 Is it out of here two years ago or three years ago? Really, or maybe even four? We passed it on here, it passed the floor unanimously, and then it died over there, over there. Okay, so, Jen? Yes. Would you like to join us? Sure. Jennifer Garvey, Legislative Council. So this is very similar to the version that some of you saw a few years ago. This is S297, an act relating to the Agency of Healthcare Administration. I've updated the findings a bit to have more recent numbers toward the end in looking at healthcare expenditures constituting over 25% of total state spending, second only to spending on K-12 education, updating some dates, things like that. So this goes through, and basically the overall idea is that it splits the Agency of Human Services into two agencies, an Agency of Healthcare Administration and an Agency of Human Services. And the Agency of Healthcare Administration would comprise the Department of Health Access, which is like the Department of Vermont Health Access, the Medicaid Agency, so it's the successor there, the Department of Mental Health and Substance Misuse, the Department of Long-Term Care, which pulls a piece out of Dale, the Department of Public Health, which is the successor to the Department of Health, the Healthcare Board, which is like the Human Services Board to hear appeals from decisions of the departments and the Vermont Health Benefit Exchange, Vermont Health Connect, where the exchange plants are that's currently in D-Va. And the way it's structured is very much, I mean, I took the Agency of Human Services statutes and kind of created a parallel version for the Agency of Healthcare Administration. So for the most part, it is just the same general thing creating a secretary, a deputy secretary, talking about the role of advisory committees, transferring personnel and appropriations as appropriate, moving a couple of the specific policy sections that are in the AHS chapter on the duty over healthcare reform, having a director of healthcare reform, moving that person from Agency of Human Services to Agency of Healthcare Administration, having the wholesale drug importation program, again, in the Agency of Healthcare Administration, not in the Agency of Human Services. So a lot of it is fairly standard, I think agency language, but in some cases, obviously tweak to fit the mission of this Agency of Healthcare Administration and talking about the different departments within it. What, where is the division of all the, like, Dale? So some of where that ends up, so there are a couple of provisions. There's some language in revisions to the AHS statutes that talk about what is left there, which I think we called the department. So on page 24 is what's left in the Agency of Human Services, which will be the Department of Corrections, the Department for Children and Families, this is section three. Sorry, what was? Section 24, page 24, section three. Section three. So what's left in the Agency of Human Services is the Department of Corrections, Department for Children and Families, the Department of Independent Living, which would take the disabilities and independent living concept from Dale. And it becomes a dill instead of a dail. Yes. And then the Human Services Board is still there for the appeals side on Human Services programs, but the rest of it moves over to the Agency of Healthcare Administration and in some cases gets some revised names. And then there is also a little bit of language toward the end about, where is this? About the healthcare, so in the very end of page 36, the Agency of Healthcare Administration is the successor to and the continuation of Department of Remind Health Access, Department of Mental Health, the Long-Term Care and Home and Community-Based Service Components of Dale, and the Department of Health. And so the Agency would continue the duties of those departments. There are some transitional provisions, I'm jumping around a little bit, but I think sometimes it's easier to understand the concepts than marks through the language. So on page 32 and a few pages thereafter, there is transitional language talking about transfer of positions, so directing the Secretary of Administration to create the new Secretary of Healthcare Administration position for October 1st, 2021, and then beginning October 1st, 2021, the Secretary of Administration would place under the supervision of that new secretary, all of the employees, professional and support staff, consultants and positions in all of the department's offices, divisions and offices to which the agency is the successor in interest and the balances of appropriation amounts for those up to 20 positions from the Agency of Human Services to staff the office of the Secretary of Healthcare Administration and the funds to go with that. It would require the Agency of Human Services to provide fiscal and administrative support for the Agency of Healthcare Administration until March 1st, 2022, and not later than January 1st, 2023, that the transfer would need to be complete. So there's sort of transitional provisions as you're moving people from one agency to the other, but that should be finished by January 1st, 2023, the people and the money. Where is, sorry, I just don't see 2023 anywhere. Page 33. Oh, page 30, I'm sorry, I was at 37, I thought we'd see it. Okay, no, we didn't get that right. So 30, we did, but then I moved that, yes. So subsections D and E are looking forward to January 1st, 2023 as the end of the reorganization and transition process. And then there would also be directive to the Secretary of Administration. This is now on page 34 to submit to the committees of jurisdiction, including this committee by December 1st, 2021, a proposal for dividing up Dale into a Department of Long-Term Care in one agency and Department of Independent Living in the other, and then talk specifically about the Department of Long-Term Care having the authority to administer the choices for care part of Vermont's Medicaid waiver and that the Department of, I'm sorry, and to regulate long-term care, regulate organizations providing home and community-based services and certify long-term care facilities on behalf of CMS, which is Centers for Medicare and Medicaid Services, which is something Dale does now. And then the Department of Independent Living would provide services to Vermonters who are elders and to individuals with disabilities to allow them to remain in their homes, including voc rehab services, vocational rehab services. And then another proposal by the same date, December 1st, 2021, again to various committees, including this one with any additional modifications to the Department's units and divisions that were transferred from the Agency of Human Services to the new agency as needed to reflect the new departments of health access, of mental health and substance misuse and of public health. It's basically that they're directed to my office on page 36 to fix the statutes over the summer as would be needed to reflect the references to Agency of Human Services and Agency of Healthcare Administration as appropriate. And some transitional, some intent language on transitional funding, that it would be the intent of the General Assembly to provide in the Appropriations Act funding the Agency of Administration in fiscal year 2021 to be transferred to the Agency of Human Services for transition costs associated with reorganization. That is basically what's in it. So even though you talk a lot about transfer and transition, workers moving here and there, there's no real physical movement necessarily going on, right? I think there would have to be discussion about whether there was needed to be physical movement or not. I don't know what the capacity is or whether this would be adding, is maybe adding, I don't know if it would be adding new positions or not. So I think that would, some of that would depend on the reorganization. And then in that case, there may need to be physical moving to lump people who are working together into the same lump, isn't a good word, but to put them in the same space to allow them to work together as opposed to maybe spreading out two agencies across facilities. But I think there are other people who would have thoughts on that too. Right, I'll see what you're going to say. I don't know why, I don't want to say that because that way, there's all kinds of money here. Nolan is going to tell us how much money it means. And also, no, you're not. No, not today. But we all know that the person who is passionate about this is the person who controls it. So, but she has, this is like the fourth time she's tried to get, right? She's introduced this, she's introduced it several times. It has been introduced at least a few times before. I recall this is my second time, but I don't know, it may have been happened before that. Was that the first one? It's never passed the house. They never even took it up. I don't know, I think the issue has been around for a while. It may be only the second time it's been introduced. The second time it's been actually physically introduced. I think the concept has been around for a while. So we're going to hear from the sponsor about why we, what the objective is clearly. And thank you. And it's also, you know, I think laid out to some extent in the findings. Yes, I think the findings are terrific. I'm enjoying it here. Any more questions for Jen? Over there? Okay. No, but it's nice to have you with this committee. It's my first time here, I think. So she's going to go get it. Yes, March 11th. Yeah. Her, the secretary. Yeah. Yes. I'll work with Gail, but that should be absolutely fine. It's far enough. It feels like a lifetime right now. It's been a whole new month. Perfect. It is a whole new month. I know. Perfect. Yes, we're going to get to this too. Okay. Don't have to go get Jen. No, she just texted her. I mean, she just emailed her. Okay. Ooh, baby Canada. Everybody can vote it. Thank you. Okay, we should read the findings and be prepared for Jane. I'm channeling the house at the moment. And I believe that last time we did this, the only opposition came officially from some of the commissioners, but unofficially they actually supported it, but officially they couldn't support it because the then administration did not support it. Have you heard anything from the administration? Yes, Mike Smith is going to come in and testify on March 11th. Oh, right. That's what we just heard said. And at that point, we will also then, I guess here from the SCA, or today we might, we'll probably have time. Chair, if it would please the chair and committee, listen to today's testimony and brief our members in order to get a better understanding of their position on the issue that came in. And make it short. Yes, of course. I didn't tell you that Gail was going to give me that plaque, right? It says, I am not bossy, I am the boss. Oh, yeah. This is giving me all sorts of ideas for your birthday presents. Thank you. Jen has walked us through. Oh, she has. Oh my goodness. Word for word. Oh. We did an overview. She did an overview. And if you would like to just give us your understanding of why we feel this is necessary. Okay. Well, this isn't my first time with this issue. And I just want to start back a little bit because I have been around so long, I predate the agency of human services. I started in social welfare and there was no agency. So I have been there when it was created and I understand the world as it existed in the early seventies. And during that intervening period of time, our healthcare spending, our agenda and the role that the state is playing has grown enormously. So healthcare is now our second largest area of spending in state government after K through 12. And we have a very ambitious agenda as it relates to how we want to finance care, how we are moving through. We have another waiver to negotiate. And my reason for proposing a healthcare administrative entity that is focused on the administration and the management of our healthcare policies, resources is accountability. And the agency of human services is half of state government. And everybody will say, well, it's, you know, you can't take that as all connected. And if you carry that argument out, you should manage everything out of the governor's office because everything is connected to everything else. And if there are areas where people talk about the need being the greatest, it's housing, transportation and jobs. So you have to look at how systems need to understand and work across systems, but you also have to have organizational entities that are of a size and scope and complexity that you can hold someone accountable for administering. And right now to ask one administrator to be responsible and the agency of human services is an umbrella agency. So the secretary's office is really rolled to bring together all those various functions and make sure the policies align, that there's oversight, that the financing and everything comes together in the best possible way. So back in the early 1970s, we of course still had institutions and you had state hospital with, when I first started was like 1300 patients, you had Brandon. So you had a very different kind of environment in terms of how people were being served, what those relationships were. So the fundamental question I would say, would we expect the CEO of Blue Cross Blue Shield to run prisons, collect child support, protect children and the list goes on and on. And I think we would say that is a scope of such diverse area that it is very difficult if impossible. Now I know that I'm seeing this from a different perspective because I've maintained my involvement. If I had not been involved when I left in 2002, I would be seeing the agency as I knew it. But sitting next door, I see how that healthcare agenda has evolved and how it's expanded and the enormous fiscal and policy implications that are there. So if you don't have that continuous kind of understanding and what the challenges are, it's easy to say, well, that's the way it was or that made sense. In 1973, healthcare was essentially Medicaid, plus your institutions, as I was talking about. And Medicaid was limited to people who were on public assistance or in a nursing home. Pretty simple. I mean, we said the director could manage the program out of his bottom drawer. Those days are long gone, but our organizational design is still the same. And yet you look at the other part of the system, which is under tremendous pressure and need for attention and leadership. And that is look at what we wanna do in corrections. Justice reinvestment as we're moving people into the community, how we provide those housing supports, how we transform that system, major agenda. I think corrections does fit very much with our other casework and our social work functions because families are attached generally to the inmates or individuals on probation. Some, in fact, are mothers. Children could be in the child welfare system. Our child welfare system is under tremendous pressure. No question about it. We're trying to understand why we bring more children into state custody by far than other states around us. How we can look at that system, what is driving it, because that's a major area where we put more money. But let me tell you, if we're concerned about trauma, anyone ending up in child welfare system, it's tremendous, tremendous trauma to the kids and to families. The other part, as you're looking is there's an agenda looking at in general assistance on housing and emergency housing, moving away from vouchers, how you do that, how you work with communities, tremendous amount of work associated with all of that. So I was, my thinking is that we need to look at what should be the right functional alignment of responsibilities and programs and activities of government and how to create organizational entities that are manageable and we should expect an administrator to be able to oversee and to pay attention to this myriad of things, whether it's on the healthcare side and anybody who's on health and welfare in the morning knows the work that's attached, there's the waiver that's gotta be renegotiated, the development of the ACO, how that is being rolled out, the connection with other parts of the delivery system, it's payment reform, it's the complexity and the financial stakes are enormous there. And then the connections back, and I talked to Secretary Mike Smith and I had talked with him the first time we were considering this legislation, which the Senate passed unanimously. And he said his thinking had evolved because he's been working in vital, he's been looking at all these pieces that are really important to the administration of our healthcare and eventually hopefully providing better care and looking at costs and how technology and data help do that. So he's not able to come in today but he is able to provide that perspective because after he's left, he's actually also had connections with other parts of the delivery system as well as Medicaid and understands the huge stakes that are involved in the renegotiation of our waiver. And you don't know but the waiver allows us to pay for services that Medicaid would not normally pay and we have over a hundred million dollars of those services. So that's why I'm just using an example of how high the fiscal impacts are. So if you look at all the different areas that really policy committees are saying needs a lot of work and a lot of attention to put together, it doesn't mean that you disconnect everything. I want to understand that. Our problem is we talk about siloed funding and we do have siloed funding but what bothers me more is our siloed thinking that happens too frequently and people not being able to see those connecting points with other systems and working across those systems because education is a separate system. Economic development, job creation, transportation and yet those are critical components in terms of improving lots of remoders. So siloed thinking allows you to feel very comfortable with what you have. Another area that I have been harping on for a long time and that is we have case management. Everybody's a case manager. They case manage their bundle of services. They're not, it's not like healthcare where you have a medical home where that primary care practice is responsible for your overall healthcare. You may need to see a specialist or several specialists but you have a medical home. Right now we have, as I say, we have systems where we have everybody involved and nobody accountable and everybody's doing their part perfectly, they think and yet you're not moving forward. So I would love to get us at some point when we're looking at the social services side, the case work, the case management side where we have a system where you have just like a medical home, a case work home because a lot of times you find families are served by four or five different entities but who has overall responsibility. So there are many, many systems issues that have gone on, unaddressed over time. And I just, I feel that some of it is there's only so many hours in the day. There's so much mental energy you've got in terms of what you can look at at any one time and what you can be, anyone can really realistically expect any person to be able to understand. And so that's why I feel that this is a way of better accountability. I'm not doing this because I think it saves money. It might, but it's not. It's making sure that we have an organizational construct that is realistically within a manageable scope. So that's kind of it in a nutshell. So Jane, why do you, I hear you on all of this but I'm just curious how you think this is going to improve accountability? Just because it will be smaller or the, I mean, I'm just curious how you think this is going to improve accountability? Because it will allow us a more focused managerial attention on all our healthcare policies, spending and those how, and the transformation of our delivery system. And do we not ask for that now? I mean, we ask for a lot of that now. But for a secretary to be managing that process, which includes how vital it's functioning, remember that was no luck good for a long time. We're very unhappy with the spending that was there and so forth. It's how do you, how does one person have the time to deal with corrections on top of that healthcare agenda? We have a very ambitious, if we do it, the justice reinvestment. There's a lot of work that needs to be done in corrections. We know that that system is really under great pressure. We can't hire the staff. We've got a whole lot of cultural and policy needs that have been identified and need to be addressed. We need to look at our child welfare system. We need to look at how, what we're funding, how we're funding, how we're holding the providers accountable, how we're serving families. Those are all great examples, but they're very, they take a lot of time. And so you've got people with different perspectives in terms of how you wanna solve that problem. You listen to one group and this answer for child welfare is one thing versus another. An example was, to be honest, the issue around the rate of children coming into custody was one that we, I picked up in appropriations. It didn't come from the administration. Didn't come from DC. No, it didn't. It came from, and that was why we put money in the budget last year for 200,000 to work with UVM, school of social work, nursing. And then we have the Children's Health Improvement Project to take a look at what is happening. Why are children coming in? Are we funding the right services? Are we intervening in the right way? Are we using interventions that might have worked 20 years ago, but don't? And people will say, well, it's the opioid crisis. Well, every state's got opioid crisis. We're some, many worse than Vermont. Poverty, well, we have poverty, but we don't have the deep depths of poverty that some other states have. So the question is, what are those factors? How do we shape the policies? How do we look at what we're doing? Those are all very massive pieces of work that need administrative time. And it's easy for me to say, gee, this is a real problem. Let's take a study and look at it, but then someone has got to be able to act on it and say, how do we change what we're doing? The same thing is true. Senator White will know this when you talk about justice reinvestment. What that's gonna mean to the whole correction system, both institutional and on the community side. So these are times when our old legacy systems are having to be re-looked at. And some of our practices need to be challenged. Some of what we're funding probably needs to be maybe used in different ways. But when you put it all together, it is the needs of today and shedding and moving out of these kind of legacy compartmentalization really are gonna require some time and some leadership and some vision. And so I'm just trying to give a scope of responsibility where it's realistic for a person to be able to succeed or just say, oh my God, that's so big, no wonder they didn't get to that. Or whatever, so we're kind of reacting. So it's with how many years of perspective? 53 years, starting in 1967 that I am looking at this and saying the construct that we put in place in the early 70s is not serving us well with the demands and the complexities of today. So that is my story and I'm sticking to it. So, does that help? Yeah, it does help. And I have supported this measure and I have loved and appreciated all the things that have been done currently sort of in and around the edges of making it work and streamlining services. So for example, from a user point of view, when we, they now have a sort of a navigator in each county who, in our county, it's Sue Graff, but Wazzling Boyle who you could call about any of the connected AHS things and you wouldn't have to call each area but they could intervene in all areas and when you're dealing with constituents we have whose lives touch every one of those. And there are times, I have to say, It's very helpful. And I will say that there are times when in fact, I feel like I'm the case manager for a lot of the people in my area when they call and I'm saying that isn't right or I'll help you with that. Or why didn't you get referred for this? You know, your mother qualifies for SSI. That shouldn't, I mean, you know, that's not the way you wanna have assurances that people are uniformly getting the information. And, you know, I, so I understand it. There's a lot of information there to absorb and I understand those regional coordinators. They're great. Well they are. I was there when we put them in place and we actually gave them some flexible money which we've been taking away bit by bit, which bothers me. So that was an effort at the community level to look at, you know, and if we're gonna move together with that housing initiative to get away from motels that those are the kind of positions that are gonna have to lead that. They're gonna have to bring together the agencies or so to me that that is at the community level trying to make sure that all the people that have got to come together in fact do or to get the community engagement that's necessary. But it takes a lot of time and it takes being able to move beyond what my program is or what my department does. Have other states, I assume other states have, Yeah, they're all over the map. They're all over the map. But I, you know, we change our committees here within the building. We have, you know, sort of every five or six years we have no needs with our committees. We change them around hopefully to address things more effectively. It makes sense to do some of this. I don't think, oh, there they are. That's not us. No, it's cannabis. Oh, it's cannabis. Cannabis are us. It will be coming towards us. Oh, I know, I know. I know. So you can slice and dice this a variety of ways but what I am trying to recognize is the way in which we organize functions in the neatest way. There'll never be any clean, you know what I mean. People still have to work across systems and so forth. But I am trying to make sure that these key systems get the administrative leadership and attention that is warranted to deal with very, very complex and very substantial areas of really service and delivery transformation. So that's my motivation for doing it. And I'm sorry, Secretary Smith couldn't come in. I'm sure you'll be having a little bit of time soon. You'll be coming in soon. Yeah, anything, come in. We're doing it next Wednesday. I mean, the Wednesday will come back. We're hoping that we'll just be able to vote it out at that point once we hear from the secretary. Yeah, and I really struggled, you know, in terms of, I wouldn't be proposing it if I were totally fossilized. I would be saying, oh, everything is perfect. Let's keep it the way it is. We just need to sit around and talk better. And I know some of the reasons where different programs or services ended up and it has nothing to do with a rational alignment. It had to do with personalities. It had to do with what people didn't or did like. So some of what we have has absolutely no organizational basis for it. It's sort of like, you know, let's jettison that or how do we, you know, make something work? So it's a good time to take a look at functions and accountability and what is reasonable for one person to really move forward on. Thanks for not bringing up. Yeah, thank you. I know, I can't believe I'm that old. No, that's not the implication of that. That's the year I got married. 1967? I did too. My God, we're still married. I thought we must be the most boring people in the world. We are, but we remember that we were both promised at birth. We were child brides. We're not that old. Oh, all right. I'm not that old. We're not that old. I'm not that old. You're not experienced. And you know, I have to say, I feel really, I have been in state government and I can look back and I really feel a sense of pride. Reach Up, which is a model program, when I put that forward to replace the old income maintenance, that was a tough sell. It was a tough sell here. I was accused of leading an economic assault on the most economically oppressed women in the state. And now people look back and say, it's human capital development. It's a two-generation approach. Yes, because it came with a work expectation for parents. Dr. Dinosaur, I mean, I'm really proud to be part of having universal coverage for our kids. The 211 system, I worked with Gretchen Morris to get the 211 system up, which was really when you think about it with, you know, and so I feel very fortunate that I've been able to institutional impact Jane Kitchell. Well, but I also feel like Jane wasn't unlucky to be at the right place at the right time and be able to do this, so. And now you think how much more we still have to do, too. Well, that's right. I know. You know, we can't be complacent, Allison, we have to. I know. But I also, and I was involved, you know, with the first effort on healthcare reform with Governor Dean, when that fell apart, then we picked it up. We did the Vermont Health Access Plan VHAP, which was the first effort to really get away from the categorical eligibility for Medicaid and help low-income workers. So a lot of things have happened over that period of time. It was no food stamp program when I first started and the overseers of the poor were still in place. So that gives you some historical context of. And fence sitters were still there. Yeah, well, fence, I'm still there. It's fence viewers who are still there. Yeah, yeah, yeah. I don't, I didn't have anything to do with them. You know, we should probably do this in more, more than just this agency. I mean, if we were going to start right now to create a state government, we probably would not create it the way it is right now. Probably not. In a lot of areas. So actually maybe this might inspire us to call for a review of the effective design of state government. No, you take on too much and it becomes, well, we can do it, agency by agency. We're great incrementalists. We succeed when we're doing somewhat, at least to some extent now some people would like the, we've tried the big bang and sometimes it doesn't work, but then we pick it up and move forward and don't give up. So anyway, that's sort of the view over the last few years. And I'm sure Jen gave you a much more. And basically I just, we work from the bill that you passed with the changes that you made from when it was introduced. So it wasn't an attempt to kind of redo that territory. Right, it started with what was passed out of the Senate. Yes, yeah. And reflects the work that this committee did several years ago. But I do have the report. I do have the report on the welfare reform foundation for change. I have quite a bit of stuff. It doesn't have those already, the archivists. Well, she probably does, but June has to do it. I have my own file. I have my own file. I have an article by Jerry Anderson. Remember he came up and testified, healthcare reform oversight on the cost of obesity to the healthcare system. He testified back in 2002. So I have, it's amazing when I go back and look at some of the stuff I've got. We have similar reports on law enforcement here dating back to 1960. I bet you do. Yeah, I bet you do. So thank you, Senator. Thank you. Well, long. Just checking in to see what's going on. All right. All right. We don't have anything else on our agenda today, I don't think. Do we? No. And you don't have to tell us how much it's gonna cost. If I knew. If I knew, I would tell you. Okay. Well, and we really don't know, do we? Because. No, I don't think it's known. I think what you would do is you'd put in some kind of mechanism for a budget adjustment, maybe. Or we could talk about it with you before, but I don't know that there is no cost. Stephanie may have worked on it on one of the other three considerations. Yeah, I think. I'll check with her. Yeah, I can do it because I think there was some stuff around that. Yeah, if we put in, some of the language we put in around sort of continuing the operations, I think we can't move forward. Yeah. I'll tell you what I'm gonna do. Okay. All right. Ready? All right. Okay.