 So the forum tonight, I'll start again, we'll focus on the need for UPC, Universal Primary Care, what has been done and what we need to do. And I'm going to go through, briefly go through the agenda, which Mark was going to put up on the screen so we can just walk through quickly. And it's in your chat as well. So we're going to start off with a couple of personal stories. Mary Chapman, who is the vice chair of the Middlebury Democratic Committee, has a story. And Mark Gibson is our vice chair of the Bristol Democratic Committee, is going to give a story. Then Ellen Oxfeld is going to go through some very recent data from 2021 from the Vermont Household Health Insurance Survey. Then we have two guest speakers, very excited to hear from them. Dr. Deb Richter, she's a private physician in Montpelier. And Mike Fisher, I think you all know is from Lincoln, and he's the Vermont patient advocate. And he was a former Vermont house rep. So then Chris Bray is going to take us into a plan of action and focus legislation. Then Ruth Hardy is going to talk about what has happened in the Senate Health and Welfare Committee, and what they plan to do. And I asked Mary to come because she's in the House Health and Welfare Committee, but she's working tonight. So she's unable to come, but we'll hear from Ruth. Then we'll end with Mark Gibson. We'll go through what has been adopted by the Vermont Democratic Party in terms of universal primary care. And then hopefully we'll have a good 20 minutes for questions and answers at the end. So Mark, we will start with you. Okay. I just want to thank everyone for coming. All right. So we're on to personal stories. And actually, first, we're going to hear from Mary Chapman, who is on mute. Mary, yourself. Linda, can you unmute Mary? I got it. Okay. Hi, everybody. I'm Mary Chapman. Hi, Cheryl and Ellen. I'm going to talk about my older brother, who just recently turned 65. But what I meant to first tell a little bit about him, we as a family grew up in Virginia. And I'm not sure when this happened. I think it might have been his junior year. He found a job up in Shelburne. And I'm sure some of us, well, some of us probably remember Cafe Shelburne. And he started working in a restaurant. And that ended up being his career. He eventually in his early 20s ended up over in Sugarbush. He fell in love with skiing. So he worked at a few restaurants around there and eventually worked at a restaurant called Old Times and was a chef there for a long time. He did the menu and he was over there for about 20 years. He also taught skiing and with kids, which he's a good over monitor, it's his favorite stories, but and he also raced. So he did this for like 20 years. I don't remember what happened, but he ended up coming back over to Addison County and lived here for a couple of years. And I've worked in a couple of restaurants, but he was working when the incident happened, he was working for a contracting company who were building the new science building and library building at the college. Never, he never had insurance. He never could afford it, but he was pretty healthy overall those 20 years. And so this was about 2000. He ended up with a tooth infection and went to a dentist and was put on antibiotics. And he overall started feeling better initially and continued working and he kept feeling like maybe at the flu or something. He'd go to the ER and this went on for months, probably six months until he got to the point where he could no longer work. He had lost like 40 pounds. He had looked for a primary care physician, but no one would take him. And finally, my dad talked to Don Bicknell, who was our family doctor as kids when we were growing up. And my dad took him in one week and Don put him on all this medication. What happened? He had gotten septic from the tooth infection. My father brought him in a week later. Don called the ambulance and had him rushed to the hospital. He had pleurisy of the lungs and they had to cut him open right there in the ER on both sides just to get the infection out. That's his first incident. He wasn't able to go to work for quite a while. He was in the hospital for probably about a week and a half. They were talking about having to scrape his lungs. The infection was so bad. Anyways, he overcame that and ended, I'm trying to think. It was nine years ago. He was again over in Sugarbush working and it was nine years ago. My mom passed away November 8, three days after his birthday. He had a heart attack a month later and he was out of work again. Sorry, this is my big brother. He again lost his job, lost his place to live and he ended up staying with my sister that time. When he had the pleurisy, he came and stayed with myself and my daughter. The last incident was when COVID hit. It was right when you guys all shut down. They have a lot of foreign students that work at Sugarbush. All those guys had to leave. Countries were closing down. He was left cleaning up the kitchen himself. He wasn't feeling well again. He thought it was COVID. I didn't hear much about it after that with him. He's a proud overmonitor. I'd hear a little bit here and there. It was December when he had finally gone to his, he does have a primary care and when he saw him, he'd pay out of pocket because he does have a heart condition. He has to take meds and he was paying out of pocket for those. He finally went to his primary care. He had to go to Porter to get a CAT scan. He had stage two lung cancer. At the time, we went to Burlington. I went with him. His spot in his lung was eight centimeters big. Surgery wasn't an option. He is a smoker and has always smoked. I know this is about primary care, but I'm going to go back to the tooth infection. We've all had them. A primary care can take care of a tooth infection. I can't imagine what that cost. I've had my own health care stuff going on. I've had several CAT scans when I've had regular health insurance so I know what they cost. On a practical level, what it's costing the state for what my brother has gone through medically is, to me, it just doesn't make any sense. Those are astronomical costs. A heart attack, pleurisy of the lungs, and now he gets treatment every three months and creates three months and goes for a CAT scan. He's on disability now. That went through because it's on his records that if he didn't have it, he'd be dead. The tumor has shrunk down to two centimeters. He's doing okay, at least what he tells me. That's his story. Thanks for listening, everybody. Thank you, Mary. Thanks for sharing that. All right. I'm just going to share my little story, which isn't nearly as intense, but just maybe slightly interesting. Interestingly, it's also about pleurisy. I woke up one morning with a chest pain, went off to Porter for 20 minutes. I was there for 20 minutes. They took some blood tests and the way they figured out it was pleurisy is that blood tests didn't show things coming from chemicals that would be in the blood for a heart attack. Then I guess if you catch pleurisy early enough, it's an inflammation. Treatment was a bunch of ibuprofen. Then I got, a month later, I got the bill, $1,700 for these few blood tests. I have a $10,000 deductible, so $1,700 was out of pocket, out of pocket, which is what we're talking about in the underinsured in Vermont, which is not abnormal. I pay for this $10,000 deductible plan. I pay over $5,000 a year, that's for my family. My company pays over $10,000 a year. If I use most or all of that deductible, my insurance company sigma gets $15,000 between me and my company and the hospitals get $10,000 out of my pocket. It isn't until after, of course, I get past the $10,000 that the health insurance company starts paying for any of that. That's just my little story. Let's move on to Ellen. Great. Well, neither of those is just so little of a story, and obviously in both cases, these high out-of-pocket costs are a great deterrence to people seeking the healthcare they need. I'm just going to share. I'm a little bit less with a personal story, but I have a couple of statistics that I wanted to share with you, and you all can get all the material from this. This is a 2021 survey, so the latest material on Vermont, and Apropos marks the story, and Mary, your story about your brother, because he hesitated to go in for treatment because of the out-of-pocket costs. So how common is that for Vermonters? Well, according to this survey, official Vermont survey from 2021, 44% of privately insured Vermonters are under 865 or under insured. That's a huge number of people, and by the way, the surveyors used a measure of under insurance that comes from the Commonwealth Fund, so it's all vetted, and it's not like they just pull it out of their pocket. That's a huge number of people. How many people is that? Well, it's 187,800 Vermonters, or only what, 650,000 of us in the state, and so over 187,000 of us are under insured. This means that the cost of their healthcare, whether it's from deductibles, whether it's like Marcad or out-of-pocket expenses, or a combination of both deductibles and out-of-pockets, is more than they can bear, and thus this leads to people often postponing, delaying, or entirely avoiding needed care. And I just like you to see, I won't take too long, but if you look at this graph on the left, you can see that the rates, or actually I'm going to show you the next one, the rates have gone up over time, so you can see in 2012, 28% of us, this is on the right, if you can see that, in 2012, 28% of all Vermonters under age 65 with private insurance were under insured, that's now 44%, so folks is getting a lot worse. In the last 10 years, the number of Vermonters who are under insured, who thus are avoiding or delaying care is going up, and now it's up to 187,800 Vermonters. If you add the 34,000 Vermonters on Medicare who do not have a supplemental plan, then that means that to the ranks of the under insured, that's 200,000 Vermonters under insured, so we just need to think about that. Another 3.5% of Vermonters are uninsured, they have no insurance, they might be sort of in the category, Mary, that your brother was in, but that's only a little bit, there's a lot more people who are under insured, which means they're not also not getting the care they need. I think I just have one more slide and then I want to hand it over to Mike and Deb who are, you know, have much more credentials here to talk about this, but this is the ranks of people over age 65 who do not have a Medicare supplemental, that's 31% of those over age 65, so it's a lot and lot of people, 200,000 people. And finally, I think this is my last slide, this also comes from, and I'll put up in chat the link to the full survey, they're like 180 slides, but fear of debt leads 40% of under insured and even 30% of not under insured Vermonters to not seek medical care, so basically because of the kind of experience that happened, let's say to you, Mark, often many people just simply don't seek medical care, they're afraid of getting a bill for $1,700 or $2,000. So they don't seek the medical care that they need. Oh, whoops, that's that's going to be for Deb. So I'll bring up that again. So that's basically what I wanted to review very briefly, and I will put up in chat in a moment just the link to that entire survey, which is rather sobering to read, but it should make all of us think twice. So I'm going to put this up in chat. Mark, can I say something real quick? It was me, Mary. The problem is, I was one of those people that had to get medical coverage, ended up with $20,000 in homeless. So just that I throw that in there. It's an important point. Thanks. Yeah, thanks, Mary. Okay, Ellen, thank you, and let's move on to Deb. Very good. Thank you for inviting me. I'm happy to be here. I'm actually a family physician and also an addiction medicine specialist. And I must say Ellen presented the data on the number of underinsured Vermonters. And but in my primary care practice, I see basically the reality of those numbers. And I think a lot like, you know, Mary's story of her brother and herself actually, people rationing their own care due to cost. Some of these underinsured patients again have $12,000 deductibles. And if you have a chronic illness, you meet that you have to meet that deductible every single year, before you get a dollars worth of coverage. And on top of that, patients are often paying for the, you know, the premium themselves. And so what they do is they suffer delayed diagnosis, like Mary's brother. They don't come in for blood pressure checks on a regular basis the way they're supposed to. They don't come in for diabetes checks. They wait with festering abscesses, they're raging fevers, chest pain, I've had patients wait even with chest pain at home, shortness of breath that clearly were actually medical emergencies, and they've waited. Some have and again, their health care worsens and some die and they're clearly much more expensive as Mary's brother. That situation where if we had treated them earlier. And again, most of these people are insured, but they are underinsured. So basically underinsured or not uninsured for the first 10 or $12,000 of their care. You know, I would also bring up the whole point that our motto in Vermont is freedom and unity. I also think that, you know, people I see people who stay at jobs, they hate because of health insurance. I've seen people get married, because their potential spouse had good health insurance, I've seen people get divorced. That does not define freedom in my mind. An example, I had a patient who's a diabetic patient, she lacerated her leg, she dropped a water pail on it. And she had, she was not a well person, and she was worried about missing more work. So she went to work that day with this deep laceration. And she waited three days until she finally came in, it was a raging infection, it took about six months for this thing to clear up. Again, she was worried, she went to work because she was worried if she took off more from work, she'd lose her job. If she lost her job, she'd lose her coverage. Many people are trapped in this scenario. And I think to me, the tragedy of all of this, and many, all these patient stories is that we're already spending more than enough money to cover every single Vermont. That is not in doubt. Every single study has shown that, that the amount of money that we spend on healthcare every single year is more than enough to cover all Vermonters medically necessary care, including dental. We could include dental, so Mary's brother could have gotten his tooth taken care of. The problem is we are spending enormous amounts on administrative costs. Turn off the music on my earbuds, please. Oh, hey, Siri. So turn off the music on my earbuds, please. I think we need to do that. Oh, okay. Can you all hear me? And can you mute, Alex? Okay. So we're spending all this unnecessary, a lot of unnecessary money on administrative costs. Ellen, if you could put up this. Can you unmute yourself, Deb? Yeah, Deb, you're now a mute. Since 1970 to the year 2021, we've seen more than a 4,000 percent increase in the number of administrative healthcare. At the same time, keep in mind, that's the blue line that, you know, the big blue portion here. I don't know, Ellen, maybe you can see where the managers are. That's the increase in the number of managers, a 4,000 percent increase since 1970. In the same amount of time, we've only seen 150 percent increase in the number of doctors. So clearly, we are spending money where we don't need it. So that's good, Ellen. You can take that down. And one of the reasons that we are spending so much money on administration, which by the way in total equals 34 percent of the healthcare dollar, that's roughly twice what other countries spend on administrative costs. You can't, you know, you have to have administrative costs in the system, but we're clearly spending way more money. And we always seem to be able to find the money to pay for these administrative costs. And yet we can't find a way to pay for many of Vermonters needed medical care. There's something very, very wrong. It's an immoral non-healthcare system. We don't have a healthcare system, and it's immoral. But there is another way. We know that making healthcare universal and simplified. Linda, can you mute everyone who's not talking or also make me kind of sorry. Okay. So we know that there's more than enough money in healthcare that's been shown in every other study. What we need to do is when you make it universal, include everyone and dedicate financing to the necessary services. You greatly simplify administration. And this we know we've had many studies done in Vermont even that we could save hundreds of millions of dollars per year that was going for administration that could now go for medical care. This is so it is not an economic question. We this myth that somehow we can't afford it, we can't afford it. It's a myth. It's not true. And the majority of Vermonters want this. The majority of Americans want it. The majority of doctors want it. There are many polls to show this. It's clearly a political problem. It's not an economic one. So we need to change the politics here. And I think now I'm very, very excited the fact that we now have a veto proof majority in the House and the Senate in Vermont. What's clear though is that doing the whole system at once we've tried to do that was too much. It's a big undertaking. That's I'm not going to minimize that. But if we start smaller, which is what we're talking about tonight, we start with primary care. Basically, primary care is most of the care for most of the people, most of the time, everyone needs primary care. The beauty of this and starting with primary care is that it's very inexpensive. It is it constitutes less than 6% of the total. And that includes mental health and substance use disorder services. So primary care, mental health, and substance use disorder services for less than 6% of the total. If we do this, what do we know? We know all the studies show that it would lower overall costs. When people are connected to a primary care clinician, outcomes are better. People live longer and quality is better. Again, that is not disputed. Everything we have and mountains of evidence to show that you look internationally and even nationally. That if you if people have access to primary care, they live longer outcomes are better overall costs are lower. It's also more humane. So what what could we do in Vermont? A universal health care program. Everyone would get it. We'd publicly fund it with no out of pocket costs. Make it universal again, would reduce the administrative costs and you could remove that from the private health insurance premium. So this is also I might add because a lot of people say, Well, what are you going to do? We don't we don't have enough primary care clinicians. This is this would be a magnet for primary care clinicians from around the country. Because right now, part of the reason that we don't have enough primary care clinicians, physicians and nurse practitioners, etc is the burnout. And the burnout is a lot to do with the conditions of practice. This would be a magnet. And certainly it would be favorable to all Vermonters. Thank you. Deb, thank you. That was great. As always. And sorry about the interrupts there. And let's now move on to Mike Fisher, who's the Vermont patient advocate and also former VT house rep. So good evening, everyone. Mike Fisher, health care advocate, HCA FYI. And so I'm happy to be here and speak a little bit about what we see. The health care advocates office runs a health line. And I can't help but resist 9177787. If you know anybody who's having any kind of problem getting the care they need. I've got a team of advocates who are on the phone every day doing our very best to help people get the care they need. But let me tell you, it's hard. We are a front line. They're very much in line with the stories you just heard. We are a front line hearing the challenges that Vermonters face in getting the care they need. And I'll just focus for a moment. This is not a new thing. But since it was brought up earlier, dental, the glaring, buzzing, flashing red light is access to dental care without a doubt. It is not uncommon that we hear from Vermonters the pain who can't get the care they need. So at some point, we decided that it was important for us to develop a storytelling project around medical debt for years and our advocacy in front of the Green Mountain Care Board for the hospital budget process. We've been hearing numbers like $85 million in medical debt. That is bills to Vermonters that are unpaid. And we've been trying to characterize that, trying to understand, I think I know what it means. One of Vermonters can't pay their bills, but we have to hear in their Vermonters' own voices. And this is sort of the human side of the numbers that balance that. So we went out and did a storytelling project. And you can see the results of that at vtmedicaldebt.org. We created a webpage that is both an opportunity for people to age through and read what people's words and also enter their own stories. But wouldn't mind, we're sort of relaunching this project. Wouldn't mind help getting the word out about that. And you can find a nice Facebook post to forward our Facebook page is HCA Vermont. So you can find us on Facebook and you can see our post about this. It's just, it's not within the last couple of weeks and forward it. We launched that project and used that project to advance a bill to improve Vermont's free care, hospital free care policies. Successful. Thank you legislators who are here today. It's going to take another year before it's fully implemented, but it's going to, but I really do believe it represents millions and millions of dollars of relief for Vermonters. Hey, anything we can do to improve access, Vermonters access to all types of care and in particular primary care is a good thing. And we support it. And many of you know the role I played in a previous role of my life in working towards passing and then implementing Act 48. And so much of the conversation and the justification for the stories that we heard today remind me of those times and the speakers who spoke earlier are right. We would be better off with a system that financed healthcare differently. I find myself today and I'll just say again, I'm in favor of and anyway we can improve access to primary care. I'll mention that one of the trains that's leaving the station like it or not is a movement towards global hospital budgets. And that may have some opportunities for us. I want to be clear, it may be a new administrative regulatory tool and amount to not much in terms of an improvement for access to care, but it may also be an opportunity for us to move some types of care out of the bat bleep crazy hospital healthcare financing system we have and into a different way of financing care. And so I'll say here the argument that I've been making in work groups, we can't make the same mistake that we made with the last all-payer model. And that mistake being, you know, hospital executives and regulators and public policy folks said, hey, Vermont consumers, don't worry your pretty little heads about this. We've got this on the back end. Payers and providers are going to develop a new relationship about how to finance healthcare and your life will get better. They were pretty dismissive, I believe, and my criticism of them is they were pretty dismissive of Vermont's views and pretty dismissive of real true engagement and looking for ways to have real deliverables that Vermonters would feel as an improvement to our healthcare system. So if we are going to move to a system where hospitals are going to get, say, 80% of their financing delivered every two weeks as a fixed perspective payment that's not shrewd up, in other words, we're going to be giving, if we are going to move to a system where we're going to be giving hospitals money in a very different way than through claims, we have to do the work to develop deliverables for Vermonters that they experience as real improvements to care. And without a doubt, access to primary care is one of those that should be explored. And so it's another angle. It is, I want to be clear, not anywhere as pure and good as the arguments that Dr. Richter just made, but it is a train that's moving. And so I find myself on work groups and trying to bring a consumer's voice to those considerations and have it not just be the folks who move money behind the scenes. So I think I'll stop speaking, but am always happy to answer questions later and happy to be a part of this conversation. Thank you, Mike. That was great. Always, and thank you for all your efforts. And let's move on to Senator Chris Bray now. Good evening. Hello to everyone. Lots of familiar faces here. My name is Chris Bray. I'm one of your two state senators along with Senator Hardy. I live in Bristol and I first came to the legislature in 2007 when I joined the House and then six years later went to the Senate. I'm also sorry, Mary, to hear your story about your brother and everyone else or Mark's story. I'm guessing many people here in this session probably had some similar discouraging experience where money is getting in the way of providing healthcare. The other thing I want to do is pause very briefly before talking about plans for legislative plans of action is to acknowledge who's with us here, with, you know, in particular, Deb Richter, Eleanor Ostfeld, Linda, and Mike have all spent, if not their entire adult careers in healthcare, much of them. And it's, we have a rich base of knowledge and experience to draw on here. So I appreciate that we're here. We are in the small county in a small state in the corner of the US and we have great experts in the room to help us out. So we also have Senator Hardy has served last term on that or currently still a member of Health and Welfare. So she has real world up to date inside information on what's happening in the State House. So it's a really great group of people and I'm thankful people joined the call. You know, for me, my interest is visceral. I'm the son and grandson of physicians, the nephew and great nephew of physicians. I grew up in a medical family, became an EMT, almost went to medical school myself. You know, this work, this kind of care is, you know, in my bones. And the other thing is, it's these stories are not something here I sit nice and tidy in a blue blazer and a tie with a fancy title of being a senator, but these are not like something outside my life experience. You know, I've been as an adult, entirely uninsured. As a matter of fact, when I was a freshman senator, I had kidney stones, went to the hospital, had them addressed, left 10 hours later, along with an $18,000 bill that was uncovered in any way. It was my bill. Since then I've had coverage through Medicaid. And I've also now have it through Medicare. So this is, you know, lived experience for me. I know the strain and stress of, oh, will I go see someone because I don't know if I can afford this right now? Or what kind of bill will I get? Can anyone ever tell me ahead of time what my bill might be so I can decide whether or not I can go afford to go see someone? And it's, it's, I'm just saying I'm deeply committed to seeing us improve this most fundamental service that we want to provide, I think, as part of living in a compassionate community and state. So for these reasons, I've been working with folks here on this call and others in the last several months to prepare a universal primary care bill for introduction to the session. I've also worked with the past chair of Senate Health and Welfare, Senator Claire Eyre, I think probably most everyone here knows well. She was a nurse herself as well as a long time legislator. I've talked with other members of our Addison County delegation and there's broad support for universal primary care going into session, which is helpful, because politics is a team support. And I've talked with Senate leadership and, and our next coming are very all but certain next Senate President Pro Tem, Phil Baruth, as well as our current chair of Senate Health and Welfare, Senator Jeanine Lyons. So I'm not saying this is a done deal in any way, but there is people are coming together talking about it interested and working on it. And that is a great place to start a new session. You know, but I'm only speaking as one of 30 senators, and I'm only one of 180 legislators. So, you know, I'm hopeful that everyone on this call will stay involved and help bring all the necessary parties inside and outside the State House forward together to do the work. I can't say that we will, you know, I've been assured we'll sort of get the court equivalent the legal system equivalent of our court and day, an opportunity to make a case to present data to have the conversations and look for a solution. I don't ever pretend that a bill is introduced is the answer. It's just a proposal to convene a working conversation at the legislative level that will help us learn more together and make decisions together about what we can do. And for those who really have been working on this issue for years and know details, my starting point is a prior House Bill H-276, which had 44 sponsors when it was introduced. So, again, a lot of interest and energy behind that version, not wedded to that version, but that's the launching point. The last thing is I want to be realistic. There are, of course, there'll be some opponents to this. And from my point of view, you know, everyone here has probably heard this more than once, you know, well, we can't afford this. As Deb was saying, as a matter of fact, we can afford it. And then the second thing is, well, we don't know how to operate such a system, even if we wanted to operate system. So I'll start with the second claim. When we don't know how to operate such a system, it's not an exact equivalent. But I'd like to point out that we have, in essence, sort of a UPC program for children and pregnant women in the form of Dr. Dinosaur, which has successfully operated since the 1980s. It's so much a part of our healthcare landscape that people forget what an accomplishment it was and is. So I, you know, I feel like we should have some confidence that we know how to do something and get that done. And then the claim that we can't afford it, the Richter's already addressed that. But just my way of capturing it is it's about a $7 billion system. And that's about the size of the entire state budget. So there is ample money in that system. The question is, how do we deploy it? And with very expensive things like unnecessary amounts of administrative overhead, you start freeing up millions and tens of millions of dollars to be deployed in the form of healthcare, as opposed to paperwork. And then since we're just coming out of an election season, you know, I was reading, I'm not sure how it came up, but I came across the words of Bobby Kennedy just yesterday. And he talked about one of his things was, was some men see things as they are and say, why? I dream of things that never were and say, why not? And I really believe that Vermont can see itself a little bit like Bobby Kennedy and say, why not? We have led on so many things. We just passed a reproductive rights constitutional amendment, this election cycle, and it's, you know, nation leading. So I feel like we're humble, we're sober minded, but we also think big and I think this is an area where we should really reasonably expect more of the system we have, because it's not for many people, a healthcare system. It's a financing system to help pay for medical expenses when they come up all too often. And so that's, I just, I'll end it there and say I look forward to working with everyone on this session and others and with all of you as partners. And let's see how far we get this session. Thank you, Chris. Great to hear from you. And let's move on to Senator Ruth Hardy. Thanks, Mark. Hi, everybody. I'm Ruth Hardy. I am the current vice chair of the Senate Health and Welfare Committee, although next session we'll all receive new committee assignments. So I have no idea if I will stay on the Health and Welfare Committee or not. I, sorry, my phone just started ringing. I am from East Middlebury and I have served in the Senate since 2018. I'm also the former executive director of the Open Door Clinic. That was my first job here in Vermont 20 years ago and served there for three and a half years. So I have heard many stories very similar to the ones that Mary and Mark shared. And as Mike said, I think the thing that we heard the very most at the time was dental access to dental care. So one of the things that Linda asked me to do was to sort of give an overview of some of the things that the Health and Welfare Committee or the legislature as a whole has done over the last few years to improve access to primary care. And so I came up with a top 10 list. And Mike, if I've forgotten something, please chime in because Mike follows our work closely. I have him literally on speed dial on my phone because we work together very closely. But the very first bill that I introduced and was the primary sponsor of was a bill to improve access and affordability for dental care. This passed as part of the 2019 budget. And it was the largest expansion of access to dental care in 30 years in Vermont when this passed. It greatly expanded access to dental care. And I have a feeling, Mary, that this had been done when your brother had his dental situation. He would have been covered and would have been able to see a dentist and have it paid for through the dent. We call lots of things V chip, V whatever this is V dent. And it provides for cleanings and preventative dental care and primary dental care for tooth infections, etc. So that was the first thing I will just run through the rest of the list of these top 10. The second is in 2019, the Freedom of Choice Act. This codified reproductive health care as is provided in Vermont in our statutes. And then also the reproductive liberty amendment was started in 2019, which just passed three days ago. So that was a four, almost five year process. Access to reproductive health care is primary care, reproductive health care, abortion services, prenatal care, maternity services, all of that. Whether you choose to become pregnant or stay pregnant or not to become pregnant, that is primary care. And we have done a huge amount in Vermont to ensure access to reproductive health care. In 2020, COVID hit and we immediately sprung into action. And we passed the most comprehensive COVID emergency health care bill in the country that was used by other states as a model for how the legislature should react to the COVID emergency. And it provided a system of supports and flexibility for our health care system to enable our hospitals to continue to work, to enable our health care health care providers to continue to work during a global pandemic and to provide access to comprehensive testing and immunization after those were available. So I just want to remind everybody about the pandemic. This has been huge barrier to doing a lot of things in the health care world because we've literally been trying to just keep our system alive during a pandemic. And Vermont has done that better than pretty much any other state. In 2021, we also created what we called a doctor dinosaur like program that provided those prenatal and child care, child health services to women and children who are undocumented. So this was a lot of migrant farm workers and others in the state who are here without sort of legal documentation. And this provides the same care that doctor dinosaur does for people who are citizens, for people who are undocumented. And this was, we were the first state to do this. California was sort of trying to do it simultaneously. And this is a huge expansion of primary care for a very vulnerable population. In 2022, we expanded hearing aid coverage. So this is now in our required health plans so that anybody who needs hearing aids can have access to support for hearing aids through their health plans. We also passed the telehealth licensure program in 2022. Telehealth expanded a huge amount during the pandemic and was one of the primary ways that people accessed health care during the pandemic. And we needed to create a system to sort of move telehealth forward in our health care system and have a, we have a sort of different levels of life licensure for providers who are providing telehealth. In 2022, we also expanded the postpartum Medicaid coverage from six weeks, I think it was six weeks to a full year after postpartum for people who are on the Medicaid program. We did a huge amount over the past two years to provide workforce development initiatives for primary care and other medical providers, including mental health, substance use disorder. Nurses was a huge focus, but also medical technicians and physicians, of course, but others who work in the greater health care system to provide tuition assistance, loan repayment, and training programs. Because one of the biggest barriers right now to access to health care is workforce shortage. There are huge weights for many, many health care services in large part because we don't have health care providers to provide those services. So we've been working really hard to try to increase the workforce in health care. Last session, we also expanded access to or support for primary mental health care, long term care and home health and community based services for for monitors who remain in their home or need home health services in their home and for our designated agencies, which are mental health agencies here in Addison County. It's the counseling service of Addison County. We provided an 8% rate increase for those agencies, which is a bigger rate increase than they've gotten for a very long time. We also did work on improving the system of care for individuals with disabilities and individuals with Alzheimer's. So those were two separate bills that we worked on to address those two sort of long term issues for a growing segment of our population. So those were my top 10 bills that we've done in the last four years that would do and have expanded access and affordability and quality for primary care. We've also done quite a bit of work in health equity, working on social determinants of health on early childhood education and childcare, student mental health, medical debt. As Mike mentioned, we did a bill on medical debt last session. Also, child and maternal health and pharmacy regulations, which is improving access to pharmaceuticals and reducing the price while also protecting our small pharmacies. That was another bill that we worked on last session, and I could go on, but those are the top ones. Linda also asked me about some bills that I'm personally working on or issues that I'm personally working on. I am on the Opioid Settlement Advisory Committee, which is a committee that is supposed to advise the legislature on how to use the opioid settlement funding that's coming to Vermont as part of the big cases that have just been settled for pharmaceutical companies and also pharmacies, chain pharmacies, and their horrible role in the opioid crisis. I am doing work on best practices and what systems of care we have that are working well and what we have that's not working well and what we need to better address the opioid crisis, which is one of the largest crises hitting our healthcare system at the moment. Also, mental health. We did a lot for mental health last session. We did a bill in addition to raising the rates. We did a bill on school mental health and access to mental health in our education system and also after school, and so I think there'll be more work to do in that area and I'm working on that as well. Reproductive healthcare access protections as well as trans care protections. We already are working on, I met multiple times with legislators who are a group of us who are working on a sort of sanctuary bills to make sure that we protect these services and for people who are coming into our state and for providers in our state who are providing these services to patients who are from Vermont and potentially from elsewhere. One of the biggest issues that as I've been talking to people knocking on doors that I've heard and I've talked to several of you about it are the quote-unquote Medicaid Advantage plans and the advertising and the sort of in-your-face misinformation about these plans. We did do a little bit of work on it last session and didn't really come to sort of a full agreement on what we were able to do as a state legislature because Medicare is a federal program so I know Mike is involved a little bit in that as well so I think there'll be more work next session because we have just seen a huge increase in this and people are scared and worried and I heard about this a lot from seniors at when I knocked on doors. Then long-term care sort of broadly speaking I think much of our medical debt in the state is because of long-term care and our lack of access to long-term care that's affordable for Vermonters. More health equity work and related issues the Senate Health and Welfare Committee has a broad jurisdiction we work on health things but we also work on things that are quote-unquote sort of welfare programs so we did a big bill last year on ReachUp which greatly improved that program which is for very poor mother single mothers with children. So this year we are going to be spending a significant amount of time and a significant amount of money on child care. That is one of the major issues that we are hearing from Vermonters across the board whether they're employers or parents or school teachers we we just need to improve our our child care system. Housing which is is definitely related to health care if you if you don't have stable and safe housing you are not going to be a healthy person and Mary I know can speak to this directly as well and paid family and medical leave if you're not able to take time off of work and be paid to be able to do it you aren't going to be able to take care of your family whether it's a new baby or a sick relative or an aging parent or yourself we need to make sure that people have access to paid family and medical leave. So those are issues that I've been working on and in terms of the universal primary care I have not seen Senator Bray's bill I am not one of the people he's been working on that bill with so I don't know what is in that bill. I I'm familiar with the other bills that have been introduced. I think we should do everything we can to increase access to primary care and affordability of primary care and you know if we can make a universal primary care system work. I think that that is a great thing and I'm certainly willing to try it it's going to be difficult with all the other competing priorities this session in terms of funding and time but we certainly can give it our best try and I'm happy to answer questions. Thank you. Thank you Ruth great to hear from you. Okay I'm just gonna I'll share my screen here. This in this this August we got a in the Vermont Democratic Party platform there is a healthcare plank that we got put in there and I'm just gonna read to you what got passed it's in as you can see here it's in the fourth part of seven parts in the platform and it's healthcare for all the the VDP supports a single payer Medicare for all healthcare system until federally sponsored Medicare for all legislation is enacted Vermont must take all available steps towards achieving universal access to and coverage for high quality medically necessary health services for all Vermonters this includes addressing critical challenges in the healthcare workforce and provision of rural care to that end the Vermont Democratic State Committee supports a universally public finance system in Vermont with primary care as the first step so we were very excited to get that in the platform so that concludes the scheduled agenda and now what we're on to is questions and answers discussions and whatnot so anyone has something they would like to share just raise raise your your zoom hand and I just think I also just once again want to thank everyone who shared tonight it's all been very interesting stuff and it's amazing the group of people we have assembled here so all right Chris you're off good thanks mark I just wanted to thank you for the reminder to on the that the first step towards universal health care in form of universal primary care was adopted and ratified by the Democratic Party for the entire state so I think as we think about this we've just seen a very strong turnout and good results for Democratic Party not that this is entirely a party alone issue and I think the party is speaking on behalf of many Vermonters but I think my takeaway is that we should have a lot of confidence that this piece of the platform for the entire party also is something that in the vote we just saw was widely embraced by you know 180,000 plus Vermonters so we're we have a lot of company and thanks for making that part to you and Linda to making that part of the state platform there are a number of questions in the chat do you just somebody want to start by answering any of those any of us I could actually want the people who said put those in the chat just raise their hand and just and reiterate them orally if that's okay. Betty Keller was one of the first people to oh okay and she happens to be the next person up so Betty to you thank you for this opportunity to talk about this really important public service that we need so in the chat I put a question about why aren't we enforcing Act 48 but actually a question that that might be like something we don't have time to talk about tonight but a few years ago Deb you had put forward a bill for global hospital budgets and having hospital care publicly funded and I mean the vast majority of what we spend in health care is in the hospital and so I'm I'm wondering why we don't and and as Mike said they're really looking at global hospital budgets why aren't we pursuing looking at that first because it seems like if that's where Medicare wants to be giving waivers anyway let's like do it the right way and and not like be focusing on universal primary care while somebody else is running away with the train in the wrong direction well I can answer that I mean first of all we you're right we did try that was H207 I believe which the advantage of that bill was that it would have reduced your premiums by 45 percent because your premiums actually 45 percent of your premium goes towards hospital care um at the time the legislature did not have the appetite for that nor did they have the appetite for the the whole system which again it is a big it's a big lift you know at that time I think it was something like I think it was a billion dollars that they would have had to come up with the reason that universal primary care is more appealing is first of all it's everyone needs it it's not just some people only about 10 of the population needs hospital care at any one time so it's something that everyone needs 100 of us need that and and most of it is prevented and it is the only sector that has been shown to improve population health which is one of the goals that Vermont has right now for their the ACO the the is that's one of the goals is to improve population health and the fact is it's very inexpensive so you get a huge return on investment unlike again I'm not against um obviously not against uh trying um universal hospital care but again I think that we've already been shown that that the legislature does not have the appetite for taking on something that big but something that would be for every single constituent every single vermonter that is much less I'm not advising this but we could do this for one and a half percent payroll tax the whole thing the whole universal primary care I do not advocate that but that just shows you that we could do that for every single vermonter to have that you can't say the same for that when it comes down to universal hospital care but certainly um I'm not against it if if some legislator said yeah we can get this through a universal hospital care with um global budgets that would actually be global revenue budgets because what is being suggested is not global budgets they are I don't know some version of that but I have no I have no problem with that but again this just has to do with because it is a political issue not an economic one it's a political issue we have to start with what is politically feasible that's the reason yeah I'm hoping it what is politically feasible might be um different from what it was when you were doing the hospital building we passed act 48 in the meantime so I would think that um you know times have changed things have gotten more desperate thank you yeah sure thank you and we're on to Cheryl and you're on mute yeah first thank you all for doing this it's it's amazing and wonderful data so I'm probably dense here but if there's legislation that almost passed a couple of years ago that senator brave referred to and if this is shown to improve um population health and we can afford it and we have a super majority in both houses what it sounds like it should be simple I'm I guess I'm looking at Deb smiling face Dr. Deb to say what you know what's the next step here can I just jump in here I I think that you know I've heard a couple people say it's not an economic issue and and it it is it's not free and it it is and there is an argument about how our system is already costing X amount of money and this is just shifting that amount of money to something else but it's taking it from something it's shifting it to having the state to pay for it and so that is uh where that it it is an economic issue because it has to be paid for out of state funding public funding and so then we have to come up with a system for raising the revenue to pay for the services and at the same time that we're coming up with the revenue to pay for childcare to pay for uh family medical leave um and and other priorities that we may or may not have so I think that it is an economic issue is is how to pay for it and I don't know what the um the fiscal note is on this bill I think last time Mike was it do you remember what the fiscal note was on I was just playing with the numbers you know if it's six percent of seven billion dollars that's four hundred and twenty million dollars yeah it's two hundred million actually because you're you're still getting existing Medicare and Medicaid funds so it is actually two hundred million in new taxes but keep in mind that that currently much of that is coming out of pocket I would like to add also that let's keep in mind that how we currently fund healthcare is very regressive so that your average for Monter who who is maybe you know a CEO of a company or of a hospital is paying the same premium as the person who's scrubbing the floors of that hospital and that is a very regressive way to pay for healthcare I think um that is something keep in mind the other thing is we already publicly fund a huge percentage of our healthcare dollar we pay the highest healthcare taxes in the industrialized world when you add Medicare Medicaid what we spend for public finance or public financing of of public employees and then the tax shift that goes on when employers get a pay for health insurance through pre-tax dollars so we're already paying huge amounts in taxes it definitely will take a great amount of political force I have no doubt about it but in terms of the economic piece of it we are already paying the whole bill and it is very unfairly financed the way it is and it was my understanding at least when secretary Hogan was working on these issues that transferring the way money is going into administrative and managerial costs down to people that are actually providing services to patients that kind of shift if it were possible to do would not require any new funds it doesn't require any new funds in total let's face it what you're really asking is for the healthy and the wealthy to pay for the sick and the poor um that is the you know the reality of it you're taking the money from different pockets I think I agree with senator Hardy that you know it's definitely not just oh we're going to take this administrative savings and then put it over here we're going to pay for medical care it's at a system level and you're taking the money from different pockets you're basically saying as Tommy Douglas said when he and for he he pushed for the Canadian system we're going to get the money from the people who have it and that's really what we have to look at in our healthcare system we have to start paying for this in a fair way so it isn't a direct you know transfer of the funds that is absolutely correct um but it's definitely in total there's more than enough money in in health care right now I think it's just really important and thank you for saying that Deb it's it's much more complicated than just saying oh well we're ready to spend this money and we're just going to move that money over here and spend it in this way it's it's a complicated shift in both how you pay for it and how you tax it so it's this is this is not just a health care problem it's a taxation problem it's a it's a finance problem so it really is much more complicated and and I I I love this kind of problem I'd love to be able to sit down with all the best people and figure it all out but it is not as easy as just saying well we it's already in the system so we just like take this money and move it here from here to here um and it's a multi-year process and a you know one that involves an enormous amount of heavy lifting from the executive branch and even if we have a a super majority if we don't have an executive branch that's willing to do the work it won't get done and it won't get done well so that's another barrier just as an example we had massive housing policy that we passed last session and the way that they're choosing to implement it or not implement it is incorrect we're basically having a hearing next week during the off session about some ways that the executive branch is implementing housing policy that is against legislative intent so we have to also have willing partners in the private sector and in the executive branch to make a shift this big even if it's just part of the system so not to say we shouldn't try and shouldn't try to do it and that it's not possible but the sort of lots of moving pieces to some change this complex great uh thank you um and we're on to Walter with a question hey mark thanks much uh my name is Walter Carpenter I live in Montpelier I live down the street from dead way right downtown I've been a health care activist for many many years involved with act 48 um UPC all the way up through and I'll just I've been I'm on the advisory committee of the Green Mountain Care Board I helped create the board I go to a lot of the board's meetings I've been in the safe house for many years as Mike knows and my quest my first statement is is that I'm someone with one of those stories and I once had to decide the price of my own life and you got to think about that for a minute and I've heard the arguments of Deb and I've heard what Ruth Senator Hardy has said we have 7.25 7.65 billion in their health care system CEOs make enormous amounts of money John Brum said is at 2.5 million the new CEO starting at 1.3 million they start current CEOs like 700k 400k 500k and that's all of our money all you know we're paying for you we're paying uvm through taxes be premiums new cross taxes be premiums and I think this is both an economic and political issue but it shouldn't be difficult I didn't have primary care at the time I lost my insurance because I lost my job because the company decided to kick me out and then I got sick again and the hospital came with a figure and we had to negotiate prices just as if you're buying a used car or in a bazaar and I I live in the Middle East for a while and I spent time negotiating the prices for good so this is also a moral issue and that's what I want to stress about this this is a moral with not just economic it's not just political I understand the economic problems of moving one part to another when we first did UTC I heard that all the codes will be all screwed up I'm wondering with a legislative majority like we have that can pretty much tell the government make the governor lane duck if we can actually do this this year and knowing that the opposition is going to be fear the hospitals exert a fantastic amount of pressure on representatives and senators and the executive branch what can we do to mitigate that they have a lot of high-price lobbyists the hospital association Devin Green Mike Del Treco are very good at maneuvering bills around what is it given that it's both a moral moral political and economic issue how can we proceed with it well Walter can I just start with a question did you manage to sit through the one care hearing yesterday at the board I missed that one Mike I would I would recommend that you spend a little time listening to the tape to hear the new chairs grilling of one care executives about executive pay I think I think you'll enjoy it yeah I've raised the issue before forward meetings and in fact I did a couple meetings to go with Owen but take a listen all right yeah anybody it should be up in the next couple days on workup right now there is a new chair of the green man care board and he is a federal former federal prosecutor and has a different approach in the few hearings that he's been a part of so and you just say that very quick summary of that like that he he just gave a good grilling to that board is what you're saying he has he has very challenging questions on many many different levels about it should be noted that just the administrative alone for one care with 18 million dollars that's just to the administrative salaries I guess I want to I want to caution us to not think this is simple and and don't get me wrong in in any way I'm not questioning the the morality or the correctness or the or you know whether it should be done whether we should pay for healthcare to publicly financed taxes but I having lived through it with many of you me included I I think that we convinced ourselves many convinced themselves that it was simple and we already pay for it and we're just going to pay for it in a different way and including then Governor Shumlin now Governor Shumlin bless his heart was is a both feet in kind of guy without thinking about the details and and so you know when we get to the financing plan part you know he and the administration bought and and so you know I think you know lesson learned we want to do something like this Deb if it's 400 million if it's 200 million whatever the right number is we got to be willing to get through the financing part first the values part that's simple the challenge is the financing part and I don't want to emphasize something that Ruth Senator Hardy said a minute ago I I spent a lot of time watching legislative committees and at some point in the recent years recent last couple of years I was asking myself hey I sat in the chair of the health care committee I sat in the vice chair of the health care committee when we passed act 48 how did we do it and it it came with an administration you know we were working with an administration that was working with us heavy heavy lifting and you know and so I have in recent years watched them the activities no offense to anybody here if you don't have the administration working with you the legislative branch is just not equipped to do a lot of the heavy lifting it's not and so you know that's frustrating as an advocate who's saying we should be able you know something way simpler than than what we're talking about here why can't the legislature you know wrap their heads around it and do it it's it's it's very hard to do and and it's not just about a veto override here it's it's about an administration that's going to dig in and do the heavy lifting with you and then implement with you know what you what you call for and so I I just I'm saying that with all honesty we have a serious challenge with the current governor in terms of being able to do to do I would like to add also that we just never think twice about increasing the amount of money that we allow hospitals to take in there have been times where we have given them 200 million dollars in extra spending because they just couldn't meet their budgets and we don't seem to have any problem the green mountain care board says okay no problem and so again nobody is saying this is going to be easy but this is such a dire problem in a few years first of all good trying to find any more primary care clinicians because right now one third of us myself included are over the age of 65 and retiring and if we do not find a way to not only increase access and and overall and decrease overall costs we're going to lose whatever primary care workforce we already have so again nobody is saying it's I mean of course it's going to be tough of course it's going to be tough but keep in mind too that this administration isn't going to be there necessarily when we try to to work on getting this thing implemented so I I mean again I think for monitors have taken on many many challenges Dr. Dinosaur by the way was one sentence in a piece of legislation one sentence we're going to expand right one sentence in that legislation and they managed to get it done look what we've this one care thing is a monstrosity you can't get more complicated than that yet we've shoved all kinds of money in that in their direction millions and millions and millions of dollars no questions asked I do think we can get this done it's going to take there's no two ways about it is not easy but just because you you did a shout out about nobody nobody's opposing hospital budgets my team is opposing as opposed to every hospital budget with as much voice as we have but you're right we've lost in those battles yeah can I just offer a quick I don't see a such a separation between the money and the values piece now I think we express our values through money and sometimes we need to lean in to a question and invest and I think there's there is an endless number of ways to avoid avoid leaning in and making a commitment through seemingly reasonable financial considerations Harold Gaillard who preceded me in the Senate he used to say there are advocates who will come into your committee room and sometimes they just walk you into the swamp and they drop you off and I feel like we run into this on complex issues like healthcare energy climate change etc that there can be a crippling complexity introduced so that in the end we don't make changes that we need to make and so if I sound a little impatient I think it's probably like other people here now after you know 14 years I would like to see us somehow break the paralysis on that side thank you I think we're going to move on to Ellen now yeah I just wanted to point out you know it's already been said you know we're paying the entire bill already right and every time a budget goes up we're paying more through our premiums or out-of-pockets we do appreciate there is a political issue in raising some of that money from publicly raised funds as opposed to a premium I did want to raise a couple of things number one I think an important part about raising the money publicly for primary care is then that amount of money could no longer be charged by your insurer because the insurer by statute cannot charge you for services they are not paying out for so you know primary care is only six percent of total spending I wouldn't sell it as oh hey your premiums are going way down but we could certainly say you could advertise that it will be a break to a little bit of a break on the premiums going up secondly I want to say about complexity oh does anyone understand all this one-payer risk-adjusted capitated model the aco value-based care I mean we have been through so much I would say about one percent of Romaners understand the you know rigamarole that's being invented and now we we're going to have value-based player and global hospital budgets which by the way how does that work with a multi-payer model I get it with a single-payer model you fund your hospital as a public good but a global hospital budget with you know team payers that's going to be but business team so I do think we have to consider that we do take on and often create unnecessary complexity and I don't mean to say that universal primary care would be simple politically but we can all understand it we can understand we raise the money publicly we pool it and then primary care is a public good without you know um team payers that seems easier to me at least to understand than the aco and the value-based payments and risk-adjusted capitated and then all the other stuff uh that you know gets thrown around so I do think it's worth trying and I applaud senator break for taking this on and I also think people will be behind you if you're a legislator the people will support this and so I think yes it will take some work and I'm not saying it's easy but I think we shouldn't give up because maybe some of the powers that be will push back but you may get a lot of support from people like the people in the zoom room tonight and you know part of our job as citizens and also our representatives you know we can gather that momentum and hopefully make make it happen. Thanks Ellen um and I think we're on to deb. Debra Ramstell. Hi um I just wonder well you know you mentioned um Dr. Dinosaur couldn't this be like Dr. Dinosaur for everybody? Maybe why not. Deb? Dr. Deb? Yeah I mean you mean like a doctor like basically Medicaid for everyone the the only problem I think we might have if we sort of use that as our definition because that's a Medicaid program would be the fact that you would have to um increase the reimbursement to primary care because if when Dr. Dinosaur happened actually there were many practices that actually went out of business because they couldn't afford to stay open if everyone had had Medicaid so yeah I mean you could call it that I suppose but if that has to be it has to be somehow sustainable to primary care practice um so uh yeah I think what you're suggesting is I can move everyone again as long as there's um adequate reimbursement so so practices are sustainable they don't have to be profitable they have to be at least meet the fixed costs of the um primary care practices so I guess I didn't know that Dr. Dinosaur was the Medicaid program yeah because my grandchildren are on it and um aren't all the children in Vermont on it no no it's up to I think I think it might be 133% of poverty um 300 is the 300 okay that's right that's right which is which is how much uh I don't know it's a medic it's because Dr. Dinosaur is Medicaid which means it's it's more than half of it is funded by the federal government and that that is a big factor and that is a big difference between that and funding of universal primary care that wouldn't necessarily there would be some federal funding um but not half more than half of it like Dr. Dinosaur and Medicaid Medicaid is 1.8 billion dollars uh is the Medicaid budget approximately and more than half of that is paid for by the federal government uh huh interesting great uh thank you um I think we're on to Mary Ann hi um hi um I when I got onto this call all I could think of was Phil Scott oh no how could we ever you know how could it ever you know pass but um I was wondering my question is is there bipartisan support for this kind of program and um I just noticed in the most recent election I saw a lot more signage for republicans and it felt much more polarized um than ever and I was just wondering if there was work being done to find bipartisan support for this because I mean it just seems ridiculous that this would be a democratic issue well Topper McFawn was in favor of it he's a republican from barry town um and um we've had bipartisan support we we've sort of had this bill uh introduced several several times and there has been actually tribe partisan support for it it's not huge republican support but um even Heidi Shureman when I spoke at a rotary club um she came up to me right after uh this was several years ago and said I think this is a good plan I and she even had done without health care and had problems paying her own health care bills and um Heidi is um you know certainly not you know she is conservative as you can get but she was in favor of this well so and she's very well their husband right he's very wealthy I know her really okay but she but anyway she was in favor of it she um was was uh you know thinking that she wanted she didn't want to be sort of coming out of the closet to to do in other words she was worried about saying that to her colleagues but she did say that to me personally um so it's not it's not something that um and business people again are are um like the idea of it because other employees would um have access to to primary care which you know especially if you run a restaurant you know and somebody has a cough or a fever and needs a flu shot and whatever they would be able to access that without um having to worry so yes there has been tribe partisan support right um I think we're on to Chris um thanks yeah you know that just very briefly that I mentioned Dr. Dinesor not as an exact model or analog like oh that we will expand that but in part just remind us of that we can fall into a mindset of thinking that it's we can't get this done because it's too unusual it's too big a lift it's too complicated there are too many parties with vested interests um but we have been able to create a really meaningful program in Dr. Dinosaur and and figure out how to manage it how to run it how to finance it and um I'm just citing that as a reason for us not to sort of beat ourselves down before we even get started the next session um thank you Chris uh and Cheryl I yeah thank you Chris I'd like to put an example in from the other end of the H-span too with the pretty much at the same time that we did Dr. Dinosaur and we were able to really increase the levels of family income that could be covered there was also a big movement to say most of our older Vermonters don't want to be living in nursing homes we want home-based care and we were able to accomplish um with choices for care that same kind of major dramatic change against the very strong lobbies of the nursing homes in in pretty much the same fashion so I applaud Senator Brae for just reminding us that if we put our minds on what's the morally right thing to be doing we can probably do it. Thank you Cheryl um I think we're we're we're we're sort of past time anyways and I think this is good time to wrap up unless anyone has anything really urgent they want to add here at the end um and I just want to thank everyone for coming to to talk and it was really great discussion um really great to hear from everyone and um just want to thank everyone thank you uh Linda and everyone for organizing this and um this is great and uh let's let's keep the conversation going uh go ahead Chris. Yeah so uh thanks for reminding me that as I have a bill drafted and to share I'll get back to you and Linda and um so that we can you know share what's in development with this group of people and more broadly happy to have you know we we have a great history of having people come together think about problems together and find ways to get to uh yes so um I'd like to continue to be part of a much bigger group that has a lot of experience to help shape what gets introduced and develop and investigated not knowing where it will land but um that we can look into it together. Great thank you everyone thank you