 All right, welcome back after our short break. And we are going to continue with our review of house bills and we have H430, which we received, I don't know, a couple of days ago. So Representative Black is here as a reporter of the bill. Welcome. It's good to have you here. I think it's the first time that we've had you in the testify in our committee. I think so. Thank you, Madam Chair and senators. So for the record, Representative Alyssa Black, house health care. So H430, which is expansion of eligibility of Dr. Dinosaur to all pregnant women and income eligible children in the state of Vermont who reside in Vermont, regardless of their immigration status. So this proposal was brought to us by the office of health care advocate. Being the impulsive person I am, I picked it up. Not knowing what it was going to lead to. You know, just sort of researching the topic. I think it wasn't something that had ever been on my radar before. I'm not sure it's really, you know, it's sort of that out of sight, out of mind thing, but meeting with various stakeholders and just learning about this really, really small population that we're talking about who really have no viable access to any sort of health care, except for frankly the most expensive health care that we have, you know, talking to open door clinics and the free and referral clinics, which is sort of the clinics that serve this population, they don't serve children, you know, they're kind of at the mercy of the volunteer physicians. So if that physician's specialty doesn't allow pediatrics, then they have nowhere to go. They don't do obstetrics. So, you know, these children and parents are left with essentially bringing children to the emergency department. And then, I mean, they don't have any ability to pay this. One emergency room visit is going to be thousands of dollars. Some of the patient assistance programs through the hospitals do not even extend that coverage to someone with a status who's undocumented, which means they can't even make payments on it. Anyways, so this is a really, really simple bill. It just extends this coverage, you know, it solves the issue of simplifying it. There's this whole other kind of category. I'm sorry, there's really two categories of people we're talking about here. We're talking about our farm workers and we're talking about this sort of, these immigration statuses where you're, you know, you're applying for status, but you're sort of in this limbo, you've yet to apply, you have not been approved for it. So you're not covered during this limbo status. I'm sorry, where was I going with this? Oh, I think you were- I know clearing up confusion because there are people who are eligible who get denied. And it just clears up the confusion. Everybody's eligible regardless. All right, this is very helpful. Thank you for sharing your journey. In supporting the bill and we will listen to folks and see where the problems lie, but also where the benefits lie because I think there's probably both embedded in the bill and we appreciate you're taking the time to present it to us. I do have a question. One is the vote in your committee and in the house overall. So the vote in the committee was 10-0-1. And it was a voice vote in the house. Okay. On a voice vote, I think there were two nos. Wow, okay. So you did a good job reporting the bill. Yeah, I'm sure it was all because of me. The other question I have for you, Representative Black, is did the bill, then the bill must have gone to appropriations because there is a fairly hefty amount in there. It did go to appropriations. So the thought behind the bill was, I think that we really wanted to get this going for fiscal year 21, I mean, 22. And Diva has some really important upcoming challenges and we wanted to be able to give them some time to get this in place. So there is an appropriation. The appropriation is, and this is too for the agency of human services to stand this program up this year while Diva is able to take the time to get this in place. And the appropriation is based on the numbers that Department of Vermont Health Access anticipates that it might cost to serve this population. And additionally, some additional money for outreach, grants to the various groups that serve these communities in order to be able to do outreach to these communities that they are now eligible. Okay, thank you. That's very helpful. So you have a right-hand person here, Representative Houghton is here. Did you wanna add anything, Representative Houghton? Hi, thank you again, Representative Houghton House Health Care Committee. Nothing to add except I do believe the House appropriation vote was 11. Zero, is that correct? Yeah, 11, zero there. Okay, yes, thank you. That's helpful. So it sounds like it was a fairly unanimous vote all the way around with maybe two exceptions somewhere. Okay, why don't we, unless there are questions for Representative Black, okay, we'll move on to go through the bill and Jen is here and as well as Nolan, who would have the fiscal note for us and then we'll move on to hear from Nissa James, Corey Gustafson of DEVA, and Mike Fisher, a healthcare advocate. So that'll be the order of the testimony. So Jen, thank you for being here. Sure, I will put up the bill. This is H430. And as you heard, it's an act relating to expanding eligibility for Dr. Dinosaur to all income-eligible children and pregnant individuals, regardless of immigration status. It would add a new section in Title 33 in Chapter 19, which is the Medicaid and some other medical assistance provisions that I've titled Dr. Dinosaur Coverage for Undocumented Immigrants. It would direct the Agency of Human Services, which is the way we phrase a lot of our Medicaid-covered provisions, not specifically DEVA, but the Agency of Human Services shall provide coverage under the Dr. Dinosaur Program to children and pregnant individuals who are undocumented immigrants, but who would otherwise be eligible for medical assistance from the state under a particular provision of the Social Security Act. I will note, and I think you'll hear from DEVA that DEVA does have some concerns about this language and some potential unintended consequences of phrasing it this way, so they may have some proposals to make changes to the language, to achieve the same result, but without having it tied so specifically to the federal law. Section two would appropriate 1.4 million in one-time funds to the Agency of Human Services in fiscal year 2022 for the following purposes, grants or reimbursements or both, so prospective or retrospective payments to healthcare providers for delivering healthcare services during FY22 to children and pregnant individuals who are undocumented immigrants, grants to Vermont organizations that work with members of Vermont's undocumented immigrant community or with members of the healthcare provider community to provide outreach and information regarding opportunities for children and pregnant individuals in Vermont who are undocumented immigrants to access healthcare services at low or no cost in fiscal year 2022 and thereafter. So during this kind of transition year with the grants and reimbursements and then going forward under the Agency of Human Services program and also funds for implementing the technological and operational processes necessary for the Department of Vermont Health Access to administer the Doctor Dinosaur Expansion as set forth in section one, beginning on July 1st, 2022. Section three would require the Agency of Human Services to provide information on the estimated FY23 costs of expanding Doctor Dinosaur eligibility to undocumented immigrants under again that language in section one, beginning on July 1st, 2022. So that information on the estimated FY23 costs would be included as part of the Agency's FY23 budget presentation to the House Committee on Appropriations and House Committee on Healthcare to this committee and to the Senate Appropriations Committee. And then finally, we have the effective dates. So the funds, the 1.4 million in one time funds to AHS would take effect on July 1st of this year. The remaining sections would take effect on passage with the Agency of Human Services making coverage available to eligible undocumented immigrants under Doctor Dinosaur in accordance with that language in section one, beginning on July 1st, 2022, subject to FY23 appropriations for this purpose. And so some of that last piece is what was changed on the House side in the Appropriations Committee to reflect that this is not a commitment until the money is appropriated. And that is the language. Okay. So, and we're gonna hear from Diva's comments, specific comments related to their area of oversight. Questions for Jen. So go ahead, Senator Hardy. Unmuting can take time. Well, first of all, before Representative Black leaves, I just wanted to say thank you for jumping on this idea. I actually am a former Executive Director of the Open Door Clinic. That was the first job I held in Vermont. And I wish I had thought of this bill because there were so many times when we had to scramble to try to find healthcare coverage for pregnant women or their kids. And it was really frustrating. And sad. So I'm really happy that we're working on this. And I hope that we can find a way to make all the details work. So thank you for jumping on it. And Jen, my question for you is, and maybe this is also somewhat Nolan's question, but first of all, once, if a woman has an undocumented immigration status, she would qualify under this bill. But then once her baby is born, her baby's status is that the baby, if born in Vermont is a US citizen, and that baby would presumably be eligible for Dr. Dinosaur under sort of quote unquote regular provisions, is that correct? That's my understanding. And certainly the Diva folks can correct that if that's not accurate, but I think income eligible children who are US citizens are eligible for Dr. Dinosaur. And how long a woman whose income eligible becomes eligible for Dr. Dinosaur as soon as she becomes pregnant or is verified to be pregnant, I think. And then how long after the baby is born is the mom, does the mom continue to be eligible? Do you know? I think it's 60 days postpartum, although I think there may be some expansion of that under the new federal law, at least in the short term, or an option for states to extend that up to a year. Okay, right now I believe that's 60 days postpartum. 60 days, okay. And then the presumed, maybe this isn't a question for Nolan, but once we're through this first year of this transition with the $1.4 million appropriation, would the appropriation for this part of the program, if it moves forward, just be encompassed in the sort of larger Dr. Dinosaur budget, or would there continue to be a line item specifically for this purpose? I think for the record, Nolan and all the joint fiscal office, I think it says in the second year, they would add that to the budget. So I think that in 23, it would probably be an initiative specific in like, I'm thinking of envisioning a diva budget book, and it would be a line item where they show it. And then after the following year for that, it would be base. It would just be incorporated into the larger budget. Eventually, yes. Okay. Ray, I think it would be built into the base, but the important distinction here is that this would always be state-only dollars. We would not be getting federal match on this. So whether they would list that out separately because it's handled separately. I don't, Nolan knows the budget book better than I do, but I don't know if they would, in their minds, consider it Dr. Dinosaur, or if they would consider it state-only dollar coverage for this particular population. Yeah. The coverage would be the same. There wouldn't be a distinction between a woman who's qualified under this provision versus a woman who's qualified under the larger program, correct? In terms of what you get. From the patient side, right. From the patient side, my understanding, and that's why the language is drafted the way it is, although as I said, I think it may need to change, but my understanding of the intent is for the coverage for the patient to be the same. It's just the funding side of things that would be different. Okay. And Nolan, I'll let you finish, but I think these are the questions that we need to, I think we should move ahead, listen to Corey and Nessa, and then we can have the discussion, but Nolan, why don't you go ahead? Yeah, I think I'm just gonna pretty much just follow up on Jen and just be like, it would be somewhere in the Diva budget book, they might have broken out along with all the other Medicaid eligibility groups that we have, but I think that it would be really more a backend calculation. Got it. But from like Jen said, from the beneficiary standpoint, it would, no, just like beneficiaries don't know now. Yeah, okay. These are good questions that we're gonna have to answer as we go along. Anything else, Senator Hardy on that? Not at this time. I just wanna make sure that there's not some way that the services or the process or whatever from the patient perspective would be different, that these women and children would be treated like any other women and children in Vermont who qualify for Dr. Dinosaur. So you want it to be nationality or immigration status blind is what you're saying? Yeah, I mean, we have to do what we have to do from the sort of legal perspective, but from the patient care and all that perspective, it is the same program. That's what I would want from a patient perspective. I'll let Corey talk about that, but I think it'll once they get that card that says green mountain care. Nothing. They don't know, they just know they have coverage. It's all the backend stuff. So for instance, we have all these different Medicaid eligibility groups, but people don't really know which bucket they fall into from the administrative. They just know that they have the services and everybody has the same services. So again, I'll let the commissioner comment on it, but I would suspect that it's once they're in, and they get the same services as everyone else. Great, thank you. Okay, any other questions from the committee for Jen or Nolan? Okay, and Nolan, at some point, we'll look at a fiscal note from you. We don't need to do that right now. It's posted, if people want to look at it, no question, reach out to me. Okay, good. All right. So commissioner Gustafson is here and this is James, also who is the healthcare director for Diva is here. So thank you both for being here. Greatly appreciate you're taking the time. And you've heard some of the questions that very definitely relate to your role in this. And so why don't you provide your testimony on the bill and then I'm gonna also have some questions. So you figure out who's going first and so on. Good morning, Corey Gustafson, commissioner and department of Vermont Health Access. I feel like the questions that we've heard and some of the answers we should maybe can just knock right off, I mean, Nolan, first of all, Nolan's right. I think that once you're in the program, you get treated similarly to everyone else depending on provider, I suppose. I hear a budding commissioner in there Nolan. So I might need your resume soon. Oh, I think we're here to inform as best we can. I think that you're right. There was Jen is right about the language that if it's going to be state only, the connection directly to the way it's written might make it, I don't have language specifically for you Jen, but you're right that we are going probably need, if we would think we do want it to be state only and I'll explain that why right now. The reason we want it to be state only is because the process would be different if we had hoped to get Medicaid match for the expenditures and different in a way that we don't think is beneficial to the member. The process of enrollment that we're talking about, I'm not trying to leave the names outside but basically the applicant would have to be denied and then come back in and they'd be denied for normal Medicaid and then come in through emergency Medicaid and it's a, it would be different, it would be more complicated and we think it would be cleaner. The state only should this become a program that the legislature wants to have as part of its. Let me clarify that. So you're saying that not only for the first year, it's state only, but it would continue as such? That it would be most beneficial as far as process goes. It's basically to the question that Senator Hardy was asking, how do we make this so that it is not the feeling of a different process and that making it state only allows it to be a more streamlined process. It's actually a more streamlined process on the operational side for the execution and of eligibility determination. So anything that is less complicated provides for less opportunity for mistakes or misunderstandings or system failures, system by system I mean the technology. Okay, then let's suppose after the first year, obviously the first year is an appropriation that is state dollars. And then the next year when it goes into effect as a ongoing program, but it still continues to be state dollars. How, if at all does the state get match for, no. Yeah, that's what the state only part actually completely means, Senator Lyons. I wanted to clarify that. Yes, thank you. So there will be no match. Yep, no. So it would become an ongoing expenditure of the state for initially it's X number of dollars, but that would change over time depending on demand, how many folks would be eligible and in the program. Yep, that's all correct. Okay, so, and I guess when you presented this to the House Appropriations Committee, was there clarity on that or not? Well, we didn't present to House Appropes. We were in to House Healthcare to basically share similar to what we have here for you today, essentially the cost estimates, which you, I believe you probably have the fiscal note. So as Nolan said, when that NISA worked with our teams on that, so that's one main reason she's here is if you want it to go into that cost calculation. I think the other thing we shared with House Healthcare is just operationally, I believe they lit, I know they listened to us about the system work that would be necessary to create a process for determining eligibility of the population. So we shared essentially the competing efforts that are underway or will be underway very soon, just to make that every program or project has to have a implementation and it goes into the world of the other implementations that we have either underway or coming at us. And when I say that, I mean all the IE&E projects that CMS and the legislature and the rest of the administration itself really has been pushing itself to move forward on. CMS is very, very closely watching our progress on that, those efforts, you have a budget approvals for those IE&E efforts also, you don't. I'm gonna ask, I think that there are members of the committee who are maybe unfamiliar with the integrated eligibility, although I know we went through it both in institutions and in health and welfare and other committees last year, but just one sentence on the- Oh, that's, Medicaid doesn't do things in one sentence. All right, two sentences. Yeah, the overarching goal for the agency of human services is that our eligibility system is able to process not just the healthcare-ass element of eligibility for our programs, as Nolan said, we have many different Medicaid eligible groups, but also that it's a sort of single point of entry for monitors to come in and access all many different kinds of programs. So SNAP, housing, et cetera, that's the big, what do they call that, the big audacious goal, right? So we have been on a pathway to this. It was and has been quite severely hindered by our system itself and where we've found ourselves due to the implementation of Vermont Health Connect. And so, and it isn't just Vermont Health Connect that is what we need to fix, but we need to fix, we need to bring the eligibility's together while fixing a system that is very much process-based. And so it's a pretty complicated program and CMS is very interested in our continued progress. So that's how that kind of fits into what we have going right now. The other thing is on our, in front of us, we have the end of the public health emergency. I think that's coming at us faster than any of us really will imagine, but it's coming quickly. And part of the changes that were made during the public health emergency was to not execute on redeterminations and we will have to get going on those ASAP. That is another CMS. I wanna say non-negotiable, it's non-negotiable that we get going, how quickly we have to get those done. We are trying to, through national organizations, negotiate a little bit, give us a reasonable amount of time to get those done. Every month that goes by is another, time of group of people that need to be renegotiated. Although we are past a year, so we're kind of, yes, that is, we will have a year of redeterminations as well as doing redeterminations. So it's kind of a doubling of the work that would need to be done. So the reason that's important in this context is the people that are doing that work are also the people that need to test on systems. And so we're already constricted. The thing I just described about IE and E projects with the people working on the redeterminations, there isn't just another group of highly qualified and trained Medicaid personnel who can test on this. We need to sort of use them in both contexts. So that makes it a challenge. There are two others. There is our environments on the systems that are difficult to do more things. We have a certain number of environments to test in. And so as we add things, it just sort of pushes back that our ability. So the last piece I wanted to mention is the ARPA, the American Rescue Plan. Contemplates or doesn't contemplate. It has now will increase subsidies and that falls right into the same system. So we have to make system changes to address the increased subsidies. And so sorry that it's a long list. I usually like to hit a couple of points, but it is just, it gives you a context of what we have in front of us. And I see Senator Cummings hand and I just saw Senator Hardy raise her hand. Before I turn to them, I have two questions and because you brought up two things that I had questions about. One, and then we'll go to Senator Hardy and Senator Cummings. The ARPA funding and if and how any of the ARPA funding might support the work that we're talking about in this bill, that's one. And I don't know that you can answer the question. I know there's some guidance out about that. Certainly the guidance does support specific racial and ethnic groups. And I don't know about, you know, so citizenship there may not be a part of that discussion. So that's one question. Then the other question that I'll ask off the bat and I think Nissa might be able to respond. And that is in terms of the costs associated with this, the ongoing costs, I mean, the initial, I haven't looked at Nolan's joint fiscal note yet, but what are the differences between the initial costs and then the ongoing costs for the implementation and then the ongoing operation for the program? Okay, so on the subsidies question, so I was kind of referring to the qualified health plan subsidies and the work to do there. Like there is other monies. I mean, I think there are direct to provider. There's an appropriation in the ARP for direct to provider. I don't know that there is a direct line to the conversation we're having now and the population we're having now to those dollars being dedicated towards that kind of, those kinds of services. But, you know, that's, I think that's the best answer I can give on is there something in ARP that connects directly to this? I don't have that answer right now. We'll look at it again. Well, I think it might be helpful because knowing that funds are available, might be able to, you know, clear the pathway at least initially. The second question was the cost and the ongoing. There is obviously the build, the build on technology. We have an early estimate on pricing for the implement the DDI work of 100,000 dollars. And then cost ongoing, we don't have an estimate on that. But I would say obviously less than $100,000. So, you know, there's the work that needs to be done by creating a new program. You know, I don't think it's a huge population. So I wouldn't afford a huge amount of staff time and resources to it. Of course, depends on what the process-based is, process for the eligibility determination and enrollment. But, you know, I don't think we have a great estimate, but I wouldn't, I just would say to the community, I wouldn't stress about that. I think that- Okay. I mean, actually this is very helpful. The initial work I know, which would pull you away from the ongoing IEE work is problematic. But if there are federal dollars that support any of the work initially, that would be good to know about. And then it sounds like the operational expenses, because, you know, talking about a small population of people is something that at least our committee might be able to sell to appropriations. I mean, that is, yeah. Because we won't, because what I'm hearing you say is that we would not in the future years be eligible for a match. Yeah, never say never, right? Yeah. If federal law changes and something happens, then I guess match could be a possibility. I don't think we have the, I mean, we, yeah, I think that this is the proposal as it is now as a state-only program is what we would say primarily best for the member or for the eligible group. There is just, you know, it is secondary, but it is true. It would make a more streamlined process for determinations and for system. And so that is, you know, one of our priorities to not make things more complicated. Okay, thank you. There is one, the other piece I just say is we, we, well, I think I'll pause, I'll stop. Okay, so I'd like to turn to Senator Hardy and then Senator Cummings for their questions. And then we'll- Senator Cummings is not, is saying, she doesn't. She doesn't. Her hand is up and that's- You don't have a question, Senator Cummings. Okay, I was going to yield to Senator Cummings because I've been asking a lot of questions, but since she doesn't have a question, I'll ask my question. First of all, commissioner, thank you for your testimony and what, when you were going through the sort of list of systems changes that you have to make over the next year or two, those weren't specific to this program. Those were sort of broader systems changes that you need to make for the whole universe of the work you're doing, correct? Well, they each have a specific thing that they're related to, but they are not, they aren't prereqs to this. They are just the outline of operationally, we have a lot in the hopper. And so consideration for that, I was sort of outlining that we shared this with the house healthcare committee and they understood that and gave us that timeline of next July. So July, 2022 as a way to understand all those things. And if I did not recite all of them, you couldn't have known, I apologize for how long you took that, you're correct. It's not prereq for this. All right, that's helpful to know. So the timeline with the one year sort of buffer zone kind of thing, you're good with that. You can get your team to work on that. We think we can accomplish it. I mean, we thought we'd have IE&E done a long time ago too, but. Okay. That's a little joke. Should I hold you to this or not? Yeah, no, I'm just, you know, I just say it as like. Wait, wasn't there was something that got in the way of that? I'm trying to remember, it's called pandemic. Yes. Yeah. There always is. My other, I appreciate your comments about wanting to make this state-only funding so that the process and the care and the whole thing would be the same for people eligible under this program as it would be for people eligible under the larger program. And I think that is exactly what I was wanting and talking about before you testified. So thank you for sort of underscoring that and saying that that's what you're also looking for. And my impression just we, last session I was on the agriculture committee and we did a lot of work on trying to find, to get the payments for undocumented Vermonters, the stimulus payments that most of us got to provide equity payments for them. And Nolan actually worked on this with the Ag Committee and we ended up not using any federal money for that because of the complications that that caused. So I guess even potentially using ARPA money for this I think could complicate it in a way that is undesirable for moving this along. So it just wanted to put that out there. If you're looking at ARPA money, fine. But I'm gonna guess it's gonna make it more complicated. And the, now I can't remember my other question slash comment that I was gonna make for. You want a second to think about it? Cause I just. Yeah, go ahead. You hit on the piece that I decided not to say which is on the idea of ARPA money. I don't think there's anything in there that we would brag into this process. It was my comment was more about there might be ARPA money that it goes into this healthcare, into the healthcare that comes into Vermont's healthcare system that could be used for it. But that would be very indirect and not necessarily. So I think we're all aware of what you're referencing. When you involve the federal government, the money's great, the requirements and the execution becomes more complicated and sometimes not the best for the staff or the user of the system. Right. Especially with the federal morass right now with immigration policy. It just becomes extremely complicated. I remember the last thing I was gonna say in terms of the sort of fiscal impact of the program. I think one of the reasons they're not here anymore but that the house was so in favor of this despite the $1.4 million price tag is that over the long run and even not such long run over even a short period of time, the health benefits and savings and healthcare costs to the system as a whole are very real. Because women have better outcomes if they have healthcare when they're pregnant and newborn babies and children have better outcomes when they have healthcare. So I think that that is not part of the, of no one's fiscal note, but it's sort of should be embedded in our thinking about the fiscal impact of this. Well, we'll also hear from Mike Fisher who I'm hoping will reference that benefit to the bill. I think a couple of points on the money pieces or the federal piece as well. Yes, please. So I just wanted to make sure it's clear cause I'm not sure from some of the earlier questions that it was that a big part of the reason it's state only dollars is because a lot of this is specifically not matchable under federal law. The federal law says we can't do this under the Medicaid program. And so that's why we would be doing it with state only dollars. But I think another piece to know, then Corey mentioned that it's administratively burdensome to go through the emergency Medicaid process where somebody has to apply and get denied. And then, but that's also, I think only for emergency medical situation. So it's not preventive care for children and things like that that would be eligible under this kind of Dr. Dinosaur like program. It's just emergency and emergency based medical care. So it's not as comprehensive as what we're talking about either. Right. No, that was clear. But thank you. That was helpful. It's important to underscore that. And Nolan, I did look briefly at your fiscal note and you seem to indicate that the ongoing expenditures would be closer to 260,000. I think Corey mentioned 100,000 after the initial implementation. I'm wondering, Nolan might be talking about, I'm not sure what the 260 is. I was talking about the design development implementation on for the system work, not anything related to the expenditures on the program. Yeah. Okay. And the 260 was specific to the... PMPM 100 kids. Just for the kids. Yeah. Okay. Just a part of them. Yeah. Okay. Got it. All right. And then in terms of the outreach to different organizations to get the information out to the population that we're talking about, maybe Mike Fisher will be talking about that. So I think we should probably move to Mike unless... Sure, I'll just say on that, that we don't have necessarily a plan but we do have our assistor groups, our assistors across the state that assist with qualified health plans and other Medicaid enrollments that we partner with. They're not, we have Victoria Jarvis is one of our people that works all the time with them. And this would probably fall into that category. And then I think we would rely on other organizations that specifically I think if you went down the path of appropriating dollars to be granted out in the first year, then where the grants would go, we would be relying on those groups to really be communicating out. And of course, Mike Fisher organization. Oh, that's right. So you can ask back for comments on that. I think this program is one place to understand how that might not popularize but let people know that it's available. Okay. Okay. Thank you. Very helpful. Nissa, thank you for being here. You're the backup. It's always important to have a good backup. We appreciate the time, your time as well. And I just ask you if you have anything that you'd like to add at this point. So legislative council for the record, Nissa James, healthcare director for the department of Vermont health access, legislative council had indicated that the department had provided some recommendations related to the language as passed by the house. And that is indeed correct. If the intent of the legislature is to create a state-only program that is administratively, I'll use simple, but we're really talking about as minimally burdensome to ensure that these individuals are covered. We would have recommendations for the language as passed by the house. It really focuses on removing citations to the Social Security Act and specific references to the Medicaid or Dr. Dinosaur program, because we want to ensure that we're able to implement the most efficient and flexible way for this expansion of coverage without having applicants have to go through the full Medicaid screening process, be denied, and then be granted coverage. That's good. I think that that clarifies and Jen also clarified, so now I think it's even clearer. But if you don't mind communicating the language that you have, and I don't know if you've already done that, but it would be helpful to send that along to Jen, and then we can look at it and as we're reviewing the bill. Okay, good. All right. So anything else, Nissa, at this point? I should say Dr. James. No, but thank you for asking. Okay. Mike Fisher, I need to grab another pen. My pen just ran out of ink, but Mike, go right ahead. I'm listening. Thank you, Senator Lyons, and thank you to the Health and Welfare Committee, Mike Fisher here, healthcare advocate. I want to attempt to sort of recognize the importance of this moment. This is a pretty phenomenal bill, and pretty important bill. At this moment, for us to be able to consider this sort of really important address, way of addressing a recognized racial disparity in our healthcare system, and to actually do something about it, is really phenomenal. And so I just want to, before sort of launching it to any details about the bill and how it came to be, I just want to pause and recognize that with full appreciation for the healthcare committee in the House and for the House, and for various legislative leaders. And now you, for taking some time to address this longstanding recognized real problem in our healthcare system. So to that end, we at the healthcare advocate's office brought this concern to the House Healthcare Committee last year at the worst possible moment. COVID really interfered with any real consideration and really stopped me from bringing it to your attention last year. And so we took another run at it again this year, and we're just again very, very pleased. And I often, you've probably heard me talk about the different sides of my shop, the individual advocacy side, and the sort of more theoretical policy side that tends to come to the legislature with concerns. This issue really grew out of the individual advocacy side. We had real people living in our communities coming to us saying, I don't know how I'm going to afford to have my baby. And bumping into one problem after another, after another, after another, sometimes without real answers to help these Vermonters be able to maneuver through what should be. What we all would hope would be a joyous moment, give me the opportunity to say, nobody should have bad debt on their birthday. Now I know it's the parents who have bad debt on their birthday, but nobody should have bad debt as a result of a birth. That's maybe more aspirational. So because no one's talked about the numbers, I'll spend just a second. We talked with the people who support the farm workers, primarily the Bridges to Health program, and also talked with the Immigration Assistance Project, people who are supporting people who are seeking humanitarian status to try and get a sense of the numbers. Now that's not an exhaustive list, but it is a substantial list of the people who are here with that documentation. And I'll just say, overall, we came up with an estimation of about 100 kids and about 20 pregnancies. So to a representative Black's point earlier, this is a relatively small population of Vermonters, but it has a substantial impact on their lives. You didn't hear anything about the testimony that the house took, and there were a couple of, should you feel the need to take more in-depth testimony to hear from people affected by this, both migrant justice and Bridges to Health and the Immigration Assistance Project assisted in bringing people forward, real people's lives to really describe the dynamics and sort of the pressures on them as they go about their lives here. That thank you, that's helpful. And we may call on them to bring some real stories to us where they were in our committee last year as we were talking about some other issues and actually related issues. So that would be great. So I just messed up my screen. So one of the things that we have learned some about in the process of advocating for this bill is some more details about a program called Emergency Medicaid. There is a program called Emergency Medicaid and it is for people who are in true emergency who would otherwise be eligible for Medicaid but for their immigration status. And my office supports people and supports providers in applying for those funds. And so one of the things that became very clear to everybody and I appreciate Diva's recognition of this and verbal commitments, public commitments to work on it. It is tremendously underutilized. You know, again, we estimate that we think there's about 20 pregnancies a year in this population and I think we heard that they covered one pregnancy in the last four years. So that means that the costs of those pregnancies are turning into both unpaid bills for people. I don't want to minimize that and bad debt for the hospital that gets cost shifted. To the point, so there needs to be some work there, both on the provider community to know about this program and in communication, I believe, to people who would be affected by inappropriate language. So I think maybe I'll just list off the organizations who have expressed support for this bill. Can I just ask a quick question before you go on please? So the underutilization of the emergency Medicaid is because of the problem in applying for it. So cumbersome, what would be the reason for not utilizing that? It is likely one part what you just mentioned, Senator Hooker, how cumbersome it is. And I also believe it is one part lack of knowledge about the program. And while the likes of me is going to say, hey, Diva, make it easier to do, I understand there's federal rules that make it burdensome. So you're agreeing then with Commissioner Gustafson to do it through the state to fund this with state dollars would make it a whole lot easier. Yes, yes. I'm sorry, the emergency Medicaid is a little bit of a side comment. This proposal in front of you considers a state funded program for children and pregnant people. Emergency Medicaid is eligible for all Vermonters who are here who are not eligible because of their immigration status. Yes, Senator Hardy. Sorry if I can call on. Madam Chair. Okay, nice try, Mike Fisher. But well, I just want a comment on emergency Medicaid. I think the commissioner alluded to this or said this that it is really an emergency program. So it wouldn't cover the sort of general care for kids that we're talking about going to the doctor and getting their annual physicals or because they have an ear infection or whatever. Those aren't considered emergencies. And I think a lot of the prenatal care even is not covered. It's really just the birth itself is considered quote unquote an emergency, which is problematic in and of itself. And then though there's not the 60 day other period afterwards. So it's really just this single event that's an emergency. And so it's very limited in what it will cover and the process for applying is complicated and not user friendly. Yeah, absolutely. And that also gives me the reminder of making the point that I'm sure everybody here knows, but it just needs to be said. Clearly, everything we're trying to do in healthcare reform is getting the right care to the right people at the right time to avoid more expensive costs later. If there's any place where that is tried and true, it's in prenatal care. You know, if the funding of this program over the last five years prevents one premature birth, we've paid for it. So, and that's just on the money side. I'm also here to say the human side. Well, the human side I think is really important. Really important. Yeah. So let me just, you know, we did, we did not do a really exhaustive search to try and find supporters of this bill. These are largely people who came to us when they heard us discussing it. Of course, my office, ACLU of Vermont, Vermont Academy of Pediatrics, Bi-State Primary Care, Migrant Justice, Planned Parenthood, Vermont Academy of Family Physicians, Vermont Association of Hospitals and Health Systems. Free and refer. Oh, you just, whoop, you froze a bit. Just when I was going fast. You were. Keep going. I'm going to just keep going. Vermont Interfaith Action, Vermont Medical Society, Vermont Worker Center, and the Open Door Clinic. And then because of their association with the university, they can't express a real support for a piece of legislation, but we're integral to helping us understand the population also bridges to health. So that's the list of organizations that have stepped forward in one way or another to support this effort. And I really thank you members. All right. Thank you. And now this is, this has been a very helpful, helpful discussion. And I think we're, I think we're seeing the issue around, you know, state dollars versus federal match. You know, if we don't, if we don't match that 1.3 million, then we don't get another 1.3, you know, where we end up with 2.6 million less to spend on current and existing concerns. However, it's probably more than balanced by the benefit that people are receiving through the state-only program. Wouldn't it be nice if the federal folks understood these needs? But I guess, you know, it does raise the question. I don't want to prolong the discussion because I think we've had a good, healthy introduction to the bill, but it does absolutely raise the question about how healthcare is being managed along the Mexican border right now. And what, what resources are being invested there to take care of people? Just, I don't know the, I, we've heard some of the answers to that, but as it goes through FEMA, does it go through other emergency funding processes? And then what are the long-term, what are the long-term policies that are going to be put in place? And, and can Vermont benefit from that? You know, that doesn't, not going to hold this bill up necessarily, but certainly something to keep an eye on. We'll have to ask our congressional delegation to keep an eye on that for us. I'll talk with Congressman Welch, perhaps. If we can be of any assistance in helping you get people to the table. Thank you, I greatly appreciate that. And you certainly will be. Be careful what you, be careful what you ask for. No. Thank you. Any other questions for Mike Fisher, healthcare advocate? Okay. We're good. All right. So I'm going to suggest a two-minute stretch and then we're going to move on to H-153.