was some great conversations over that time and then Teresa and I took that report that um came out of Dale they did a great job on it and we were able to work with uh Jen Carby and and draft some legislation that um we ran uh within our committee and human services committee and then um then we had our break and we came back to it and really brought in some uh issues that have come up during COVID as Teresa was talking about um you know a couple other things in there that I think are really um gonna be important to see move forward as a master plan on aging which the scan foundation gave a presentation to uh both our committees on um and also um we're moving towards an age-friendly state designation um I think these will really um really help the department and um our communities work together as we're gonna see one in four of us are gonna be over the age of 65 so um thank you for having us here and thanks for taking it out really appreciate it no thank you I certainly appreciate the length of time that you have spent in fine-tuning the work I know it's been uh a lot of effort on your part and we really appreciate it um so thank you for bringing us this I know that the um I I had met separately with the person from scan on the master plan and I think that her suggestions have offered improvement so that's great and everything that you said is so absolutely key so we'll I gee I don't know sounds like it's a bill that we're going to have to take up so we'll be moving on um good news thank you well you know the one I do have a question for you both and that is as you're talking about um moving Vermont to become an age-friendly state one of the criticisms that we hear consistently about Vermont is that we take money away from our older population that we have we're a high tax state and I just want to know if there was any conversation at all between you and Ways and Means uh committee regarding the effect of taxation on older Vermonters we we did not address that issue madam chair no but that is the that's the type of discussions that's going to come up in a master plan on aging um where we look at how property taxes and access to housing um be improved okay I mean I think it's I think it is absolutely worth a worthwhile conversation everything that you have said uh is also a worthwhile conversation providers at home uh self-neglect I know how difficult that is um and I and I think so is there anything in the bill that would direct the group to having the conversation regarding financial security or um it doesn't specifically state that um but I I agree with represent noise that that would be the intention um of a master plan on aging to address financial security to address accessibility of our communities to address health care um you know we talk about uh community streets being wide enough uh there there's a saying that people use that you can you can roll the walker just the same as you can roll a baby carriage and you need good sidewalks to do both of those um it just takes a few more seconds a little bit more 20 instead of 16 right yeah um and we so that's the intent of bringing this um the making the secretary of administration responsible for convening um this plan because that will give it the um the the breadth and the depth of all of state government okay thank you that's very helpful and some of the conceptual parts of the bill we do talk about adequate income and uh and income of older vermoner so okay that is one of the right that is one of the rights I thank you Dan for um remembering that yes okay okay we'll we'll keep our eyes open for that appreciate it are any other uh questions for representative noise or representative wood wow thank you we're always available can I ask can I ask did you both present the bill on the floor yes we did you shared it okay good good to know thank you all right um so Jen uh why don't you take us through the bill briefly and so we can see what what we're talking about sure I'd be happy to um it's a 25 page bill so how much detail do you want to go into uh I think let's do um the not the 10 000 but maybe the 5000 foot level let's let's go through as at a fairly high level I think and then if we we can come back and ask questions and I know we'll we're going to be hearing testimony about the bill so why don't we just do a a big fly over sure would you like me to put it up on the screen yes please okay all right can you see my screen now terrific great all right so this is age 6 11 and it's an act relating to the older vermontres act um it starts out with a uh by adding a new chapter entitled 33 called older vermontres act and specifying it can be cited as the older vermontres act then it has um some principles of a system of services supports and protections for older vermontres um and it has the state adopting principles for a comprehensive and coordinated system of services and supports for older vermontres so I'll just name these and you can look at the language in each of them um or we can go through them at a later time so that the principles deal with self-determination safety and protection coordinated and efficient system of services financial security optimal health and wellness social connection and engagement housing transportation and community design family caregiver support and that's the last one family caregiver support then we have a number of definitions that get used throughout the uh chapter many of them will be familiar some of them are new um but I won't take you through the details of the definitions at the moment um then we can I can I ask one question sure on the older American uh older older American act just going back to the actual older americans act okay well yep uh yes um do is there is there a continuous financial uh investment from the feds to the states uh as a result of this act and and what does it go to do you know off just off the cuff no but I think one of your later witnesses um angela sneth jeng from dale could probably answer that for you either now or we'll go back to that okay good that's a heads up for angela okay great all right so then we get into um new section 6204 this is the duties of the department of disabilities aging and independent living dale um and it says it's the the state's designated state unit on aging um and it sets the department as the subject matter expert to guide decision making and state government for all programs services funding initiatives and other activities relating to or affecting older vermonters um and one of the pieces that was added in in the house side as you'll see at the bottom of the page here public health crisis and emergency preparedness planning so this has um inserts make sure that dale is included in that process of um public health crisis and emergency preparedness planning as it results to older vermonters um once we get once we get health and welfare raised above the bottom of the planning process we'll be all set um goes through some other provisions on that talks about the area agencies on aging and their duties and i think you'll be hearing from vermont's triple a's from janet huntt in a bit but it talks about the role of the area agencies on aging and their requirements both things that they do and and kind of highlighting their role in the system of services and supports for older vermonters um and it gives them some additional duties around promoting the principles promoting collaboration um facilitating awareness things like that the next section requires dale to adopt a state plan on aging which they're already required to do but it it sets some of this into a state statute and put some additional provisions into it so this is the plan for comprehensive and coordinated system of services supports and protections so at least once every four years dale must adopt a state plan on aging uh must be consistent with those principles near the beginning of the chapter and give some categories that must be included priorities for continuation of existing programs and development of new programs criteria for receiving services or funding the types of services provided and a process for evaluating and assessing each program's success it talks about how the commissioner will determine the priorities for the state plan on aging it has the department considering considering the uh funds available after determining the priorities and gives a process for including the dale advisory board in developing the plan and then it would have by january 15th the department january 15th of each year has the department reporting to this committee as well as the house committee and the governor on implementation of the plan the extent to which the system principles are being achieved the extent to which the system has been successful in targeting services to individuals with the greatest economic and social need and those terms are defined the sufficiency of the provider network and workforce challenges affecting providers of care or services for older vermonters and the afford availability of affordable and accessible opportunities for older vermonters to engage with their communities so that's the end of the new chapter on the older vermonters act then the next section is as representative wood was describing this adult protective services program reporting requirement and this sets in statute really the report types of reporting that the aps program is doing now but it sets it out in statute and requires it to continue so this would have by january 15th of each year the department again report dale reporting to this committee and the house human services committee regarding the department's adult protective services activities during the previous fiscal year and then it has a lot of additional information or details about all of the information that needs to be reported so this goes on for quite a while i won't take you through the details of it but maybe something you want to revisit the next is the section on the vermon action plan for aging well so this is what representative noise was describing this really just talks first about the development process so how they're going to put together this vermont action plan for aging well and this has the secretary of administration in collaboration with the commissioners of dale and of health propose a process for developing the vermont action plan for aging well to be implemented across state government local government the private sector and philanthropies it talks about what this vermont action plan for aging well would include but this is really setting up the the process for or setting up the framework for developing the process and then the process will inform the plan so the first thing you're getting back is just the process and it requires the secretary to engage a broad array of vermonters with an interest in creating an age-friendly vermont and then submitting to this committee and house human services by may first the proposed process for developing the vermont action plan for aging well including action steps and an achievable timeline as well as potential performance measures to use and evaluating the results of implementing the action plan and the relevant outcomes set forth as far as results based accountability goes and related indicators to which the action plan should relate next is the evaluation of the Medicaid rates for home and community-based service providers you'll see sections four and five were deleted this was through the appropriations process in consultation with the human services committee so the outcome of this then is looking at the provider rates for the home and community-based service provider network so first it defines home and community-based services as long-term services and supports received in a home or community setting other than a nursing home under choices for care and includes home health and hospice services assistive community care services and enhanced residential care services it directs the diva and dale to conduct a rate study of the Medicaid reimbursement rates provided provided to or paid to the providers of home and community-based services and to look at their adequacy and the methodologies underlying the rates and then it would have the departments determine the Medicaid reimbursement rates for these providers that are sufficient to recruit and retain individual service providers and allow consumers to attain and maintain their highest level of functioning in accordance with the care plan while also creating a fair and equitable balance between cost containment and high quality care establish a predictable schedule for Medicaid rates and rate updates identify ways to align the Medicaid reimbursement method for these home and community-based service providers with those of other payers to the extent that those methodologies and rates exist limit the number of methodological exceptions and communicate the proposed changes to the providers before implementing them and it has diva and dale develop criteria and a process for calculating an annual inflation factor so originally the bill had had an annual inflation factor that would be applied this is having them develop criteria and process for calculating an annual inflation factor for potential application to Medicaid rates for these providers in future fiscal years but it doesn't actually apply the inflation factor and then it would have by April 15 the department's report to this committee and the human services committee and the appropriations committees the results of their rate study and the criteria and process for calculating the inflation factor so again this is setting up this is looking at the adequacy of the rates and and identifying a potential way to apply an inflation factor but it does not actually apply the inflation factor or change any rates so there is no fiscal you'll hear from null and at some point but there is no immediate fiscal impact section seven is the self-neglect working group so this creates a self-neglect working group to provide recommendations regarding adults who due to physical or mental impairment or diminished capacity are unable to perform essential self-care tasks and it uses the same definition of self-neglect as in sorry as in the older Vermonters Act chapter it gives the list of members there are a number of members 16 members I believe unless there was a two somewhere including a few consumers and you'll see near the end those are the only participants who receive a per diem it directs the working group to consider issues and develop recommendations relating to self-neglect including how to identify adults who live in Vermont and who are self-neglecting how prevalent self-neglect is among Vermont adults what resources and services currently exist to help Vermonters who are self-neglecting and whether that can be improved what additional resources and services are needed to better assist Vermonters who are self-neglecting how to prevent self-neglect and identify those at risk for self-neglect and whether the definition provided in the older Vermonters Act is consistent with the principles of self-determination elsewhere in Vermont law has the report coming back by July 1st 2022 so this is one of those deadlines that Representative Wood mentioned that they the house pushed out in recognition of pushed later in recognition of all the work that's going on to address the current pandemic but by July 1st 2022 the working group report its findings and recommendations for both legislative and non-legislative action to this committee and the house human services committee it talks about how the meetings work and has the consumer members of the working group eligible to or entitled to receive per deem compensation and reimbursement others do not receive that and then finally the effective date this one we don't have to change unless you want to has the act taking effect on passage except that the plan the new plan for comprehensive and coordinated system of services supports and protections would apply with the next state plan on aging the state plan on aging taking effect on October 1st 2022 under the federal timeline so that there's a lot there yes that's I have I just just briefly I think that we'll get the answer to my questions but I'm going to ask the questions now when we have testimonies I'm hoping there'll be some so I asked one I asked about financial the other one is why nursing homes were excluded when we were talking about community based services and then my other question will be because it we went through it quickly and I don't remember from when I've read it the last time the definition of self neglect and then I have another question and that is there is a lot of work in here for Dale commissioner but then we're also looking to reduce the silo effect through state government and what is the relationship between the commissioner and the secretary of administration in accomplishing all this work and I know that's along with the other folks uh nonprofits so on those will be some of my questions I see representative noise is shaking his head he's probably thought of some of these already but um so good uh hold your thought but go ahead who was that that was the one that was me do you want me to address any of the either the looking back and pull up the definition of self neglect that's helpful I think the first question I heard uh was why nursing homes were not included in the home and community based services I think given our our usual use of the term home and community based services nursing homes are not um based either in the home or the or the community in the sense that people live in the nursing home they're not in their homes and receiving services either in their home or in the community but returning to their homes so there is a whole there's a whole step very large statutory and regulatory framework for adjusting and increasing the rates for nursing homes under Medicaid it's set up and statute and and has an extensive rule as well that sets that up and and there's a whole division of rate setting that addresses just that there is not a similar analogous unit for home and community based service providers nor is there anything in statute that that affects their rates good representative would have something to say as well that's great thank you uh representative would I just wanted to mention that um also the the feds um define nursing homes as institutional based services um versus home and community based services and as uh as um let's counsel just talked about uh one of the primary reasons for this distinction in this bill is that there is already a statute and regulatory process for providing um a review of the costs of nursing homes good thank you all right you want me to put up the definition of self-neglect um look at before you continue just look at that briefly and then um we'll hear from our beginning to hear from our witnesses okay so the definition of self-neglect that would be added for the older vermonters act um chapter and then pulled in for the self-neglect working group define self-neglect as an adult's inability due to physical or mental impairment or diminished capacity to perform essential self-care tasks including obtaining essential food clothing shelter and medical care obtaining goods and services necessary to maintain physical health mental health or general safety or managing one's own financial affairs and then it specifies that the term self-neglect excludes individuals who make a conscious and voluntary choice not to provide for certain basic needs as a matter of lifestyle personal preference or religious belief and who understand the consequences of their decisions okay good yes now i remember reading that i remember the especially the second section so that's helpful all right um good and we'll go i think what we'll do is let's let's hear from uh everyone who is testifying today and then we can i know that there are other folks who are going to be critical to to the bill i i know that the attorney general's office is very interested in testifying and we'll get them in um and others and then we as a committee will have to review the language of the bill and see what changes if any we want to put in so um ah we have angela smith ding here director of adult services from dale it's good to see you good morning everyone thank you for having me um for the record i'm angela smith ding director of the adult services division at dale um first uh i want to address your question senator alliance about the older americans act and the funding um and services so yes there is ongoing federal investment um in oa services for vermont so annually vermont receives about seven million in federal oa funding um and that primarily goes to services for people over the age of 60 in community through it goes the funding goes through dale to the area agencies on aging and out to providers providing the services so for example meals home delivered meals and congregate meals also case management transportation legal services information and assistance health promotion disease prevention family caregiver support a whole host of those kinds of programs primarily to support older vermonters staying independent in community have yes it is it's very helpful and um i think we're all aware of of the support but not how much and the extent to which it is used the the other the question that i have is what if any increases have we seen in that coming from the federal government over time i know there's always pressure on us to add funding in the budget um it has the federal government had is there a cpi or any kind of uh regular increase attached to the these dollars not there there is not a regular increase attached um each time the oa is reauthorized at the federal level um when it's reauthorized there's a recommended increase um to that funding but it's subject to appropriation each year um and that's been hit or miss over time it it certainly hasn't increased um as our aging population has increased to the to the same extent so um and janet could speak more from the triple a's but um the funding has pretty has has not increased significantly i would say um over the last five to ten years okay um and so it's not a per capita type of appropriation it's just a flat appropriation dependent on what our congressional delegation can advocate for but yes to some extent yes and and um then among the 50 states it's divided by a formula based on the population of each state okay so as one of the top older states in the country we should be getting a higher something if yes if that was taken into account in the formula yes okay but um generally vermont receives a small state minimum because our population is so much smaller than other states okay thank you for that i mean and every step that you take you find there's more to to learn so that's true that's true uh i ask you this angela do you have at your testimony or could we get your testimony in writing yes i'm um following following the meeting i'm happy to send it in writing perfect that would be helpful uh because we do have pretty specific questions that i think are going to be helpful for folks to know as we go through the bill great yes we'll do go ahead um i don't want i'll try not to we will try not to interrupt your flow it's okay if you need to ask questions along the way that that that's no problem okay um so dale overall we're very supportive of h611 um and very appreciative of the extensive work put into it to date you know beginning with the older vermonters act working group in 2018 um that work to develop the recommendations for the bill and then all the way through its passage in the house um from our perspective section 6206 the principles of the system of support services and protections for older vermonters that's really the heart and soul of the bill in many ways these were developed collaboratively in the working group over that year and a half that we met and to gather the principles outline a really positive vision for collective action around the work we do and the vermont we're trying to build for all of us as we age so at dale we're eager to use these principles which really strengthen our mission as we strive to serve all all vermonters the section on the state plan on aging the expands our work on the state plan on aging which were all as um as has been said we're already required to develop every four years for the older americans act work but this expands it to include not only oa but also our long-term services and supports work and in particular choices for care so our next state plan on aging will include a really comprehensive review of our system of services and supports for older vermonters across the spectrum of of support and need so from meals and programs at senior centers all the way through to high levels of of care need for example for those living in with dementia in our communities so we'll incorporate these new elements um into our next state plan on aging which was um as was said will begin october 2022 and we've already begun the needs assessment process we have to start that a couple years ahead um and we've begun the needs assessment and we'll be asking older vermonters family caregivers and stakeholders key questions that will help address some of the elements that are talked about in this section of the bill so section two about the adult protective services providing an annual report to the legislature so as was noted it's important to note this isn't part of the older vermonters act but um modifies the APS statute and dale is uh supportive of the report since APS is already submitting this in this information voluntarily to the legislature so it just makes it a yearly requirement in statute and we're happy to continue to do that um section three sets forth the process for the creation of the vermont action plan for aging well similar to california's master plan on aging um and this will really be a blueprint for moving our state forward in a way that embraces and celebrates aging and older vermonters and we look forward to collaborating on a proposal for developing the action plan with AOA and department of health you know for a few years now um with department of health um we've been exploring the idea of seeking to make vermont a designated age-friendly state and i think this effort will really move us forward towards that goal um the challenge may be timing the proposals do may 1st uh 2021 given the intense focused on COVID-19 by all three of our agencies um and not knowing how long that focus will really need to be maintained on COVID we're concerned we're not necessarily going to be able to work on this proposal and give it the time and energy that's needed so perhaps um our later deadline would be valuable um regarding section six the home and community-based rate study and the inflation factor and report dale is also supportive of this work we recognize this is much needed and long overdue within our service system for the sustainability of our provider network um and we will support diva through this effort um again i'm not sure about the timing and the feasibility of the timing given the intense workload at diva related to COVID-19 at diva and dale um but i would defer to diva as the lead on that work about um that that timing and then finally section seven the self-neglect work group and report one of the original recommendations of the old of vermont's act working group was that the state seek to better address self-neglect you know it's a complex issue and dale is very supportive of the work and the task we're given um as a group to develop this report to seek to understand the causes better the prevalence the resources and prevention you know vermont's one of only a few states that doesn't address self-neglect in statute and our community-based agencies the triple a's the da's everyone is doing great work in trying to support individuals that are identified as self-neglecting but the issue is growing and it needs more systemic focus so our hope is that this work towards this report will guide us forward in a more proactive way and with the due date being july 1st 2022 where we believe that'll give us the work group enough time to really develop a thorough report for the legislature so i think um i think that's what i wanted to touch on and um appreciate the opportunity to testify and happy to answer any particular questions okay uh questions for angela uh senator angraham you're muted no you're not thank you um yeah thank you angela um i was just wondering especially in light of um covid if um there's a particular concern around food security for older vermonters and i don't um i don't see uh anything jumping out at me that specifically mentions uh that although i suppose broadly in the principles it is probably included but it do you think there's any need for us to um you know address that more uh specifically in this in this bill or that's a great question yeah i think um food food security is um kind of embedded in the principles both under sort of the financial security umbrella and under health and wellness um and our our our system of providing um good nutrition for older vermonters during the pandemic has definitely been been pushed um um but our you know um as as janet contestified to as well the triple a's and the senior centers and meal providers really stepped up and have been um serving a lot more people and a lot more meals during the pandemic trying to reach all of those folks who had to have been staying home and need that support um and there's been the additional families first and cares act funding that has been uh provided for nutrition as well as some uh crf as well um so i think in the immediate that the need is um is fulfilled but we know that hunger in older vermonters is a significant issue so um i always think that there's room for improvement in in reaching people with with good nutrition in new and creative ways i think it actually uh can be a factor in the self in the self neglect uh i i know in my experience in working as a pastor you know i i've seen older folks um through the years not be able to you know get the assistance they need with being able to to find food and meals and it's um sometimes they just kind of give up um so yeah i you know i don't know anyway i might think about maybe i'm in maybe offering a little more specific language from madam chair specifically well this is good keep track of of your ideas as we go forward because you know i'm trying to do the same thing and then when we go through the bill um we may find that we would like to make some uh slight additions and changes it's not that i would suspect that human services has thought about this as others uh but if it might be important to have um some specific language so good do that it's great thank you other questions committee okay so Teresa did you i i know that you want to make it did you want to make a comment now or i i'm going to i'm going to try and hold it to the senate at this point unless you have that's some okay all right good i was just going i was just going to um point to the uh areas that uh reference food security or insecurity so they there is reference in the bill we'll get it no so that's good no thank you and um so as we as we jot down our ideas and then when we go through the bill well the your language will pop out at us and we can decide whether we like it or whether we want to improve it if we can we know we can't always improve your language senator mccormick i i appreciate the the curmudgeon protections in there you know in other words if someone has chosen something and they know what they're doing um but i i did notice uh or unless i missed it i didn't hear a mention of of hygiene of people who are neglecting uh personal hygiene which to me would indicate not may or perhaps a lost ability to pay attention what why is that not in there angela do you want to speak to that while you're on the hotspot that's a good question um because we do see that as um as a piece or a potential um area of self-neglect so i'll have to the definition um that was included in this was developed by a self-neglect task force that um formed and did a report in 2012 looking at self-neglect so we used that definition as the foundation here um but it basic basic needs around health may it may be trying may be embedded in there but we you know there's the potential we could be more explicit um around hygiene yeah yeah no that's a good point it may be around health and personal hygiene uh as a combo uh senator keep that thought good yeah i mean i've certainly seen it in uh folks that i've been i've dealt with yeah any other questions for angela all right uh so we have uh the director of from coming says waiting her her hand rather oh excuse me thank you now we full disclosure i worked in an adult day uh one of them that has been closed and i know a lot of the self-neglect the the food a lot of the depression that leads to that were dealt with by adult days and i'm wondering is there a plan to open the ones that were closed they weren't fairly large you know met metro vermont metropolitan areas um and and to expand that because that was a way that you really got to people before the problem got to be too severe um that's a great question senator comings and i would say that a plan is in is in development at this point um you know dale um has a process for approving and a new adult day but has generally not had to go out and um find an organization who wants to start a new adult day especially during a pandemic when the future is unknown so it's a little bit of a tricky process right now but there is an in like for example in in both barry and ruttland there are organizations that are interested in exploring the option and we've also pulled in the triple a's in those regions kind of as uh facilitators to help explore that with some different providers so those conversations are happening actually this week next week um and and there is a process to to then start an adult day if we find an entity that's really interested in doing that that that's great because they really do good work but it finances were always a struggle absolutely okay so and so you know one of the things that we will uh be doing uh fairly soon is looking at how the CARES funding has been utilized and adult day certainly is a big part of that so we'll we want to hear back from you about that and i don't know the date yet we're still we're still in the planning process for when that'll happen but angeles a heads up for you okay thank you okay um so and then i guess the question is as the bill um flowed through human services were the adult days considered as part of the planning process are they in the bill itself in in age 6 11 the um the adult day association was part of the older vermont rzak working group participated in that process and i do believe um testified um during the process and human services as well okay so we'll have to keep our eyes open because i think we all agree that the adult days are significant um they're they're really important for this population the older population okay good question thank you senator comings senator ingram senator mccormick this is all good um so ruby baker is here and she is the um are you're the executive director of uh the of cove so ruby have are you here yeah she is i think she might have had to step out for a minute i saw she had some company with her all right so why don't we um why don't we hold off on ruby's testimony and we'll move to janet hunt um and you're the executive director of triple a's merit of the aging uh association on aging ah area vermont association of the area agencies on aging i always say triple eight so then when you have to say the full thing who knows what it is so janet right that's like yes thank you madam chair and senators um so thank you for the introduction my name is just for the record my name is janet hunt and i'm the executive director for the vermont association of area agencies on aging which has five member agencies uh on aging located throughout the state i've revised my written testimony uh that i've already submitted uh this morning uh and i'll follow up with um the revisions to nelly after today's testimony but thank you out of a few other things that i wanted to add to it i'm going to interrupt you just for a second and because i see that ruby is back and and ruby i i i saw that you had um a little guy with you and i'm my question is um our is your time okay to listen to janet first or should we jump you in at this point yeah i'm i'm good janet can go ahead and i will uh i'm happy to join in afterwards thank you okay good and thank you for being um patient with us so it's good janet go ahead thank you okay sure sure thank you so h611 the older vermonters act is truly a what i call a call to action for all individuals as we're aging and fits exactly how v4a uh v4a is the acronym for the vermont association of area agencies on aging it fits exactly how v4a envisions a vermont that values and supports us as we age um and before i go any further i'd like us to think about aging as not something that's different from who we are it's not a separate population of who we are it is it is all of us it contains all of us it involves all of us to be thinking about aging it isn't a separate population so the area agencies on aging already provide the supports and services that is outlined in h611 through the older vermonters act so therefore we fully support the passing of the bill especially as it requires more collaboration and more accountability and overall purposeful inclusion of aging within our vermont communities i was a participant of the older vermonters working group as a representative of the of the area agencies on aging to build the foundation for the act as we see it today as we're looking at it today and i know firsthand how strongly invested all members of the working group are and were to see us improve the health and well-being of older adults in our in our state i know you've that jennifer's already reviewed some of the certain and and angela to the the elements but i just again want to highlight it it's it's definitely a wonderful piece of work and want to highlight and accentuate some of the key areas that the bill addresses it addresses the key principles that the state of vermont must adhere to for the supports and the protections and a system of services that are critical for older vermonters to give up to have optimal health and wellness housing and transportation and community design family caregiver support and financial security that you asked about before senator liens it defines how we care for older adults who have the greatest economic need greatest social need and those who are at risk of self-neglect it makes it clear how who within the state is responsible to administer all aspects of the older vermonters act and hold specific agencies accountable for the implementation coordination and follow-through of services and supports the bill will require both qualitative and quantitative data to monitor and evaluate the system's success as it focuses services to individuals within the greater greatest economic and social need the bill requires that the secretary of administration in collaboration with dale must develop a vermont action plan for aging well and which shall provide strategies and cultivate partnerships for implementation across sectors to promote aging with health choice and dignity in order to establish and maintain the age-friendly state for all vermonters the action plan also addresses the additional needs and concerns of older vermonters and their families in the event of a public health crisis a natural disaster or other widespread emergency in this state it requires home and community-based rate studies to determine Medicaid reimbursement rates for providers of home and community-based services that are sufficient to recruit and retain individual service providers and allow individuals to attain and maintain their highest level of functioning in accordance with a care plan while also creating a fair and equitable balance between cost containment and high quality care it requires the creation of a self-neglect working group to provide recommendations for adults who due to physical or mental impairment or diminished capacity are unable to perform essential self-care tasks it provides purposeful inclusivity to a population that might otherwise be marginalized the vermont association of area agencies has worked to build support from our partners across the state who have signed on to support h611 and these partner agencies include to name a few the vermont association of adult day services the vermont association of senior centers and meal providers green mountain transit sash the support and services at home bayotta home health care cathedral square barry housing authority united way of addison county orleans county restorative justice center and of course the five member agencies of the association of area agencies on aging h611 and all of the elements that it contains should pass because we all care about our parents and our grandparents and because we should care to set the stage now for the sake of our children the sake of our children and our grandchildren future as they age my testimony includes the supporters my written testimony includes the supporters that we've gathered as attached to my written testimony thank you very much uh thank you uh you know what you have done with your testimony is to remind me how critical this is not just for looking at older vermonters but looking at aging as a part of all of our lives yes exactly the time we're born until yes the end we uh we're aging so yes i'm glad you got that i wanted to frame it in that way so that we would realize this isn't just about the current population of 65 and older no i think it's about everyone in the state and so the difficulty is ensuring that at each developmental stage of our lives our communities are receptive to our needs and in particular right now we're thinking about a population that is over 65 and has some needs that we probably haven't provided as adequately as we should have in the past so yes questions for uh for ruby and not ruby janet any questions for janet so janet you said that you were going to update your testimony i am and i'll send it to nally so and as you're as you're listening to the discussion that we've had and the questions that we've asked i i noticed that you did mention a couple of the areas of our of our interest and it would be helpful if possible to elaborate on any one of those including the financial security piece or others that you might have ideas about that might improve the bill whether it's food insecurity or personal hygiene or whatever so sure absolutely okay good any other questions for janet okay um so b4a is the new acronym that i have to remember okay i can't use triple a anymore well we have an association it's actually been in existence for many years all right 2012 2007 i'm so far behind the times no well thank you thank you okay ruby baker is here from cove and ruby thank you for being patient and why don't you give us your testimony i think we have it online as well yes you have my testimony online and thank you for being patient with my small people oh small people are delightful yeah yeah it's most of the time um for the record my name is ruby baker i'm the executive director of community of vermont elders cove is a grassroots and membership based organization and we have been advocating for the rights of older vermonters since 1984 um i want to start off just thanking this committee for making this bill a priority this has been a very unusual session as you know and um and we're really grateful that you're taking this bill up um we know that you have a lot of priorities on your plate and a lot to work on so thank you um firstly cove very much supports age 611 of course and we have been part of this process through the passage of the older vermonters act working group we participated in the working group and um and have been very vocal in our support of this bill as it passed through the house we believe it will improve the quality of life for older vermonters uh specifically by increasing the safety and security of older vermonters and the self-determination and i know we've sort of highlighted those things um both in in Jen's walkthrough and Angela's testimony but those are really key to um to how we want to think about this bill and holding those two things in balance um as again as you've heard there was a huge amount of collaboration that happened throughout the course of this bill and um you have to go in the other room sweetie and um so i want to highlight a few areas of the bill where we support some minor changes or where we see some very specific strengths and charlie's gonna join me um all right hi charlie so first in the house we supported the original language in the bill which included a path to secure appropriations that would begin to build financial parity and stability for our home and community-based services and i know you had questioned um why nursing homes were not called out and this bill actually really that that original language was an attempt to pull home and community-based services onto the same level as nursing homes in how we think about them every year we fight for an increase to our home and community-based service um medicare rates and we are asking um that we not have to fight quite so hard that that move through a regular process and so you know those home and community-based services are underfunded they're always underfunded we're seeing that now as we see closures in our communities as we see um services being dialed back when uh when specific strains come on the system um this language was replaced with a study we don't think we need another study we know that they're underfunded and we would support the reinsertion of the original rate setting language um in light of covid we have seen just how fragile the long-term care system is and um as we respond to covid and begin to repair our home and community-based service system we really have to focus on fortifying our programs so that they can be responsive and flexible when crises come up and um you know they they need the financial capacity to uh to be competitive in the marketplace to be up to date in their training and safety and to be kept um for their facilities to be maintained at a level that can provide safety for for and the best care for everyone and if we don't take the time to recognize the true process of doing business we can never have a truly robust and coordinated system of services and supports that has the capacity to address the needs of our growing older population we know one in four vermonters will be over the age of 65 within this decade that's huge we have to talk about it we have to address it and we have to pay for it um so I you know we need to invest in our service providers and and guarantee them stability of funding and I would say that the need for funding goes beyond home and community-based services as defined here and I'm specifically in this situation calling out the senior centers they are critical and there really is no state funding mechanism that supports senior centers and I think that this committee could spend some time thinking about how to um how we might do that because they are part of um they are part of our health and wellness system and deserve that consideration can I ask you this question while we're on senior centers have we an identified um set of senior centers through the state so obviously there are places where seniors congregate which are not what I would call senior centers and then we have senior centers like the Winooski senior center or the Heineberg senior center in my district to name a couple um do we have a system of senior centers similar to a system of parent child centers that we've fully that we've identified and that we provide funding for yeah vast camp vermont association of senior centers and meal providers so there you go you can have another acronym for your alphabet soup today um vast camp would be the place to go for more information on that and janna claire at the Montpelier senior activity center and deanna jones at the thompson senior center are co-directors of that or it's so it's volunteers but when you submit your written testimony will you include this information for i've yes okay that would be great um okay that's my so funding is is the first and foremost second i would say that the bill highlights the protections that older vermonters need and deserve uh cove supports a stronger stance on the need for coordinated systems of protections for older people we um adult protective services is called out in this bill but there is actually um not much recognition here about how APS and law enforcement and state's attorneys and all of those other pieces of the safety system could work together you senator would not um be covered and protected by adult protective services but somebody needs to be protecting all older vermonters and there needs to be a real recognition for how that's happening and a coordinated system of of referrals and and services so we would support a stronger stance on protections for older adults um additionally the statute that um that establishes adult protective services is one of the oldest statutes in the country right now and is working um throughout covid with very outdated guidelines based on a time when most uh most vulnerable adults were living in institutional settings and that's just not the case anymore vermont has really committed to our aging in place model and the vermont statute for adult protective services hasn't really caught up with that so um um so yeah I would recommend that that we looked at a little more closely um the third and fourth things that I want to highlight are areas that we are just very supportive of I don't see any additional changes that I want to call out but the self-determination and safety and protection sometimes those two feel like they're at odds and I just want to recognize that in order to create the vermont we want to create where where older adults and younger adults can grow old with dignity those two really need to be held in balance and I appreciate that those are called out first and foremost at the front of the bill that that this is what we deserve and then fourth is the master plan on aging I was also at the presentation by the scan foundation um and um I I want to highlight that during covid and and for many years before older vermonters have been the victims of ageism whether it's benevolent ageism negligent or hostile and the things that we do now whether what the things that I do the things that you do all of these things traveling working singing hiking raising children um they could very well be the exact same things we're doing when we're 70 80 or 100 including raising children there are there are thousands of kinship caregivers there are grandparents who are supported there there are just those are all the things that we continue to do throughout our life and so the systems that support us when we're 30 and 40 are the same systems that are supporting us when we're 60 and 70 and 80 um you know you know all the agencies but whether we're talking about transportation or fish and wildlife or health or public safety these are all the same systems that are supporting us so we need really to pull out and higher level when we're thinking about aging dale is is vital to the aging process but they're not the only ones and they know it we know we all know and they shouldn't be left with this task alone so um pulling that master plan up into the secretary of the administration really ensures that um that the plan be statewide that we're talking about everything that affects all older adults and I really see this section as the next evolution of aging policy so we are very very strongly supportive of creating this master plan questions for me that's all I have thank you and it would be great to have your testimony in writing in particular you've made some suggestions about changes that I think we need to discuss before we accept to reject and then your other comments at the end are really important so if you have this money in writing good you have it great all right um okay I didn't see it online and I got Nellie you'll get it up for us all right questions for ruby it's there now if you refresh oh great thanks centering room no more no more ruby any questions for ruby baker of co I greatly appreciate your comments about how agist we are um it hits all of us at different times when we start talking about bringing young people into the state because we're too old that really affects a number of us when we talk about getting younger people into politics we're too old that really hurts so um you know we're all vital uh until we're dead so I I I really uh I'm glad you said what you said and I'm going to become more vocal about that when I start hearing my political counterparts talk about we need younger people in the state house so not that we don't need them but it the people we have are not bad uh senator mccormick your hand is up thank you yeah there's also the problem that anytime a computer doesn't work right if you're an old person using it the assumption is you messed up even though you know I know how to I know how to click send for example that it's I didn't mess up the computer messed up and people don't believe it that's ages in my testimony you will if you if you read it word for word uh which you may or may not uh you will see that um aging is um discrimination against our own future selves so we would be wise as young people and old people and infants to remember that so thank you uh that'll be good we need that we need that fuel for our fire but you know and and it's an interesting conversation I think that we all need to have uh when we're in our 20s and 30s and and then when you get in your 40s you start to realize that golly ned you know 50 isn't so old and when you get to the end of the 40s you realize gee you know 60 isn't that old and I'm still climbing the high peaks so um people need to have this conversation so that they can appreciate life as a continuum and not uh these little chunks of time that show up at different different places so I was just on a call this morning uh with a man who is celebrating his uh he and his wife are celebrating their 59th uh wedding anniversary um today and you know he's 81 and he's one of the wisest and most vital people I know so yeah it's oh yeah it is just because someone walks slowly doesn't mean they think badly no all right any so now now that we've uh fully let out vented uh questions for any of our witnesses on h 6 11 so committee my question of you is now that you've heard a little bit about the bill and the time that the house human services folks and others have spent putting it together is this a bill we want to we want would like to complete work on before this session is over can can I just ask um yes is is Dale going to um have um their testimony posted yes it's not listed everybody else has got something up but um we we have we have coerced Angela into that and she will be putting it up for us thank you yeah very important okay so committee uh will we are going to schedule additional time on this bill I'm not sure that it will be tomorrow unless uh unless we can get some of the folks who I know are interested to be with us but we are going to uh follow through with the bill it's really it's really very important uh I think we all understand that uh and and it will be important for us to read the bill thoroughly so please do that if you haven't already and then uh there are some suggestions that have been made about moving a little more aggressively in some of the sections and whether this is the time to do that or not and we'll talk about that I think Ruby Baker brought up the rate setting language that was in the bill and was taken out and whether or not we want to proceed with that and there'll be other areas as well so but I do think we just we just need to have some time to read the bill and then I do know that the attorney general's office is very interested in testifying so we'll be connecting with them and getting them in and um as well as others so any other um any other comments discussion on age six eleven okay so uh what I'm going to say is thank you all for being here to provide your input on the bill um seriously uh yep uh you you have added a great deal appreciate it our two house members and we may be circling back to you with questions about how decisions were made and where the issues lie as well as with Angela, Jana and Ruby so don't don't leave us when we're looking at this bill we if if you and I will say this if you would like to be invited into our meeting as we hear additional testimony just let Nellie know and we're happy to have you uh with us so you can make comment when we start getting into the markup part of the bill okay all right so committee what I'm going to suggest is um sort of blasphemous that uh we take a 10 minute break and uh yeah so let's take a 10 minute break let's come back at at 10 55 Nellie Nellie are you there? I am yes okay good why don't you uh why don't you put the uh the the shield up for 10 minutes and we'll we'll be back uh to move on to H 607 okay great we'll do all right thank you take care everyone see you in a bit thank you I think what what we'll do is we'll begin with our two house members who can introduce the bill to us H 607 this is the act relating to increasing the supply of nurses and primary care providers in Vermont it's a really important bill uh and I know that the house human services committee worked very hard on this bill and worked also with their appropriations committee so we'll hear from them then we'll hear from uh Ina Bacchus what we'll go through the bill with Jen Carby first and then we'll hear from Ina and Nolan and then we'll decide our next steps so we have about an hour to do this we may not use all that time but we might we never know we never know how much time we're going to use so um I will ask uh representative Christensen and representative Reed how you are want to proceed who's going first and thank you for being here uh to introduce us to the bill I'm going to go first and I'll give you some I'll give the bill some context and why it's important and then just give you summaries of the sections and Jen can walk you through and Peter will talk about this and other other two sections of the bill and I'll turn it over to him then okay terrific okay um as I said this is um let me give some brief context and outline the problem we're trying to solve the world health task force commissioned last year it reported that Vermont is currently short five thousand nurses and that was before the COVID pandemic um this number includes hospitals uh nurses in hospitals long-term facilities and home health agencies um a heck hold on my computer's doing something funny okay sorry um let me see a heck the area health education center in 2018 um snapshot identified a shortage of 70 primary care positions in Vermont which includes family medicine internal medicine obstetrics and pediatrics and the reason for these shortfalls as we all know and heard so many times before is we have an aging population and workforce 36 percent of Vermont's primary care physicians are over age 60 close to 20 percent of primary care APRNs and licensed practical nurses are over age 60 provide a burnout especially with COVID rising higher education costs close to 50 increase for medical students and nurses in the last 10 years as well as a tight national health care workforce all contributed to the shortage we have to dig out of we already spend 20 percent of our state and personal budgets on health care providers must deliver quality care they cannot reduce staffing levels cut hours or provide self-checkout PS currently providers must rely heavily on contracted traveling nurses and these traveling nurses technicians and primary care staff which costs double the amount of staff dollars for these positions in FY 19 11 of 15 hospitals spent 56 million dollars on traveling staff um in home health agencies spent 10.5 million on travelers every new addition to our health care workforce directly saves us money on traveling staff this is also workforce bill that will develop and keep professional people in Vermont to train at our colleges and raise their families and send their children to our school so basically this is a strike all bill and has four principles components section one creates a small task force led by the director of health care reform to evaluate and update for months strategic plan for our health care workforce we have not had this in a number of years position is on the statues but we haven't we haven't done anything with it and so we don't really have a census of what the shortage is we have to get the health care workforce world task workforce together and we had you know we're just catching snips of numbers of how short we actually are so anyway section one creates a small task force and it's a small one so it's nimble and and flexible it's led by the director of health care reform to evaluate and update for months strategic plan for the workforce seven member team will include representatives from health care providers state agencies and importantly our educators in the colleges the plan will review the current capacity of our health care workforce and delivery system in Vermont it would also include how state government universities and colleges and the state's education and training programs may develop the resources to educate recruit and retain health care professionals to reform principles and purposes section two requires reports from the task force to be delivered to the green mountain care board by december 2021 and to the relevant legislative committees by january 15th 2022 so the meat of the bill here is i'm going to talk about the nurses and peter will talk about the positions section three um expands this oh no section three peter will talk about section four proposes a program specifically targeted at nursing the section leverages existing nursing scholarship program administered by uh bsac and expands funding and also relaxes some restrictions on eligibility and timing of the application we seek to encourage entry-level nurses those nurses by prioritizing those pursuing pursuing practical nursing certificates and these are as we know our our um long-term care facilities have such shortage of these so we're prioritizing the practical nursing certificate and second those pursuing associate degrees which lead to our end you can take the national law and exam after an associate's grade and then finally those seeking a bachelor's degree the testimony received suggests that as nurses move up they move up the career ladder ladder and often have a lot of opportunities for training often with employer incentives and support so if you get them in the pipeline they will they will move up probably and we have made financial need a primary factor in awards as well as prior academic success um and this was not in the current bsac program it was a very different scale of entering in we're talking about financial need now somebody wants to move up to a licensed practical nurse often they don't even have that little bit of money to get started um so we have financial need a priority factor in the awards the application process will have no specified deadlines it shall be awarded on a rolling basis um as nursing students often go part-time and do not follow a strict academic calendar excuse me priority will also be giving to nursing students attending for month nursing programs and as with the physician program the payback is the nursing scholarship recipients will be required to work um in vermont for one year for every year of scholarship they get I'll turn it over to peter to talk about physicians and where the money's coming from take it away peter so jumping back to section three which addresses the physician scholarships this was was really one of the original core pieces when this legislation was first proposed and we modified it a bit but the the main objective is to try to start building a better pipeline of physicians in vermont to address the the shortages as mentioned by representative christensen so we have uh we have basically expanded um statute to include a new scholarship program aimed at building much needed rural primary care physician resources in vermont so we modeled this initiative after a national program the national health service core program which has been very successful and uh to help address the shortage of physicians across rural and underserved regions of the united states it's a very competitive program so uh it's it's difficult to to get uh access to but it's it's a great model for how this could work the proposed vermont program would be administered by the department of health and a heck and provide five grants to third-year students and five grants to fourth-year students at the uvm college of medicine for the full in-state tuition which is currently 37 000 the grant recipients must commit to practicing primary care following their residency in a rural health professional shortage uh or medically underserved area of our state for two years for each year of scholarship granted primary care includes the specialties defined by the national health service core program and scholarships would be reduced by any other state or federal educational grant assistance received by the student for the same academic year a recipient who does not fulfill the practice requirement will be required to repay the grant plus interest based on guidelines determined by the national health service core program so it's not a freebie if you decide to not stay in vermont so the the funding for these two programs the the original idea came from the governor's proposed budget way back in january where he called for a million dollars of tax credits specifically aimed at nursing and so we took that million dollars to sort of our guide and refashioned it a bit and basically took the first cut of it was three hundred and seventy thousand dollars to fund the 10 medical scholarships and then the remaining six hundred and thirty seven or six hundred and thirty thousand dollars we allocated to the nursing scholarships which is a significant boost compared to what the nursing scholarship program was that exists at this moment so in in working with the appropriations committee to then find the million dollars to start this process of the the conclusion was that we could take a million dollars of an original five million dollar allocation to the department of health from the tobacco settlement fund back in 2018 for 2019 fiscal year which due to an oversight was really never spent so by taking a million dollars from that fund to fund this program we can also use federal funds to match that million dollars which using the existing existing formulas that the doctor scholarship program would receive a four hundred and forty one thousand dollar match for a total of eight hundred and eleven thousand and the nursing program would receive a seven hundred and fifty one thousand dollar match for a total funding of one point three eight million so we can we can basically double more than double our our our funding that comes from the state to allow us to safely fund these programs for at least the first couple years and our anticipation is that that we would include these in future general fund requests obviously we're in a in a difficult situation budget wise over the next couple years so we'll see how that plays out but I think having a couple years funded would be an excellent start to this program so that is the sum of it and not sure where we pass it back to next I would I would like to just say that the committee voted ten zero one on the bill and the house unanimously with no vote no no votes passed the bill and now we turn to you you're muted I said no pressure thank you no that's it's a lot of work I understand the work that you've done on this and we'll have to sort out where the financial piece is right now where the appropriations is right now I've asked Nolan to help out a little bit with that but certainly the need is there we understand that and workforce is a is a very important part of the work that we have to do so thank you very much for that questions for Anne Marie or Peter senator Ingram thank you um yeah thanks so much for that that was very thorough walkthrough appreciate that um just a question about the nurses um the well the doc the primary care physicians have to work in rural areas right but the nurses can work anywhere after they receive their scholarships is that is that right in Vermont and I believe I think we also kept in part of the original scholarship within 10 miles of Vermont no we took that out we took that out you just got to work and sign so Jen go ahead so well I'm actually we should go through the language I'm not well that's why don't we hold that question and when we go through the through the bill itself the language of the bill itself um so why don't we do that right now and then we'll come back and ask further questions if we need to we'll go through the bill and then we'll hear from uh Ina and Nolan and in whichever order they think is the best sorry didn't mean to start that yet no go right ahead no all right I was trying to get it ready it's all trying to get it ready and I jumped again all right go all right so this is um H-607 an act relating to increasing the supply of nurses and primary care providers in Vermont you did get an overview a pretty detailed overview from two members of the house health care committee um so we'll just look at the language for a bit um the first section deals with that health care workforce strategic plan that representative christensen talked about this requires the director of health care reform in the agency of human services to maintain a current health care workforce development strategic plan rather than an existing law it's oversee the development and it takes out some language allowing that the director to designate someone else to convene meetings and prepare the draft plan and move some language some on care board language um to session law so there's a number of changes that would be um implemented if this language were to pass um but mainly the takeaway is that in maintaining the strategic plan it would direct the director of health care reform or designee to consult with an advisory group composed of seven members at least one of whom must be a nurse to develop and maintain the strategic plan it would have one representative of the green mountain care board's primary care advisory group a representative of the state colleges someone from a hex workforce initiative a representative of fqhc's a representative of vermont hospitals a representative of physicians and a representative of long-term care facilities the director designee would be the chair and then it changes some of what needs to go into the strategic plan um so it still requires the director to ensure that the strategic plan includes recommendations on how to develop vermont's health care workforce including the current capacity and capacity issues um but it eliminates requirements around resources that would be necessary to achieve certain goals uh leaves in how state government universities and colleges the state's educational system entities providing education and training programs related to health care workforce and others can develop the resources in the workforce and delivery system to educate recruit and retain health care professionals to achieve vermont's health care reform principles and purposes this is the same as existing law um takes out a requirement to review the extent to which um individual health care professionals begin and stop practicing in vermont and uh looking at factors that hinder or assist in recruitment or retention and so it just leaves a third criteria assessing the availability of state and federal funds for health care workforce development so under current law beginning january 15th 2013 the director or designee is supposed to provide the strategic plan um and provide periodic updates on modifications as necessary uh i think there was an original an initial plan but i'm not sure if there have been any updates since 2013 iina may know more on that and then section two has the health care workforce strategic plan and report so this directs the director of health care reform in connection with that advisory group to update the health care workforce strategic plan and submit a draft of it to the green mountain care board for review and approval by december 1st of this year requires the board to review and approve the plan within 30 days following receipt and then would have the updated plan submitted to um this committee the house health care committee and the economic development committees in the house and senate by january 15th of 2021 so those are the two sections on the health care workforce strategic plan then we look at the sections that you heard about from representative reed the first being on medical students and primary care this directs the department of health in collaboration with a heck really with the office of primary care and area health education centers programs at uvm college of medicine to establish a rural primary care physician scholarship program that would cover the medical school tuition for up to five third and up to five fourth year medical students annually who commit to practicing primary care in a rural health professional shortage or medically underserved area of the state and for each year that they get the scholarship the the recipient incurs an obligation of two years of full-time service or four years of halftime service students who get it in the third year are eligible to get another scholarship for the fourth year and as representative reed said the amount is set at the in-state tuition rate and that would be less any other state or federal education grant assistance that they get for the student gets for that year the approved specialties are those recognized by the national health service corps at the time of the scholarship award which may include these are the current categories family medicine internal medicine pediatrics obstetrics and gynecology and psychiatry and if a scholarship recipient does not fulfill the commitment to practice primary care in accordance with the terms of the award is liable to repay the full amount of the scholarship plus interest as calculated under the national health service corps program and this is the appropriation of 811,226 dollars in global commitment investment funds so this is the this is the gross amount appropriated to the department of health and f y 21 for scholarship for these scholarships and i think no one's going to talk to you more about the money but this also expresses a legislative intent that scholarship funds to expand vermont's primary care physician workforce should continue to be appropriated in future years to ensure that vermonters have access to necessary health care services preferably in their own community so it can only appropriate for one year but it's expressing intent to continue this as an ongoing scholarship program section five appropriates funds from appropriates 1,381,276 dollars in global commitment funds to the health department for additional nursing student scholarships that are administered by visac and as you heard about from representative christensen the first priority goes to students who are pursuing a practical nursing certificate and who will be eligible to sit for the nc lex pn examination upon completion of the certificate so first priority is practical nursing certificate second priority is for students pursuing an associates who will be able to sit for the nc lex rn exam upon graduation and third priority is for students pursuing a bachelor of science degree in nursing eligibility requirements the applicant must demonstrate financial need demonstrate academic capacity by carrying at least a 2.5 grade point average in their course of study prior to receiving the fund award and agreed to work as a nurse in vermont for a minimum of one year following licensure for each year of scholarship awarded it also gives first preference to students attending an accredited post-secondary educational institution in vermont there's no deadline to apply as you heard from representative christensen these will be awarded on a rolling basis as long as funds are available and the funds from any funds remaining at the end of fy 21 would roll over and be available for the same purpose in fy 22 and it expresses legislative intent that scholarship funds would continue to be appropriated and for this purpose in future years section 5a is where the money comes from so this is taking from an fy 19 in fy 19 there was five million dollars appropriated from the tobacco litigation actually was appropriated in fy 2018 some of five million dollars was appropriated from the tobacco litigation settlement fund to a hs for workforce for high quality substance use disorder treatment and mental health professional workforce development and so that was broken out to be 1.5 million for fy 19 1.5 million for fy 20 and 1.5 million for fy 21 and then 500,000 for fy 22 so this would take of the fy 21 appropriation of that 1.5 million it would take 1 million to be allocated as the state match to fund the scholarships for the nursing students and medical students and then the remaining 500,000 would be subject to agency appropriation proposed expenditures to the agency for the mental health and substance use disorder workforce and then sections six and seven are really just some technical cleanup stuff reorganizing a little bit in the reorganizing and redesignating to make the statutes lineup in a way that makes sense in the chapter that deals with these nursing program or nursing and medical student scholarship programs and then we have an effective date would take effect on July 1st so this is another one that would need to be revisited okay thank you sure I know there would be questions do are there any questions right now for Jen before we move on to Ina and Nolan I think a lot of my questions lie with the the funding process and where it is with our appropriations committee if anywhere any questions okay Nolan Nolan do you think that we should move to you or to Ina at this point I think it can be real quick I mean really it's just okay reiterating what representative Reed said Nellie can you pull up the fiscal note or do I have access we don't have access what's that I will give you access uh your co-host now and it's posted to the senate health and welfare webpage as well okay okay so I think the page of the fiscal note kind of highlights the high points and I like I said I representative Reed covered it but this sort of lays it out for you visually that there is a total of one million dollars of general fund which draws 1.1 to federal funds for a total uh gross of 2.2 million um 370 was for the primary care position scholarship 630 was for the nurse education scholarships as representative Reed indicated in the governor's budget he they had allocated a million dollars for a nurse program um legislature wasn't quite keen on how it was being implemented they heard from the different schools and just felt there was a better way to allocate that amount of money however that money was had already been scooped in the bigger picture of the appropriation side on the house but at the same time we were able to we were able to find a a bucket of money which was laid out as gen laid out where they took one point they looked the the third year of that 2018 bill where there was 1.5 million for mental health and substance use uh workforce stuff and they took a million out of the 21 dollars that was in that 2018 bill took and reallocated in here so that's how they found that money and that's what I highlighted in section 5a and the second page of this note so again uh I think representative Reed iterated it I'm just reiterating it so you can see it visually that's all I have to say so let me ask a question of clarification about the 2018 lack of expenditure was that a department of health expenditure um it was I think it might have been uh I have to look at let me get out of this here how do I stop the screen share I never got to stop the screen share I was just had Jen's bill pulled up and it was uh it was it was tobacco it was tobacco litigation money is five million in and it was just appropriated to agency of human services it didn't it didn't specify which uh department it was going to in the in the bill underlying bill right so just to to clarify a little bit too if you look a little bit further at the language the sums that are appropriated were not allowed to be distributed until the agency provided proposed expenditures as part of their applicable year budget adjustment request or budget or budget adjustment request depending on the year um so some of them I think hadn't hadn't necessarily been decided and I'm not sure that there were proposals made in in the budget and budget adjustment acts no one does that sound all right all right can you hold on a second okay um I'm sorry I had a phone call in on uh on the answering machine it would have gotten in the way um sorry um the questions for no one about the uh about the fiscal note at least the you know the total appropriation that we're seeing here um the question I have is is it currently in the budget do we know that so it was initially um the way it was uh framed in the house was that they would incorporate it as part into their budget framework okay so at this point what I'm hearing you say then is that at this point the house is formulating its proposal and that as far as we know this will be in the house budget yeah I mean this this bill was passed out of the house with the underlying premise that it would be covered in the budget and the house so this of course and so I know that the house health care committee plans to communicate with the with the appropriations committed to remind them if they have don't already know that it would be part of their context okay so um before we move on to Ina and listen to her testimony um I mean this it doesn't preclude our continuing work on the bill itself but we also need to know that especially Senator McCormick and Senator Westman that this is a heads up for the appropriations committee as well so there's going to have to be some coordination going on and I I think it makes sense to have you two be leading that go ahead Senator Westman my question was what was the timing of its passage in in the house was it early when when when was the timing of it it was on June 16th oh so it was after thank you that's very helpful okay all right yes that is helpful okay well let's just keep all of this uh rolling around in our brains a little bit um and and why don't we any other questions for Nolan or Jen all right so Ina thank you for being here and um perhaps you could comment from your perspective of health care reform but also administratively your your perspective on what's in the bill thank you for the record Ina Bacchus director of health care reform in the agency of human services my primary comment on the bill regarding um the activities outlined for which the director of health care reform position would be the primary responsible party um relate to the timing and the timeline for the submission of the report to the green mountain care board and then subsequently to the legislature I uh due to COVID-19 I'm somewhat concerned that we can arrive at a meaningful update to the strategic plan in the timeline that's prescribed currently although I recognize that through the rural health services task force or commission on which I was a participant that there were good priorities and strategies identified through the that group and that those could certainly be uh core to recommendations and I would expect that they would be however the legislation does require the the work with the advisory group and so I couldn't make that determination unilaterally that those priorities identified would be the priorities so that's my that's my my feedback is um a little bit of uncertainty regarding the timing due to the many um potential variables at play in in this time where we are working at the agency of human services every day to address the global health pandemic so uh given that what timeline is more appropriate from your perspective I certainly recognize that we need to and support work to address workforce shortages now and some of that work is indeed playing out with the uh health care stabilization grants that we are providing in terms of um stabilizing the health care workforce although it's not a direct workforce development initiative it certainly is important for maintaining workforce during these times hazard pay similarly um we are very much involved and administering that program that has a significant impact or could have a significant impact on workforce uh so we are we are involved with initiatives related to workforce now that are very important in this moment a realistic timeline may may be um looking to extend the deadline uh by a year but I don't know that that's necessarily um I don't know if that feels like too long but I think that that would be realistic okay I mean that's very helpful we can't we're not going to be able to squeeze water out of a stone and I know how hard everyone is working on uh the stabilization issues that you're talking about so we'll we'll we'll put this uh into our discussion uh on our discussion list and appreciate the work that you're doing um very much and we this is this is critically important but if if it's not going to be done right because we're trying to rush it then uh it makes sense to consider a change in the timeline so thank you for that um so questions for Ina because I do have another question but I'll open it up for the committee do you have questions for Ina okay um the the report is going to um the Green Mountain Care Board um so I'm trying to understand the relationship and maybe this is also for the house members between the Green Mountain Care Board and some of the planning that we're talking about and the reporting that's going on okay can you talk to that or is that something Amarie you want to speak to well I believe that the Green Mountain Care Board has identified the workforce as the priority just the same as the rural health task force and um I'm not I don't believe the Green Mountain Care Board was in effect in 2013 when this was in statue and um I think maybe there was another body and this was a comparable body but I can't Jen I think they were so I the Green Mountain Care Board I believe started in late 2011 um so they were in existence but this is having the report go updated report go first to the Green Mountain Care Board and then to the legislature I believe it follows with what had previously been a requirement that the board uh review and approve the the workforce strategic plan right okay all right so there is an exist a requirement in the existing law that the report or that any updates to the report and the original report go to the Green Mountain Care Board um so this is moving this is sort of revisiting this this idea of a strategic plan setting an update for now with a report going to the Green Mountain Care Board and the legislature okay all right I I understand that um the question I have is the role the board is playing in understanding that workforce is key and they have the over oversight of the health resource allocation plan and what um um what do individual practitioners play in that planning process um so just some thinking uh we're all going to have to do on that one uh Ina is there anything else that we should hear about from your perspective okay um I'm happy to answer questions okay good uh I do have a general I have do have one more question and that is um and I think as we take testimony on the bill later on we're going to hear the question was dental uh were dental practitioners considered in the workforce development process no because the there was a shortage of dentists um several years ago but the dental society did its own push recruiting push and uh the dentistry workforce um in a survey conducted by the department of health uh that the full-time employees for the dentist increased 8.4 percent since 2005 so it didn't look like they needed help at this point it was more on nurses and the primary care physicians okay and that includes pediatric um dental care primary care yes all right uh we may hear more about that but that thank you that's you're on your toes thank you the data that's super thank you also you have a a letter from I believe an email this morning to the committee from the coalition of health care providers in support of the the bill um right yeah okay so we will um we're going to try and get Jill Olson in as the we call that the star wars alliance and we're going to have them come in and testify so they are supportive and we did get that letter thank you welcome anybody else a question okay committee my question of view is on this one uh your thoughts on moving forward with the bill itself I mean we think we have decided to keep moving on 663 and on 611 and now we have 607 in front of us and we've heard at least one uh one it's not really a barrier but we need to be in touch with our appropriations process but your thoughts on H-607 and I'd like to move ahead it's extremely important we've been saying that about our healthcare workforce for a long time so it'd be nice to make it and I you know I yeah go ahead senator McCormick yeah I guess I'm kind of asking senator westman what he thinks because I I don't I'm not sure where we are on appropriations on this rich do you have any thoughts you know the difficulty becomes um as um you look forward to next year's budget and where we are when we come back January in what room we might have it becomes um it becomes different difficult to say exactly where the appropriations committee in the senate will be but I will say um um and I'm going to speak personally I applaud the fact that the house went out and found the money you know and they um they set aside a discrete pot of money and and do that so I think that makes it easier to um take this to the appropriations committee um then um then some of the other things that are coming in front of us where we're laying out a path that we might not be able to fulfill in um in January so um but um I I don't want to speak for the whole of the appropriations committee but I do applaud the fact that this does have money tied directly to it and I'm prepared to advocate for this to the appropriations committee I oh you know I would say personally I think this is um the most important thing that um that we've seen yeah good all right this is all sounding very good I'm I I'm agreeing with each with both of all three of you who have spoken for the bill um Senator Cummings did you want to add anything or a different perspective okay um I do think it's critically important and I and if uh the fact that the house appropriations committee is working with human services and we'll we'll keep our fingers crossed that the funding stays in as we see it then it does give us a little wiggle room while the house is is going through this but in the meantime we will uh take um I think we'll have to take no one's fiscal note to the appropriations committee uh so that as we go through the bill I mean there may be some policy changes that are in the bill that we would like to um to work on but other than that I think it's going to be up to uh you guys in uh in appropriations to sort this one out can I um just ask the the question how many um um nurses or or nurses students were we potentially thinking this could help it's hard to say we had I understand that because you have different levels and different levels these sac had a pot of money it was an ongoing scholarship for nurses but their criteria was very rigid and they did not award all the money even though financial need was a big need and they didn't they didn't really that was on the bottom of their priority list in the the scale and so we moved that up because we figured that was it plus we opened it up to licensed practical nurses and in different levels to get them in the pipeline so it's hard to say and that's also why there's a rolling basis on the scholarships anything that's left over and not not given can be given on a rolling basis that helps I guess a little but it would be it would be be helpful to be able to say we're going to help but there's the potential to help this as a minimum up to this amount um you know when you say dollars like this it doesn't put it in real terms on the people that we need to get out um doing this work so I believe I have the number for bsack but I can't get my hands on it right now of how many people applied in the previous scholarship and how many did not get the scholarship because of the criteria was so strict they needed essays they had deadlines and just people didn't you know didn't fit into the categories I get I'm just in in maybe Ina or somebody else can take a look at this and say within this field it could be a minimum of this or a maximum of that it's always nice to have the number of individuals that were we would be helping got it well let's let's uh Ina maybe you know uh or um or you guys from the house might know who testified from Vsack I know we're going to have a heck testifying a heck usually has a pretty good understanding of numbers it's a slightly different set of uh constituents but that's a very good question um over time because this thing goes on for a little while so let's uh we'll we'll we'll go after that and in our testimony going forward we heard testimony from from bsack from maryland cargill okay yeah okay good we'll we'll um go after that okay any other comments discussion questions all right I you know I I I kind of resist um sending the fiscal note out without having the information the the information in the bill and the background information supporting it but I do think that uh senator kitchell fully understands the demands for additional workforce so we um I will probably communicate with her and I'm going to I'll I'll try and copy everyone um committee members on that email and I'll with no one's fiscal note I believe that senator kitchell will be familiar with the mental health and substance use disorder money because she was um a part of that bill 18 so she should be familiar with it okay all right well she'll assure you she's she's aware of that one I'm sure she's anybody that's not spent of course we're aware of it okay any other comments discussion questions all right um committee thank you for your work today and thank you um representative reed representative christensen and inna and back as for being here with us today as we take the bill up we might rely on your expertise again so um keep an eye out and we'll keep you posted thank you I think uh committee unless I hear something different from you we have achieved the goal of the senate health and welfare committee and finishing early is there anything else we need to do gen no one okay thank you all um see you at one o'clock take my kids nelly we're we're good to to end thank you