 Okay, good morning. This is Friday, February 26th. It's 830 in the morning. And this is the house health care committee. This morning we are going to hear testimony from a number of witnesses regarding a proposal to expand Dr. Dinosaur to pregnant women and children of Vermonters whose immigrant status does not make them currently eligible for pregnant women and children of Vermonters. So I'm going to turn this over to, well, first I want to say I appreciate Representative Black helping to take the lead on working on this. And I'll join by Representative Cortis, who I understand representative Cortis, you are going to guide us through the testimony this morning. Yes. Thank you, chair Lippert. Representative Black for leading this. I'm happy to help in whatever way I can. So just a time check we have until what time? We have 50 minutes. Five oh minutes. Okay. So we're going to start with the executive director of the office of the healthcare advocate, Michael Fisher. Good morning. I think they call me chief healthcare advocate. I think they call me things. But good morning. Thank you. I really want to appreciate the. The health committee. And I'll echo and apologize. Representative Black, I'll echo representative Black for stepping up and taking leadership. The committee is recognizing that we have neighbors in our myths who, who are locked out of healthcare because of their immigration status. And this is a proposal for a very modest, small change to crack open the door for a small set of people who would have a really tremendous impact. Tremendous positive impact in gaining access to prenatal care and care for children. And so our goal here is to listen directly as much as we can from people who would be impacted by this and, and listen to people who work directly with them. These moments happen from time to time where, where the moment is right. This is not a new issue, but the moment is right. And not only because of our current recognition of the needs of racial justice. But also because of COVID. If there is ever a time when we need to make sure that people have access to care. All people. Or as many people as we can manage. Now's the time. So with that, I will get out of the way and, and, and let people who, who know this popular, know people who would be impacted by this. Speak. So if I may jump in for a moment as the chair and just say that. I'm going to suggest that we hold committee questions until all witnesses have been heard. Thank you, chair. And I'm. Representative black and I second that. Thank you. Chief and my apologies for the, the misnaming you. Next we have good morning. Marisela. We're so happy to have you. In our committee this morning. And I'm very grateful that you were able to take the time. And may I, may I call you Marisela. And I'm very grateful that you were able to take the time. And may I, may I call you Marisela. Hello. Good morning, Marisela. The lady Marie Cordes, Representative, I was giving her the welcome. And I asked her if she was okay. Marisela, is your name. Yes. Good morning to all of you. Good morning, everybody. Good morning, Marisela. So please feel free to share with us this morning. And so, yes, very good. When it's this list, feel free to share with us this morning, your testimony. I think we can do it now. Yes, my, well, I think you know my name. Hello, my name is Marisela. And. I live in Vermont, but I'm from Guatemala. I think you've already heard my name, but hello everybody. My name is Marisela. And I live in Vermont, but I'm originally from Guatemala. We live in work on a dairy farm here. And I live with my husband and my children. And I have four kids. Two kids were born here and two were born in Guatemala. And I have four children, two who are born here and two who are born in Guatemala. Well, in my experience here, well, well, if there's a difference and it's a bit complicated for us as immigrants, And in my experience here talking about my children's health, there's a big difference between my children and it's it's a difficult and it's a complicated experience for me. So I recently had a baby, my baby is now nine months old. And then in the hospital or in the doctor, I went, I was going but after I was born, some very high bills have been sent to me that according to the hospital covers it, but this time it's not. They've been sending me a bill of, they're giving me a lot of money. So it's difficult for us and sometimes it makes us not go to the clinic because it costs us, that is very difficult to earn money and to be paying a lot is difficult. And during my pregnancy, I would go to the hospital I would get medical attention and after the birth of my child, then I started to get the bills really high bills and I thought that maybe the hospital would be would be covering those expenses but I'm getting charged lots and lots of money. And that sort of experience makes it so that my family and I decide that in the future we can't go to the clinic when we need to because it's really hard to make money here and then to be spending money that you don't have on health care is very difficult. Sometimes they've had diseases like this, not serious, but it also costs us to pay the bill because it's a lot of money that they always send and sometimes they say that we didn't want them to have serious diseases but it costs us a lot because we're afraid to take them because they send us very big bills or quite a lot. And then with my children from Guatemala, they don't have health insurance either and so when they've been sick and thankfully they haven't had any severe illnesses yet, but even with the illnesses they have had it's really hard to pay the medical bills because the bills that they send us charge us a lot of money. And so we think what would happen if one of them did have a serious illness and we'd be scared to bring them to the clinic or the hospital because of the bills that would come afterwards. It's complicated to know that we don't have anything and it's already for the state or for the community, as I could say, not only us, but there are more people who need it as immigrants. And for those reasons, we would like to ask you today to expand access to health insurance to cover our children because as immigrants, it's hard knowing that you don't have access to anything. But this change would be something that benefits not just us, but the entire community and the entire state. And at the same time, we'll continue to do our part, working on the farms and I think that's something that the state benefits from as well. Thank you, Marisela. I want to clarify something about. Do you have children that are that do have insurance and children that don't? Thank you very much, Marisela. So to clarify, do you have children that do have insurance and children that don't have insurance? Yes. The children born here do have, but my two children from Guatemala don't. Yes, my two children who are born here do have health insurance, but my two children who are born in Guatemala do not. Thank you again, Marisela. I am so grateful that you took the time with us this morning to share the extreme difficulties. And this time that you spent with us will be helpful for our committee to continue working on fixing this, this problem. And I also want to acknowledge your labor and the time that you took away from your family to spend time with us. I very much appreciate it. Well, thank you very much, Marisela. I thank you very much and I appreciate the time that you have taken to share these difficulties and the time that has passed with us. It is very important for our committee to be able to work to fix this problem and finally I want to acknowledge the labor and the time that you have taken from your family to be with us this morning. Yes, it is a pleasure to be able to communicate with you and it is a joy for us as immigrants to know that they want to do something to be able to have some benefits here in that country. It's a pleasure to be able to be here with you this morning and to speak with you all and I also want to say that as immigrants it also gives us great pleasure to know that there are people like you who are looking to do something so that as a community we can have benefits here in this country. Bueno gracias Marisela. Adios. Adios. Thank you very much Marisela. Alright, now we have Naomi will cut McCausland who will be sharing a video with more testimony, experiential testimony for us, and Colleen Kent, are you able to give Naomi. So she can share the video. Yes, we should have those now. It looks like I am able to. Okay. All right. Thank you. Good morning everyone and thanks for the opportunity to join. Can you just be sure to state who you are. And for the record, thank you. Yes. So my name is Naomi woke up McCausland. I work with UVM extension as the migrant health coordinator. We support access to health care services for immigrant farm workers across the state. We cover 13 counties and work closely with the open door clinic who covers the 14th County and hideous on the call representing them today. So I, you know, as I do work for the university, but just want to say that this testimony doesn't necessarily reflect the views of the university, but are my experiences. Anything I want to just be able to pass my time on to two individuals who are going to speak about how this particular issue has or would impact them. And so it will take a second, but I'm going to get to just pull up a video. They weren't unfortunately able to join today, but felt compelled to share this with all of you. I may want Naomi is preparing the video. I want to express my appreciation to will limb back for offering translation services to our committee today. Thank you will. Yeah, thank you chair. If someone can just give an audio response that they can see the screen. I can see it. Hello, I'm Yadira. I live here in the state of Vermont. My family is integrated by my husband and nine-year-old son and one year and two months. For us as an immigrant family, it's very complicated to go to the hospital for the bills that arrive at home. Every visit to the hospital, they raise the amount of money. I am Yadira. I live in Vermont. My family is made up of my husband, my son who is nine and my son who is one year and two months. For us as an immigrant family, it is really complicated because of the bills that later arrive at the house. Every appointment or visit to the hospital brings an additional cost. For me, during my pregnancy with my son, I had a lot of problems. I had a surgery. And with every visit, the bills increased. You get to the point where you don't even want to go to the hospital because you get to thinking. How am I going to pay for the large amount of debt that appears? With my son who was born in Mexico, if he goes to the hospital or to the pediatrician or emergency room, every time he goes, because he isn't a citizen, every visit could be $2,000 or $3,000 or $4,000. It turns into enormous quantities that are just too difficult for us to pay. And then when we are there, they ask us about paying. And if you cannot, you get these looks like, why are you here if you can't pay? And when they begin pressuring you about a family member's immigration status, you become afraid. You don't know the rules of the hospital. So you think that maybe they'll call immigration. And then you no longer want to go because you're afraid. And it ends up being so much money. I think about the big difference between my son who was born here and my son who was not. For my son who wasn't born here, I can call to try and get him seen. But it takes days in contrast for my son who was born here. It's quick. Sometimes I get to the point where I don't even want to bring him in instead try to bear it to avoid racking up the bills. Because if you can't pay the debt, they send it to collections and the people call you and send letters demanding payment. If we had the money, we would pay the bills, but we don't. It's difficult, stressful, and depressing. Hello. Good morning. To all who are watching this video. My name is Annalie. I live in Vermont and want to thank the people who are thinking about the well being of my family. It is for that reason that I'm recording this video. I'm unable to participate in the call due to work. So it was easier for me to make videos for you to see and for me to tell you a bit about my story. Two years ago, I came to Vermont and thank God have been working on a few dairy farms. I have a son and he's always falling ill. So I have to bring him to the hospital. It's very expensive because he doesn't have any health insurance. So I've been receiving bill after bill after bill for us one visit to the emergency room. And we are charged a great deal. And without all of that money, the bills keep coming. One day I called them up and told them they could just come and get me because I don't have that kind of money. The bills come $1,342 and they didn't do much of anything for my son. Without health insurance as immigrants, they charge a lot. And what can we do? I would be very appreciative if there were an opportunity to have health insurance at the very least for my son. There are so many others like us who suffer the same. I thank the person who invited me here to speak by video, to ask the legislators to expand insurance, because it would be a pleasure, something special, if my son could have access to health insurance here in Vermont. I hope it is possible. In advance, I'm thankful. God bless you. Thank you. I hope I can do it. In advance, I'm very grateful. Thank you very much. I didn't hear anything, so I'm assuming that you are all able to watch that. So these experiences that we've seen over the past decade plus are not unique. I think something that sticks out for what we have seen with women who need prenatal care and children without insurances that their experiences really vary across the state. Certainly the experiences of receiving large bills and fear about payment are consistent, but in some cases hospitals are covering that cost through financial assistance programs. I think one of the things that we have seen in our experiences, care at the hospital is not able to happen with a financial assistance plan. And so we have seen many scenarios where a family is traveling maybe an hour away to go to an FQHC when there's a hospital, 10 or 15 minutes away from where they live. And so we have experienced difficulty accessing transportation. And so certainly we have seen delays in care as a result of long distances that people have to travel as well as the fear of cost. So I'm going to leave it at that and pass it back. Thank you. Thank you. Naomi. We'll move on now to Alicia Rodriguez. And we have just a time check we have a little over 20 minutes for Alicia Erin and Heidi. Hello everyone. Good morning. My name is Alicia or Alicia Rodriguez. I'm the communications coordinator with the office of the healthcare advocate. And I think the first thing I want to do is just genuinely thank the committee for giving space to hear testimony from the folks that we've gotten a chance to hear from this morning. I think that those voices are very, very powerful in this conversation. It's really important to put them at the forefront of this issue. And essentially what I'm here to do this morning is to just tell you all a little bit about Vermont's complex rules related to immigrant eligibility for insurance. So I'm hoping to just kind of contextualize some of this information and tell you a little bit more about the legal framework that exists here. And I just hope to demonstrate how our current system is failing to meet the comprehensive healthcare needs of undocumented pregnant people and children in Vermont. These individuals are members of our community, obviously, as you heard this morning. And fundamentally, I think we have a duty to reduce the inequities in our healthcare system. And specifically so when they disproportionately impact people of color in our state. So the HCA or the office of the healthcare advocate has both a policy team and an advocacy team. Our advocacy team operates a free legal helpline that enables any Vermonter to connect with a paralegal that can help them untangle their legal questions about health insurance. We've been working over two years connecting with hundreds of Vermonters as a member of this team. And while serving as a healthcare advocate, I had the opportunity to learn a significant amount about the complexities and shortcomings of our healthcare system as it currently exists. The advocacy team witnesses Vermonters struggle with a multitude of affordability and access related challenges every day. And the cases that really highlighted the disparity in our current system are those related to access to care for undocumented individuals. Today you've you've heard from these people themselves and you'll also hear from providers who do a lot of fantastic work to serve these members of our community through their clinics. The lack of access to care in these situations is really often dependent on your geographic location in the state. And there's very limited access to comprehensive care for undocumented pregnant people and children within these particular settings. I believe that this deficit exists in part because of the lack of access to affordable health coverage for these individuals. And it is my hope that by highlighting these complexities in our system that can it can give you all a better understanding of how inaccessible our current system is and how these inequities really play out when we talk about access to care. And specifically a lot of these inequities really shift the cost of this care onto hospitals and these low income Vermonters. So here to begin, I just I'm going to, you know, throw a few health insurance terms for everyone. So, I want to start talking about qualified health plans and Dr. Dinosaur so these are traditional health benefits that both citizen Vermonters and some non citizens that lawfully reside here are able to enroll in. If they meet those financial income criteria. So undocumented Vermonters currently cannot enroll in health insurance programs through Vermont Health Connect. That means they can't get any help related to financial costs of their health insurance. They can enroll in a direct enroll with Blue Cross Blue Shield or MVP for the full pay the full price for her health plan. However, for most Vermonters, regardless of your income level, these prices are unaffordable between the monthly premiums and then the cost sharing that would be associated with that. And really the only system that we have for covering some of these outstanding medical expenses is through a program called emergency Medicaid. And emergency Medicaid has some really complicated coverage criteria. And in addition to that the application process is very, very complicated and by virtue of that really inaccessible. So emergency Medicaid coverage is only available to Vermonters who are ineligible for Medicaid because of their immigration status. Recipients of this benefit must meet all other eligibility criteria for Medicaid, meaning they must reside in Vermont and they have to meet the income qualifications as well. Emergency Medicaid also has a very limited coverage criteria. It only covers the treatment of sudden emergency medical conditions. Labor and delivery is considered a covered service for this benefit. However, organ transplants follow up care and routine prenatal and postnatal care are not covered under this service. And despite the existence of this benefit, it's significantly underutilized within our state, considering what we know about this population. And Diva reports that between 2016 and 2021, this type of coverage has only been granted 10 times. And in that period, only one labor and delivery was covered, and there were no children under 21 that received payment for those covered services. And as I mentioned before, the application process for this benefit is very burdensome. It's actually more burdensome than any other health program that I'm aware of. So to apply for emergency Medicaid, a person must fill out a document, a very long application called a 205 all med. And then after that, both that individual, in addition to the provider, have to fill out another application called a 201 EM form. And when both of these applications are complete, the provider and the individual client or applicant within that circumstance also has to submit documentation related to their medical bills and their medical claims. And once all of this is done, and it's then submitted to Diva's clinical team, and they're the ones who have the opportunity to retroactively approve or deny this kind of request. So I think that you can get a sense of how complicated this application process is from that application, from that explanation. Again, it's burdensome. It's more burdensome than any other program that I'm currently aware of. And I'm also not aware of any language appropriate applications or outreach material for this particular type of coverage. So I think all of that is to say that currently many Vermonters who need access to care, you know, rely on going to hospitals for this kind of care. And one other inequity I just want to highlight in the system is that often people rely on patient financial assistance within the circumstance. However, Vermont does not have a comprehensive framework to really understand and receive patient financial assistance in the state, meaning that you can go to one hospital and they may have particular eligibility criteria that you meet. However, other hospitals may find you ineligible for any type of assistance, even though you have the same household income in the same household size. So there really is a huge geographic issue to access to care within our state that I think is really important to highlight in these conversations. So as we continue to address racial equity and healthcare on a state level. I think we have to improve our systems with these community members in mind. Many children and pregnant people in our state don't get necessary care because they don't have health insurance and don't have the money to pay for their medical costs out of pocket. Some children struggle to obtain necessary vaccines and primary care and pregnant people often give birth and fear because they're never going to be able to cover the cost of that care. Prenatal and childhood access to care are really undisputed on building blocks for better health throughout life. And as Vermont's current health reform efforts really focuses on the principle of providing primary care to everyone as reduced as a means of reducing the risk of long term, undetected and non treated illnesses. So we really think that we need to keep access to care for this population and all Vermonters in mind as we continue to reform the system. Thank you so much. Thank you so much Alicia. Now we'll move on to Aaron Jacobson. You're muted Aaron there you go. Sorry about that. Thank you everyone I'm going to try to keep it brief. So first of all my name is Aaron Jacobson and I am a professor of law at Vermont law school. I teach immigration law in the classroom and I also run the immigration clinic. Where in we work with law students to help non citizens obtain status in the United States so they can stay here permanently. And our caseload is made up of humanitarian immigration cases so though that's people who are seeking asylum, because people who are fleeing persecution or torture, people who might be applying for trafficking visas, you visas because someone is a survivor of a crime, domestic violence cases, and cases for special immigrant juveniles who are kids who've experienced abuse, have been abandoned or neglected by one or both parents. So those are the, those are the people that we work with day in and day out and almost all of our clients at, at one point or another are ineligible for health care. I just want to add to Marisela and Yadira and Aline's testimony here and talk a little bit about some other, another category of non citizens who are carved out of the eligibility categories for Dr. So, in addition to the broad category of undocumented individuals who are not eligible for health care. There's, there's this other category of people who might be, but might not be, and it's very complex and I'm not going to try to explain all of the ins and outs and the next four minutes. But I do want to make a quick point about the fact that this is very complex and that is that oftentimes even those people who might actually be eligible under our current laws, children and pregnant women were lawfully present. There are we often see denials and error by the agency because the, because the rules are so complex and confusing. And then oftentimes, you know, sometimes I might hear about this, or someone like Alicia and maybe we can help those individuals access health care, but oftentimes I suspect we're just not hearing about it. People are being denied health insurance access to health care and they don't know that it's a denial and error. So, to be able to simplify who has access by just saying all Vermont children and pregnant individuals have can have access to health care would be an enormous benefit obviously both to those individuals, but then to to that to the decision makers here. So, the category of people that I want to to talk about are those who are lawfully present. And if you are lawfully present. If you're a lawfully present child or a lawfully present pregnant woman, you do have access to health care under Dr. Dinosaur. However, what is lawfully present. Like I just said is very complex and confusing and who is not lawfully present are people who might be seeking asylum but have not yet applied for asylum. The other thing about an asylum seeker is that you have to have applied for asylum, and that application has to be pending for six months before you're eligible eligible for health care. The abused, abandoned or neglected child who is seeking special immigrant juvenile status under the federal immigration laws but has not yet applied for that status is not considered lawfully present under our laws. So you have this group of very vulnerable individuals, people who are fleeing torture, people who are fleeing persecution, people who are fleeing abuse. And their children and their pregnant women and they are not eligible for health care and they won't be eligible for health care until they can apply for a very complex, difficult to obtain humanitarian immigration status and even if you can pull that off. And that process in and of itself is very challenging and takes a long time so those individuals are often also new arrivals, and they're here in a very vulnerable situation, both in terms of what they're, they're fleeing, but in terms of their legal status. Again, then they do not have access to health care so I just want to give one example. So that hopefully we have some time for questions and I'm not taking up any more of anyone else's time, but I think this will help illustrate the, the people are facing and the and then another this other category of folks that we're talking about that isn't that's in addition to our undocumented farm workers. So, this is a person who came to our office recently. She is from Africa, she is fleeing horrific torture. She has been in the US for about a year. She came with her husband, who then in the United States he became severely abusive. She fled him and that relationship, and she is, she has now found herself in Vermont. She is with her young child who's three years old, and she is eight months pregnant, and she is homeless. And she ended up at one of our sister organizations, the Association for Africans living in Vermont, they called us, they're trying desperately to find her health care, because of the fact that she is eight months pregnant. She hasn't had any health care in the United States since her arrival, her three year old does also does not have access to health care. And she also has a very complicated medical history connected to her torture in her home country, and the fact that when she was living there, when she had her first child her now her three year old, she had a very complicated and difficult birth. And at that time, her care providers told her that if she were ever to have another child she would need a cesarean. And so now she's in the state of Vermont, with no access to benefits, and it's the nonprofits who are trying to scramble and quickly get her some care. Another complicating layer to this story is that a lot of these individuals. As I mentioned there, they are new arrivals, there's language barriers, and there's also an immense amount of fear about whom to trust in our government. And when you when she presents herself to try to get some care. There are a lot of questions about her immigration status, and she fears that she could get arrested, that she might be separated from her, her child, because everyone is hearing about these things happening in the news. And so there's a lot of barriers built up toward for allowing these people to access health care. And yet this could be a very. This is a life and death situation for her. My last point is that when we're talking about these individuals, people who aren't yet lawfully present, but will be for so for this woman, for example, when we help her, and we, we send in her asylum application, she will then become lawfully present, once later. So it's, while she is in an extremely vulnerable difficult situation now, it's also a relatively limited amount of time that she is excluded from that lawfully present category. So I think it's important to know that for many of the people we're talking about. First of all, it's a limited number of Vermonters, and then also for many of them it's for a limited amount of time. Thank you so much. You're welcome happy to answer questions. Well, before we do that we're going to move on to Heidi Sue list. Thank you. And thank you for this opportunity to testify. My name is Heidi Sue list and I'm the executive director of the open door clinic in Middlebury. We're a free clinic for the uninsured and underinsured. And we're a member of Vermont's free and referral clinics. There are nine free clinics in the state of Vermont. We provide a tiny bit of context. Last year we saw 948 unduplicated or distinct patients, and almost 400 of those patients were either undocumented workers, or h2a, h2b, or asylum seekers. I have concluded testimony among the sustained group of people this morning and the brave women who provided their testimony, which I think is, you know, stories are always the most compelling means by which we can learn of real circumstances. And I think that perhaps the most important point I can make today is that by the time patients reach our doors, they are most often frustrated, sick, and desperate for care because they've hit one barrier and dead end after another, and trying to find help. My humble opinion and I've worked in healthcare since 1985. We are now in a multi tiered broken system of healthcare that's riddled with inconsistencies and a multitude of barriers to basic access to care that include but aren't limited to language, culturally appropriate care, transportation, daunting bills, prohibitive costs, and last but not least insurance status. There are so many types of tickets that you have to have in your pocket to get in the door, and they all have to be there at the same time. And, you know, if you don't have them, it's another dead end. It's actually a recipe for disaster and we see it all the time from the inside out at clinic. And unless we have blinders on now, we're also seeing it from the outside in as the pandemic has really ravaged this global community. So while in a different day, I would proudly talk about all the good that we do in our community and what a gem we are within an integrated system of healthcare. And one of the things that really matters is pre clinics are safety net organizations, and by the time community members reach us we're often working in a reactive mode. We're working to shore up all of the places that have been neglected by via lack of equitable systems. We provide care we provide case management we connect people to resources. And what we know in 2021 to be optimal health care, optimal and consistent health care, optimal care means equitable access for all. And as the pandemic has harshly shown us, none of us is healthy until we're all healthy. Simply put access to care and basic preventive care are the greatest indicators of excellent outcomes. As executive director I do a lot of fundraising because our services are free. We can't charge for any of our services and that's a world I comfortably live in. And when I was talking with Mike yesterday about what what would this actually cost. Julia, my colleague Julia and I just did some admittedly very quick research and math. And if we in fact are talking about a small number of women right now I'm just looking at pregnant women alone. I would just like to offer this for some, some thought to you all. You know, we learned yesterday in our Google search that the average cost of a vaginal birth in Vermont is without insurance is just over $12,000. The median birth is over $17,000. And then I threw in having been a childbirth educator for many years. Well we have to include some high risk women and some high risk pregnancies. And I literally pulled that number out of a hat. But if we were to assume that 10% of let's say we have 20 women we're talking about right now to put this in concrete terms. And 10% of those are high risk at $100,000 apiece 20% are cesarean and 70% are normal vaginal birth. I came up with a cost of care of just over $400,000 for these women, which in my view is peanuts for care. So, I guess, and I'm very happy to take specific questions about what we see and how we work at clinic and either care for people or connect them to resources. But I'd just like to leave you with I think that it's in the best interest of our society to take care of each and every one of us. And I really encourage you all to move forward, so that the human beings behind these categories of people that we often throw out in our discussions. But the real women that you've seen today who have shared their stories and who have taken huge risks to try to do better for their families and come here and contribute to our communities. Let's do it so they can be more equitably and optimally served. Thank you. Thank you so much Heidi and before I pass this over to our chair. I wanted to again thank all of you for your powerful testimony and encourage you to, if you have it written testimony to please send that to us so that we can. Our committee assistant can put it on our website. Thank you so much. Thank you. Thank you. Thank you, Mari and each one of you who brought testimony to us this morning. We are at our time limit but I'm going to, I'm going to indulge myself with one question and I see representative Houghton as a question and then I think we're going to finish for the morning we will return to this, possibly another point in time. This is very, very important and helpful testimony. My, my one question before hearing from representative Houghton is am I understand and I maybe direct this to Alicia and Aaron. In terms of barriers, I found myself on a number of occasions asking if the barriers were federal or state. Whether we have the ability under state law to make available to make Dr. Dinosaur. Available on a to make it more more available to pregnant women and two children of non citizen Vermonters. I realize this is a complex issue but if I guess I'm asking in a broad sense, whether you see us having the authority and the ability to do this. Yeah, I'm happy to address this question a little bit further and the answer is it's a little bit complicated but I'm happy to simplify some of the language. So under chip. So the Children's Health Insurance Program which is a federal benefit. They actually give states the option to extend prenatal care so it wouldn't be as comprehensive as Dr. Dinosaur coverage but prenatal care to those pregnant women. So that would mean that that individual coverage related to pregnancy care and labor and delivery can be potentially expanded under that benefit for a state option. When we talk about coverage for undocumented youth within the state of Vermont, that likely would have to be something that would be state only funding, just because there are certain federal restrictions related to immigration status and enrollment and Medicaid. So there is an option for expansion under chip and there may be some flexibility with state funding to expand coverage for those children. But there's not a federal barrier to states choosing to do that that I guess that's part of my question as well. I would need to be a little bit precise about language here but what I will say is there's not a federal barrier to extending pregnancy care so that prenatal care to undocumented pregnant women. And if I can jump in other states have done have extended coverage with with state only funding. And clearly, we will need to ask many questions and come back to this but I wanted to just have that broadly on the table for us to be thinking about representative Houghton and then we're going to then we'll stop because we need to be on the floor, our speaker to ask us to be on the floor promptly at 930 which is when we convene this morning. Good morning representative Houghton. Thank you and I just thank you everyone. I mean I sit here and and and listen to everything that you all are doing to help Vermonters and it's very impressive and I'm sure very difficult for each of you so thank you. I just, I, you know, when I think about all of this I go back to all the things we talked about with social determinants of health and how important it is for young children to be treated early to have a good outcome or be able to have a better outcome in life. And so it was any of these programs or lack of programs. I'm just asking for clarification so right now there is nothing available for the early years of care would only be during if we were able to do something it would only be that that pregnancy piece is that accurate. Heidi I don't know whether you can jump in from the provider perspective. I'm not sure if this is going to answer your question clearly but one of the things that we do with undocumented. So, if we are serving families who have undocumented families who have children, let's say who were born in Mexico, and therefore don't qualify for services. So what we do representative Houghton is to work with them to apply for Porter financial assistance and see, and that is by income, see where they qualify. So do they qualify for 100% free care 8060 etc, and then try to place them into, for instance, Porter pediatric practice so that their children can get care. I unfortunately don't know beyond that, if they can then access a multitude of other programs, you know that, depending on what their needs are. Anyone else here can that. So that's how we'll try to get them access to health care. Thank you. Complicated and Okay, well again. I want to thank Mike Fisher in the office of the health care advocate for bringing this issue forward on behalf of others who And to thank each of our witnesses and especially those who provided direct testimony about their own personal situations it takes courage, both to create a video, or to come before this committee. I recognize that and I want to expand extend my as the chair of this house health care committee extend my personal appreciation for that. I'm going to stop here this morning. This has been a full but fruitful morning. And thank you all, and for members that's run down the hall and get to the house chamber.