 Now, on committee, this is, and great minds think alike, I was chatting with Nina. This is really sort of a accountable care organization 101, because S7, which is, for the most part, the health care community deals with accountable care organizations. There is a bill that came over from the Senate currently sits in House health care that really is, you know, having to study to bring human service, long-term care, perhaps, into ACOs. And then there's two other pieces that have nothing to do with ACOs, little added bows and ribbons that have nothing to do with ACOs. But I thought it was important that whether we formally get the bill, but however it's going to happen, that we understand it so we can be thoughtful. Welcome. Thank you. For the record, my name is Ena Beckes. I'm the director of health care reform and the agency of human services. So are you in the secretary's office? Correct. Yes. Who else is in the secretary's office? It's a policy person, aren't you? That's a policy person. So you're the director of health care reform. So do you know? Sorry, is that an unfair question? It's not an unfair question. There's another policy position in the office that's vacant right now, but is being recruited for. And that's an AHS policy position. And it's one that Paul Dragon, who you may be familiar with, formerly held. I also, in the office, work with Auburn Waterston. I believe you've met in this committee, who's the director of trauma. Yes. Trauma prevention and resilience development. And Auburn reports to me in my position because we think that the link between trauma prevention, resilience development, and health care reform is one that we should foster in the agency. Aside from that, policy persons in the secretary's office, I'm not sure that there's there's this special assistant to the secretary. OK, that's the time. I began in my role in June 2018. And so I think that I have one year before I have to know everything about AHS. I'm not sure. And I think that realistically, I should get 10 years to know everything about AHS. So as you mentioned, this presentation is intended to help provide context for accountable care organizations and to do some basic overview about what accountable care organizations are and their intent and how they fit into Vermont's health care landscape as well as what they look like nationally. So you have some perspective about accountable care organizations. In order to do that, I'll discuss with you what an accountable care organization is, what an alternative payment model is. Because while accountable care organizations are organizations of providers, they also serve to accept alternatives to fee for service. And they are a vehicle for changing payment from fee for service method to alternative payment methodologies. I wanted to give you ACOs in the national landscape. But look at that, as well as ACOs and alternative payment models in Vermont, what Vermont has experienced with ACOs here in our health care landscape from 2013 up until this point today. And then talk to you, if we have time, about the Vermont All-Pair Model Accountable Care Organization Agreement. You've probably heard some about the All-Pair Model. The All-Pair Model, its official title is Vermont All-Pair Accountable Care Organization Model Agreement. So accountable care organizations are central to the agreement and are the component of health care reform that is driving our agreement with the federal government and the expectations therein that Vermont reduced the rate of growth in health care costs and improved health care outcomes in the state. What is an accountable care organization? This is Medicare's definition. Medicare defines accountable care organizations as groups of doctors, hospitals, and other health care providers who voluntarily form partnerships to collaborate and share accountability for the quality and cost of care delivered to their patients. The Affordable Care Act made it possible for Medicare to facilitate these sorts of arrangements between providers and to provide through the Center for Medicare and Medicaid Innovation, as well as through CMS, the full Center for Medicare and Medicaid Services for alternative payment flows to accountable care organizations by Medicare. ACO. I'm sorry, can you read me? Try it again. The Affordable Care Act created a pathway for Medicare to pay accountable care organizations differently than fee-for-service. From the beginning of Medicare, 1965, Medicare has paid providers for every service that they perform after they perform that service. Accountable care organizations can be paid differently by Medicare in ways where there are targets for their overall spending, and then there's a reconciliation or a true up to that target. And here in Vermont, Medicare is actually paying the accountable care organization upfront a fixed perspective payment prior to the care being delivered to the population for which the group is responsible for. That means that the providers have more flexibility to provide for a range of services that may have not been reimbursed by the traditional fee-for-service model. One is a care coordination service, calling another provider to see, if you're a healthcare provider, you may wanna make a call to another healthcare provider to make sure that there's a warm handoff with your patient or to seek expertise and otherwise coordinate around care to make the experience of care more seamless and more efficient for the patient. That's not something that has been paid for in a fee-for-service reimbursement model. I have a short video here that I think will help to describe ACOs. I wanna preface the video with the information that this video is a little bit dated. There are now more advanced alternative payment models in circulation than the video describes. And also this video is talking about a particular type of accountable care organization. The accountable care organization that's operating here in Vermont is one that's broader than just physicians. And we can talk about that more. This video is about physicians. But I think it's very helpful in describing, isn't just a new way to get health insurance. It also ushers in them who approach the care. Meet the ACO. The accountable care organization is a network of doctors and hospitals that shares financial and medical responsibility for patients. The goal is to coordinate care and eliminate unnecessary spending. Medicare set these up around the country and private insurance have to. In the health system today, patients are usually responsible for coordinating their own medical care. The doctors that work with heart disease may see a primary care doctor, a cardiologist, and maybe even a heart surgeon. But the doctors might not talk much, so they could order repetitive tests or prescribe funding drugs. That isn't good for the patient. And it's expensive. It's also not the way things work in most other industries. Imagine your car won't start. Now imagine that to fix it, you had just left the transmission whisperer, the battery variant, the timing belt tycoon and the piston professional. The patients would only look at their piece of the car and not think about how the cars work together. That makes no sense. Instead, you go to an auto garage where an organized group works together to make your car run again. The ACO brings that kind of coordination to your medical care. Your doctors, imaging specialists, surgeons, hospitals all work together and share information to figure out the best way to get to life and keep you healthy afterwards. What's an end for the ACOs? ACOs that are safe and care money get to keep a portion of that savings if the doctors and hospitals can show they're doing a good job keeping people healthy. So, are ACOs working? Well, the jury's still out. It's unclear how much money ACOs save and some organizations that try to form ACOs have quit. There are also concerns that ACOs could reduce competition and lead to higher prices. Wait a minute. How is this different from an HMO? ACOs have been accused of being health maintenance organizations in disguise. Both depend a lot on a primary care doctor who coordinates care. But there are some major differences. Patients in HMOs are covered only when they see doctors that aren't part of the HMO. In a Medicare ACO, patients can also see doctors outside the ACO. Should we worry that an ACO can save money by cutting corners? ACOs get rated on the list of quality measures to make sure no one scans on care people needed. These measures don't yet track all expenses of care, but the goal is to get ACOs financial incentives to keep people healthy, instead of just treating them once they're sick. Want to learn more? Go to the address on the screen. You've got the color of dancing. Oh. I did that quietly. Not much dancing. It's a very helpful video. I do think the narrator speaks pretty quickly. I can't talk that fast, but I'm sure that she rehearsed. As I said, the video talks about an accountable care organization that's chiefly made up of physicians. And here in Vermont, we have one accountable care organization at this time, which has a much broader network than just physicians. The network includes hospitals and physicians, but also includes health providers, mental health and substance abuse providers, and a broad continuum of care. I think that's important to talk about, because a lot of times we think about ACOs working best if they're able to achieve clinical integration. And that means integration between different service providers. And if we're imagining how an integrated system promotes health, well-being, and emphasizes prevention, I think that looking at the Robert Wood Johnson Foundation's framework for an integrated health care system is important and helpful in thinking about, for months, accountable care organization. The Robert Wood Johnson Foundation says that an integrated health care system is one that balances clinical care with prevention-oriented public health and community-based social services to improve health outcomes while driving down costs. And in Vermont's ACO that's currently active, we see this type of continuum of providers participating in the network. And we also see that population-based alternative payment models are in play to allow for flexibility in payment and to allow for there to be a different model of payment that embraces the clinical care balance with prevention-oriented public health and community-based social services. You can hear from the ACO, perhaps you will, about their investment in population-based health programs and how they partner with community-based social services. But the Robert Wood Johnson Foundation says very clearly that the population-based alternative payment model is important for advancing the goals of a clinical and integrated health care system. In order to meet the goal of an integrated health care system, Robert Wood Johnson is saying that population-based alternative payments matter because they create, again, that flexibility for this broad continuum of providers to work together. ACOs are the groups of providers that have come together to share accountability for patient care. It's in their title, Accountable Care Organization. But an accountable care organization may not be very effective in sharing this responsibility if it's not being paid for in an alternative way, like you heard in the video. But there isn't just one alternative payment model that accountable care organizations accept. There are, in fact, many alternative payment models. Medicare alone has quite a few different ACO programs that it operates. Then, as you've heard from the video, there's also commercial payers that are creating alternative payment models. And I'll also talk to you about Medicaid programs that have alternative payment models. So broadly speaking, alternative payment models pay providers for quality in care and improved health instead of reversing health care providers only after each individual service is performed. In the most advanced alternative payment models, service delivery does not trigger payment and payment is not linked to volume of services. Rather, providers are paid in advance and responsible for the care of a patient for a long period of time, a year. In Vermont, that's happening with Medicare and Medicaid in how it's paying one care of Vermont, the ACO, that's here in our state. So when you talk about alternative payment model, do you envision different payment models depending upon the type of service and provider that you're dealing with, that ACO is dealing with? The ACO is the unit that accepts the alternative payment model. And so when I'm talking about alternative payment models and particularly in the context of our all payer agreement, which looks for there to be an aligned payment model in Medicare, Medicaid, and commercial payers, that is the payment model to the ACO. However, the ACO then has the flexibility and the responsibility to make choices about how it pays the providers that are participating in the network. So your alternative payment model is what the state pays to the ACO and private insurance? The state, in terms of Medicaid, yes, has a contract with the ACO. OK. And then does the contract with one care include parameters around how they institute alternative payment models for the people that contract with them or their members or however they do care about it? I suggest that you follow up on that question with the Department of Health Access because they have the contract with one care and can speak to what is provided for the contract. I am not sure that that level of specificity is in the contract. I believe that there may be some flexibility for the providers in the network to work together to determine the best reimbursement strategy. OK. That was a question in the call. Oh, and then sorry. Do you know how they came up with the prepayment amount? Yes. In these alternative payment models, the most advanced of which are a prepaid amount. That amount is based on the historical expenditures, health care expenditures, for the population of patients that the ACO has responsibility for. So they look back at what the health care costs were for the group that the ACO was responsible for. They trend those costs forward, and then they provide for a per member per month payment. That's an average of all of their members in historical costs. Yes. And then in the trending forward, that's where there's an opportunity for cost containment because that trending forward can be at a rate which is more moderate than what otherwise might be the rate in a fee-for-service system where there's no limit on what the expenditures will be at by the end of the year. In the ACO, it's an alternative payment model to the ACO. It may be trended for it at 3% growth, but the total dollars are set for the year. Carl, anything you'd like to say? Just to say, our designated agency, NCSS, is working to try to figure out how the social services that they provide integrate into this whole thing you're saying as part of the medical results of the support services that are going to potentially get both ended. But they were still wrestling with exactly how all that works. It's quite something to be looking at. So the interesting thing here, you're saying the counter-economic group that we should be hearing from in the future that might have more on this. I think one care of Vermont is the counter-economic organization that's operating in the state today. I know, I've been in a couple of their meetings or I don't know where they've laid out the whole thing. I'm just wondering how they bring designated agencies and the followings that they go for all models. We'll probably hear more about that. Yes, designated agencies are part of one care's network. You can hear the particulars of that from one care. And the services that designated agencies are providing, some of those services are contained in the contract between Medicaid and one care of Vermont, as well as the contracts with the commercial participants and the Medicare, because designated agencies do provide mental health and substance abuse services that are considered fee for services as a part of someone's overall package of benefits. The Medicare model includes in its package and here in Vermont, Medicare part A and part B services, which is hospital and physician services. And in the part B, that's where you see mental health and substance abuse services. I think there's a future of anybody who's providing services on fee for services basis. Medicare is pushing very strongly for its payments to move away from fee for service entirely. Medicare is in the last number of years that I've been working only become more aggressive in its goals to move away from fee for service. That being said, I don't think that the whole system would move away from fee for service. And in particular, many Vermont providers accept payment on behalf of persons who are not Vermont residents. If other states are participating in the same way in alternative payment models, those payments to providers will have to remain fee for service. That's one example. I think there are other particular services that may make sense to be delivered in a fee for service. So do you think this has something to do with some of our smaller hospitals having financial problems? No, I don't. Other questions before? Not at this moment. Okay. Here's CMS's payment model framework. It shows the first category of payment being fee for service. And it defines fee for service as a type of payment that has no link to quality and value. I think that that could be argued, but that's how that's defined here. Category two of the Medicare or CMS payment model framework is fee for service payment, but with a link to quality and value. Meaning there would be at least some portion of payments that would be linked to the quality or efficiency of healthcare delivery. Then there's category three, which are alternative payment models that are built on a fee for service architecture. Meaning fee for service is still the method of reimbursement, but payments are being linked to the effective management of a segment of the population or an episode of care. And payments, again, they're still triggered by the delivery of services, but there's an opportunity to share in savings if the system does better because of its work together, its integration, if it does better than a target that's determined in advance. And then finally, population-based payment, which is what CMS defines as category four and the most advanced alternative payment model, is payment that is not directly triggered by service delivery as I explained in the previous slide, and where clinicians and organizations are paid for the response, are paid and responsible for the care of a beneficiary over a long period of time. Where does the remand model fall? Remand model falls in between category three and category four. Our model falls into category four for Medicare and Medicaid and category three for commercial. So what I don't see on this scale is payments made in long-term care services that are based on annual budgets, though that a monthly or daily rate, but that are all inclusive in services that not currently has for some long-term care recipients. And I understand the concept of being population-based, but I'm just curious if you have any information about what long-term care services might look like under a model like this. And I know that things are not been integrated into the ACO yet. Obviously, that's an issue that this committee has interest in. I think that actually those services in a way that they're paid for now, some of them, some components of home and community-based services, River Monters are paid in an episodic way. So there's a bundle of services for a particular need and that those are paid to the providers or to the families that are, or provided to the families that are contracting for care, and that they include a number of different services as a part of that bucket of services. So I would say that actually looks a little bit like in category three. And that is something that is being looked at. The way that those services are paid for is something that they're looking at, although not necessarily looking at redefining for the purposes of the all-fare model, but looking at redefining for the purposes of alternative payment models to make it a stronger alternative payment model. So one of the things that's interesting is that the payment framework it seems to really be based upon it's really based on a provider level of not need, it's not my word, but in it I'm trying to figure out how it enables adjustment for things that are individualized. So where people, we're a consumer, an individual who's gonna require care for the rest of their life, that could be 20, 30, 40, 60, 70, 80 years, and has an individualized budget that might have a whole array of services. How that fits into any of this? I think you're raising a really important question and I'm not sure that it does necessarily fit into this, whether or not that type of payment can be, there can be innovations with that type of payment to make it more complementary with this model because certainly those persons are active and involved with the healthcare system. I think that's work that we have for the one to do that. But it may not be appropriate for certain services to be included in a total cost of care budget, the target for an all care model. Inmate, at the same time, it may be. Yeah, yes, I'm not holding anything, they don't work. I have a personal case of question. You started out by talking about the healthcare continuum. Yeah. What is a healthcare continuum? And because we're talking about efficiency of healthcare delivery and so delivery of services. So what is or is that coming later? It's not coming later. I think I'll go back to the Robert Wood Johnson Foundation slide. It does not delay the healthcare continuum. I think that to a degree the healthcare continuum is defined by those providers and those patients who are a part of it and are utilizing it. The healthcare continuum is one though that I think according to Robert Wood Johnson Foundation and others who are thinking about what an integrated healthcare system looks like. It means providers who are providing preventive services as well as providers who are meeting the acute needs of a person whether in a medical emergency, a mental health emergency is a medical emergency. So whether in an emergency situation, whether in a chronic care, in terms of complex and chronic care needs, but also looking at more what we might consider more preventive upstream services. So a preventive upstream service is the tobacco patch or tell me what our prevention oriented public health. Looking at the members of the blueprint community health teams could be instructive for thinking about that. That is the result of Vermont. I'm asking, so is that what you're saying is across the board, what is that? A continuum of care. No, I think it's defined differently. So it's to improve health outcomes. So what is a health outcome? I guess what are we looking at as a health outcome is it that people live longer, people don't have heart disease? That's a great question. In the video that we just watched from Kaiser, I think that that video is a little narrow of what it's thinking about as a health outcome. It's probably thinking about that there being a good clinical outcome for a person who needs who needs services for their heart. It's pretty narrow to that definition. In Vermont, we have our all-payer model agreement has three high level population health outcomes targets which are to reduce the prevalence and morbidity of chronic disease, to reduce deaths due to suicide and drug overdose, and to improve access to primary care. So in Vermont, we have a much broader definition of what a good health outcome, we've defined a broader definition, I think, for what a good health outcome would be than other eight accountable care organizations that may be more focused on the very clinical health outcome of a patient. There are many different ACOs. And so one ACO is by no means any other ACOs. As I'll share with you, there are many ACOs operating in the United States in many different forms. There are hospital-based ACOs. There are physician-based ACOs, meaning there's no hospital component of the ACO as a group of physicians taking accountability. And there are ACOs that are working exclusively with commercial payers, exclusively with Medicaid or exclusively with Medicare. And in Vermont, as we'll continue to talk about, the ACO that's operating here is working in a consistent manner with Medicare, Medicaid, and commercial payers. And is a broad network of providers, not a hospital-based ACO, although there are hospitals, as you're probably aware, quite a few hospitals participate in the ACO. I said that Medicare was moving more strategically and with more emphasis away from fee-for-service than I've seen since I've been looking at alternative payment models, which was about the time that the Affordable Care Act passed. We've seen that Medicare only continues to push towards this goal for paying healthcare providers differently. And one key component of that is the Medicare Access and Children's Health Insurance Program Reauthorization Act, which passed in 2015. And this was bipartisan legislation that repealed what was the flawed Sustainable Growth Rate Formula for Medicare, meaning Congress had tried to control the rate of growth in Medicare healthcare costs by applying a growth rate formula. Year over year, that formula was overturned because the healthcare system required more resources. And so while there was a formula in place, it was basically ineffective in controlling growth. And so Congress said in 2015 that they wanted to do away with that and instead look towards a way to increase Medicare rates for providers, but to increase those rates based on the quality and outcomes for patients. So in 2017, based on the bipartisan legislation in 2015, the Quality Payment Program was instituted and the Quality Payment Program requires healthcare providers that have Medicare patients to either participate in heartbeat patients. So physicians, it requires those physicians to either participate in a merit-based incentive program, which is called MIPS, or an Advanced Alternative Payment Model. An Advanced Alternative Payment Model is what I've described to you. MIPS is a very onerous and labor-intensive quality reporting program. In MIPS, providers can either through their quality score, they can get an increase in their Medicare rate if they perform well, but they can also receive a decrease in their Medicare rate if they don't perform well on quality. Medicare has said that it believes that Advanced Alternative Payment Models have more likelihood of providers being able to improve quality and outcomes. And so for those providers participating in the Advanced Alternative Payment Model, they are guaranteed a 5% rate increase for Medicare. Other providers could see a rate decrease of up to 9%. They could also see an increase of up to 9%, but this is starting in 2020. But that increase is based on their successful reporting in the program, which as I mentioned is not easy, and then having very high quality outcomes. Whereas Medicare is trying to push providers into Alternative Payment Models with guaranteeing a 5% increase because they believe that the Alternative Payment Model will achieve better outcomes and has a better framework to help providers and towards those outcomes. So Medicare is having a new risk. Try this with no risk, and for the time being. And if I recall, in the month when we started to ask this, we are, it's basically a new risk for a couple of years. In Vermont, so Medicare is saying that if you're a healthcare provider taking Medicare in Part B, that if you're participating in an Advanced Alternative Payment Model, which is either in that category three or category four round, that they believe that your quality and outcomes are going to be improved in a way that will guarantee a 5% increase. That's separate from the risk arrangements in these Alternative Payment Models that providers can accept. And we can talk about those as well, and how Vermont's Alternative Payment Model programs began and how they've evolved. Because like I've said, Vermont's in category four now, part of the system is, but we didn't begin there. And I also wanted to emphasize that in 2018, the Center for Medicare and Medicaid CMS announced that ACOs that are taking risk in the Innovative Payment Models versus those that did not, are the ones that are generating savings and that that two-sided risk, providers have risk, Medicare has risk, that two-sided risk is a model that Medicare wants to move towards and to turn away from the no risk for providers. So as I said, there are multiple Alternative Payment Models with Medicare alone, it has what's called the Shared Savings Program Track 1. This is where Vermont started. This included upside only gains for providers, meaning if there were savings based on the provider's performance, the providers and Medicare could share in those savings. If the providers had not achieved savings and had spent more, then they were not on hook for that. That's the Medicare Shared Savings Program Track 1, again, where Vermont began. There's also a Track 1 plus, now Track 2, Track 3, and the ACO Investment Model, which is a model for non-hospital based ACOs in rural areas, and the Next Generation ACO Model. The Next Generation ACO Model is the model that Vermont is basically in, although because of our all-payer agreement, we have some room to slacks, and so the technical name of Vermont's model is the Vermont ACO Initiative. It's grounded in the Next Generation Model, which has the population-based payment track. We are sharing it with Dartmouth. I'm looking at the data names. Dartmouth, this is a slide from 2018. I believe that Dartmouth was in the Next Generation Model separately from Vermont and is no longer. One care of Vermont has two founding partners, which are the University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center. But you're saying Dartmouth isn't in that anymore? It is in, yes, it is a founding partner of one care. If Dartmouth was separately participating in the ACO program. So that Vermont's showing essentially two dots. There really is one now. Does Vermont and Hampshire are together? Or Dartmouth and UVM are together? Vermont should, the way I look at this is that there's a dot, the dot should really be in Vermont for Vermont Next Generation ACO participation. The video raised the question and said that the jury was out on whether ACO spend money. That video is a few years old. Like I said, it was a little dated, but it raises a good question. There have been some mixed results. However, as the ACO program progresses, there are more results and there are more concrete and clear findings that models with risk do generate savings. Particularly the Next Generation ACO program. As I said, this is the foundation for Vermont's all-pair model. This achieved net savings for Medicare of 63 million relative to benchmark levels in its first year of 2016. So there are findings that the risk models, the models transferring risk to providers are generating savings. I think that's right. $65 million saved on the ACO. Does that stay with the organization and is it distributed? That's 63 million is for the Medicare program. So as a healthcare payer, it's looking to reduce its costs. It's looking to transfer risk to the healthcare system. It's looking to remain sustainable as a Medicare program and viable. And so it's looking for ways to spend less money so that it can continue to cover its obligations to care for the member and citizens of the United States. And so those 63 million all go back to Medicare as a program. So all go back to the Medical Center? That's right. For you and for the committee, it is 1115. We're on slide six, and which is fine. Okay. Oh, slide 10. Okay, we're on slide 10. That's two thirds, I think. And at 1130, because we now have an amendment on the tobacco bill, the proposal is coming as well as we'll have two people on the phone. Sorry. No problem. That changes quickly here. I also want to give you some perspective about Medicaid ACOs. There are 12 states that have a Medicaid ACO. One is one of those states. In Vermont, Medicaid has a contract with the ACO. And again, there's a similar contract with Medicare and the commercial payers. These are the Medicaid ACOs. Now going back to how Vermont started in Alternative Payment Models for ACOs. In 2013, there was an ACO in Vermont called the Campbell Care of the Green Mountains, which was a function of health firsts, which independent physicians in Vermont. And in that year, it participated in the Medicare shared savings program. In 2014, you see that there begins what we call an all payer shared savings program. So the providers that belonged to ACOs participated in the shared savings model with upside only risk for across all payers. And that was in place for two ACOs, Community Health Accountable Care, which was called CHEC, which consisted of FQHCs and one Care of Vermont. Those two ACOs participated in all payer shared savings programs from 2014 to 2016. In 2017, Community Health Accountable Care chose not to participate in the Medicaid program because the Medicaid program had shifted from a shared savings model to a population based payment for Medicaid next generation model, which we have today still. In 2017, Medicaid launched the next generation ACO program with the full population based payment. And in 2018, as prescribed by our agreement with the federal government, one Care of Vermont, which was the remaining ACO choosing to participate, it entered into contracts not only with Medicaid, but again with Medicare and commercial for two-sided risk in the commercial contract and population based payments, like I said, for Medicaid and Medicare. So how, what's the universe of the population now being addressed in one Care as contrasting to those super public services in Community Health and through independent positions? Well, the other ACOs are no longer active. I get that, yeah. So I guess my question is they were, if I get my health care at Drew Community Health Center, I am not part of one Care. You are a part of one Care. Oh, I'm just gonna, okay, so, so everyone now is part of one Care? Well, not everyone is a part of one Care and one Care should come in and talk to you about who's in their network, but there are now FQHCs that are part of one Care. So FQHCs are part of that network. Well, I said that Medicare is strongly shifting its emphasis to population-based and risk-based payment models that are alternatives to fee-for-service. I think it's important to share that a recent final impact analysis about Vermont's performance in the state innovation model grant, which funded Vermont in its work to develop an all-payer shared savings program. That impact analysis found that Vermont was the only state among six states in the cohort to have positive outcomes on utilization of health care services, expenditure measures for health care services, and quality measures. So this is the outcome, yeah, just the fee-for-service measures. This is the outcome. Vermont gets a plus sign and a green box in all of those categories, different than all of the other states that participated in this program. This was for round one of the state innovation model. Again, there were six states that participated. Vermont was the only state that performed well in all of the categories, and it was the only state that had savings in the ACL model. Vermont generated $97 million of savings in the Medicaid ACL model. No other state had savings. Did they serve incomparable populations? Yes. These results here are, the evaluators took into consideration that while Vermont had an all-payer model, and the evaluators considered that that all-payer approach may have advanced Vermont's performance, and that a part of our good performance, they also chose to evaluate the state's incomparable Medicaid models. Meaning that the evaluation of savings is for Medicaid only, the evaluation of expenditure and quality measures is looking at the state's Medicaid participation in their models. However, not all of the states that chose to do payment and delivery system reform chose an ACL model. So you can also see that the three states that did choose ACL models are the three highest performing states in the cohort. States that didn't choose the ACL model relative to the three that did did not perform as well. This is the federal government evaluation of its own program, essentially. The federal government set up the state innovation model program to try to advance the uptake of alternative payment models and to advance cost containment after the Affordable Care Act passed. And the federal government hired independent evaluator, RTI, to look at how its program worked for the states that participated. Just a quick question. I know there are many reasons why Vermont performed so well in achieved savings, but is there kind of one overarching, simplistic, kind of reason why they did so well? I don't know that I could give one overarching reason. One thing that's really clear in the report from the evaluators is Vermont's iterative approach to reform, meaning that we innovated in the shared savings program, but we innovated while building on our existing infrastructure, like patients that are medical homes, like community health teams. We didn't just start brand new. We chose to incorporate those things and to leverage our success. And another thing, as I said, that could be helping Vermont in its performance was the fact that we were initiating these changes in all three payer groups. Another thing that's interesting about the evaluation is they look at Vermont's stakeholder engagement process and how Vermont worked with the care continuum and the community providers to get to a shared savings model. And while it's not conclusive, I think that there's something to be worried from the evaluation in terms of how it looked at. Vermont's spending on stakeholder engagement relative to other states, Vermont spent more on stakeholder engagement. What is Anna's mean of the chart? I think it means not, well, I don't know. It's not no data because that's also a chart. Do you have insufficient, non-specific data? I don't know. You could all guess from the question. You know, I don't... No statistics. I need to figure it out. Can you send it to Julie? Absolutely. Yes. I thought with myself about whether I should include all of the end notes for this chart because the end notes are as large as the chart itself. And so that's why I left them out and I apologize. That's Jesus. I just want to reiterate one thing. These six states are the leaders or they wouldn't have applied to be part of this program in themselves. Everywhere else, nothing like this type of innovation is happening. Right. But you guys are the leaders. So even if you're at the bottom, you're doing pretty well because you're in the group. Yes, round one does mean that the first states that were selected were selected because they had shovel-ready projects to test. Carl. It seems to be some sort of... Non-significant changes. Thank you. Thank you, Connor. It seems to be a lot of it also depends upon the involvement and the level of engagement of the hospitals and the network when I could see a recent Northwest hospital when I understand from my knowledge. This is just a broad disclosure. This has been my entire life for 15 years. So we both asked you to speak for your husband. You can hold on. So I know a little bit about it. I'm just going to look at the disclosure. My job is to protect. We have two more slides. OK. To sum up where this presentation has gone, we've talked about what ACOs are, what alternative payment models are, and I think it would make sense for us to end with talking about our current state, even though I've been talking about it throughout. But to describe it to you exactly what our current state is, Vermont has an agreement with the federal government, with the Center for Medicare and Medicaid Innovation. For Medicare to participate in an ACO model in Vermont on Vermont's terms. That means that Vermont is able to modify the Medicare ACO model so that it meets the needs of our state, is more appropriate to the needs of our state. It also means and the health of our population. It also means that through the model, Vermont's able to continue to invest in the blueprint for health as well as SASH services and support and services at home with Medicare dollars. If it weren't for the agreement that we have with the federal government, that money couldn't be a part of Medicare's participation in an alternative payment model. It allows there to be additional dollars on the table to support those things. And I think the findings from the SIM evaluation reinforce why it was important to do that. Because the SIM evaluation makes clear that Vermont's existing infrastructure has been helpful to leverage as Vermont seeks to take on the risk of alternative payment models. This agreement is intended to test payment changes like we've been talking about. And those payment changes are exclusive to the Accountable Care Organization. It is the entity that accepts the payment change. The agreement is also intended to transform care delivery, to invest in care coordination, to incorporate social determinants of health into the health care system, and to improve quality. And like I said, to improve outcomes for Vermonters, to improve access to primary care for Vermonters, to reduce deaths due to suicide and drug overdose, and reduce the prevalence and morbidity of chronic disease. That's what we agreed to with the federal government. We're also responsible under the agreement for limiting cost growth in the health care system and for having a large majority of the health care system participate. Again, that's what's called a scale target. I think, again, the SIM findings, the final impact analysis that I talked about from the shared savings program, is helpful in validating why we have scale targets, because the SIM findings suggest that because more of Vermont's health care system was involved in the alternative payment model, that that's why it may have had a stronger performance. So involving the majority of the health care system and thereby the majority of Vermonters is something the federal government wants to see us do in order to realize the full potential of these payment changes. There's also clear targets for quality measure improvement. There are 20 of those targets. And there's also an expectation that the payment programs align in key areas, meaning align across commercial payers, Medicare, and Medicaid, in order to reduce administrative burden for providers in order to make it more consistent with the expectations that the program are. That's a cool question. Were the real savings or costs avoided? In the Medicaid program, the $97 million was based on the evaluators looking at claims data for a cohort that was attributed to the ACO and for a cohort that was not attributed. And the $97 million are avoided costs. So the group that was not attributed to the Medicaid ACO in the shared savings program had $97 million more dollars cost than the group that was attributed to the ACO. Thank you. There will be a test after this. I took the test last night. I'm not for you. I'm not for you. Thank you. And again, please just to help us put into contact what we're looking at in terms of S7, which will also include changing, adding to the job description of the person who right now reports to you. So we will be looking for your feedback on that as well. That's correct. Great. Thank you. Thank you. We have you. Thanks. OK, committee, we have an amendment from Brian Tina to S86. Is it Logan? Thank you. Jen is in health care. We're asking her to come. But Brian, if you could please come and talk about the rationale of why you're putting this forward, the problem you're trying to solve. And committee, we will be tapping on the phone after this. Rich Holtzschu, who is the commissioner of the Vermont Commission on Native American Affairs, and as well as I hope that they can be on the phone at the same time. So a different director of compliance and enforcement from the department of liquor and lottery. OK. So first of all, since Jen's not here, I'll present the leadership to set a sentence that we're adding to the exemption section in the section of the bill that allows an exemption for an employee of a holder of tobacco license to handle and possess tobacco products, substitutes, and paraphernalia to affect a sale. And we're adding a person in possession of tobacco products or paraphernalia in connection with participation in a bonafide religious spiritual or ceremonial activity. And so I'll explain my rationale. I would like to point out upfront that it says products or paraphernalia and not substitutes because we are talking specifically about traditional uses of tobacco, which mostly involve handling tobacco, not even smoking it. I'll explain in my rationale. So in order to understand why this exemption is necessary, we have to first acknowledge the history of tobacco and its significance to indigenous people in North and South America. I'm going to give you a little bit of a history, not super detailed. I don't know if you've heard the history of tobacco from anyone else in testimony of this bill. But tobacco is a name for a plant that comes from the genus Nicotiana of the Solanaceae, I might be pronouncing that wrong, family, which is the family of nightshade plants. These plants are indigenous to the Americas and have been the part of indigenous cultures in the Americas for thousands of years. There is evidence that tobacco with smoke, snuffed, chewed, applied to the skin, possibly taken internally and used as an offering during prayers. When Europeans invaded North America, they brought tobacco back to Europe where it quickly became fashionable to use tobacco and without any spiritual, religious, or ceremonial significance. And as colonization spread through the Americas in the 1600s, tobacco became a big cash crop for colonists. This commodification of tobacco contributed to the growth of the practice of slavery because mass production of tobacco is labor intensive. And so by the time of the Civil War, the foundation for the modern tobacco industry had been laid on the soil of indigenous people on the backs of slaves. And as this modern industry is known as big tobacco, is rooted in that history. And big tobacco has indeed caused great harm to the environment as well as great harm on public health, and that's without a doubt. However, I think it's important to acknowledge that the problem is big tobacco, the corporate exploitation of a plant, and not little tobacco, the plant. And the problem is not the plant, but it's our relationship with that plant and what our society's relationship with that plant and what is the harm that has come from that. So despite the exploitation of tobacco for profit, the use of tobacco for sacred purposes never went away. Like many other Native American religious, spiritual, and ceremonial practices, elders have taught children the ancient traditions surrounding tobacco, mostly which about putting down tobacco as an offering during prayer. I'm gonna just read a little piece of an email of a community member from the indigenous community in front who cannot testify, who asked if I would share her words. I don't know if I have to ask permission to do that in committee, but do I have permission to read the news? I'm Daniel, and he would ask that we submit a public record of her name. Okay, so she said I was not, no, I wanna just point out before I read her email that originally the amendment had some additional language in it that said if a person was under 18, they needed to be supervised by someone over 21 and I removed that because of her email. So you're gonna hear kind of some of that in this email just so you know the context. And it's just a set the middle of her email, it's not the hello, how are you, and the thank you itself, all right. I was not, I also was not aware of this bill and I appreciate so much your insight and oversight in watching for legislation that may affect our community. As someone who is teaching my grandson age seven, the importance of smudging and offering tobacco in respect and honoring, I want to be able to have him continue learning and being able to practice the spiritual part of our culture. I like the idea of having someone under 18 being able to do it with supervision, but honestly it still feels like another colonization type restriction. The younger people are taught to use tobacco in a different way than smoking for pleasure. Tobacco is one of our most important sacred plants. To me it feels like once again laws are being considered that do not take into consideration what it does to an indigenous culture. No tobacco for those who are learning and practicing our spiritual teachings is the same as no speaking your language, no dancing, no heathen praying. That's the end of her quote. So Native American culture has survived constant attacks for thousands of years. As Native American cultural practices were considered illegal, indigenous people continued their ceremonies outside of the law in order to keep their cultures alive and in 1978 the American Indian Religious Freedom Act returned basic civil liberties and protected and preserved for natives the inherent right of freedom to believe, express, and exercise the traditional religious rights and cultural practices of the indigenous people of the Americas, which include Native Americans, Eskimos, Aduids, and Native Hawaiians. That's the statutory language. Bless you. So these rights, some examples of these rights would be, would include but are not limited to access to sacred sites, freedom to worship through ceremonial and traditional rights, and use and possession of objects that are considered sacred. However, this is federal law that applies to enrolled members of federally recognized tribes and not state recognized tribes. Also, there are many people who are not enrolled in tribes who treats the tobacco as sacred and furthermore, there are many people who won't even accept the colonial practice of having to carry around some kind of card to prove their tribal identity. So this brings me back to the question, do we want to criminalize a practice that has crossed cultures for thousands of years because the practice has been exploited? And are we really going to exempt young people from handling tobacco in order to sell it for profit, but we're not gonna let them handle it for their own religious purposes and their own spiritual benefit and to pray and carry out their own traditions? So that being said, I ask for your support of this amendment to protect and honor the sacred uses of tobacco in our society. Question? And then at quarter of a year, someone is expecting us to call and then, Jen and me, we want you to talk about the American Indian Religious Freedom Act. I'm not prepared to be called. Okay, or whether to reference that and specifically to reference the Abnaki, which is the only recognized tribe in Vermont, whether that would be. But go ahead and ask your question. So I'm just curious, one thing I hadn't realized when I first heard this, but I think that you're saying is that so right now, if you're under 18, it must be illegal to handle tobacco in tribes. Is that right? My understanding is that it is illegal. I think the question is enforcement, who's calling the police when they see a grandparent give their child tobacco to put down in the prayer, right? Exactly, so that's my problem. But it is definitely illegal. So it's not really, I'm assuming that the enforcement piece is a question today, under current law, so under this law, it wouldn't really change the issue that we're already, that's already. In other words, people are not having a problem with this right now, and it's even younger, younger folks who are probably learning to use, as that woman said, she was under her son, her own grandson, right? So, okay, that's helpful. Yes? I was just gonna say, there aren't, of course, many traditional practices that go on in the United States, right? For one, being a Swede has many celebration. We always had shops, people talk about it, starting probably at the age of 12 years of age, which would be illegal, all right? And we did it because that was our tradition, didn't it? And we've never asked anybody to stop that, as I said, to exempt us, because, so anyway, just a point, many of these traditions go on. I can think that you could answer the question to that point, I was talking with a Roman Catholic colleague in my committee, who I'm not gonna name, but just because, I don't think it's, we should say what other people say, but I asked her, because my recollection, growing up going to different kinds of churches, was that I would see young people going up for communion, and I wondered, do they give them wine in church? And what she told me was yes, that there's a wide range of practices within the Catholic church, but that if a person underage went up to get sacramental wine, that they wouldn't be turned away, and furthermore that I think we were looking at, we were looking at the law to see if it actually says somewhere in the law that there's a protection. So there's an exception for sacramental use of alcohol? So we have the precedent, allowing one religion to sort of honor its tradition, but in allowing priests to give alcohol to minors in the context of a religious ceremony, and so I feel like that builds the argument why we would not let families provide, because then we're talking about mostly possession of tobacco, not smoking it, burning it and smudging, smudging for those who don't know is when you burn a herb and you pray with it, or putting down tobacco is when you take tobacco and you put it down as an offering to spirits, or to the great spirit in prayer. So that's really the main use that we're talking about. Okay, come on, we're, go ahead. Dapper? Representative, the way you've worded this, possession of tobacco products, that opens up quite a bit. Yeah, or paraphernalia. And paraphernalia opens up. Because the pipe itself is a sacred item. That smoke, that putting down tobacco is one way in praying, but when you smoke tobacco on a pipe, it represents a union of the male and the female, the bowl of the pipe and the stem, and in that union, or the masculine, feminine, the god and the goddess, and in that union you smoke, and that's the way to connect with the spirits. So the reason I use that language is that's the language of the bill, but also it does leave it open, because some cultures do chew, and some cultures do snuff. And as, you know, as- What, as in Vermont? Well, people, I think there's a difference between abinac-y tradition and other native traditions. Tobacco was used from the tip of South America all the way as far north is. So there's different variations amongst the indigenous people. Yeah, well I think Vermont, as it becomes more multicultural, we're seeing indigenous people move to Vermont from other places. So it's not just about abinac-y tradition, but it's about indigenous traditions, and which is why we left it broader. Thank you. Thank you. Thank you. Does that mean move? Yes. Yes. That means move to be a native school. And it's yet non-statutory. Okay, sorry. I can just stand over here. Thank you. We really appreciate your assist. Yeah, I want to sit somewhere out of the way. I can squeeze in here with a lot of this. Oh. So where's the other ones? She's right up there. Okay, wait. I'm sorry. I think we need to hold. I just got something at the color-based group. Oh. That's all right, here's the one. Thank you. Hi, this is the head. Okay. Okay. Thank you. Please unplug anything that's on there. Yeah, I'm sorry. I'm sorry. I'm sorry. I'm sorry. Oh. Sir. Yeah. I'm here. Good, and you can hear us. Can you hear us? Can you hear us? Here, you're breaking up. Okay. We're working on it and I'm trying to, can you hear me now? I can hear you a little bit better, yes. Okay. We keep trying. We sent you a copy of a proposed amendment which would be to, I need it. Sorry. I believe we sent it to you, which would be to exempt from the possession of tobacco, a person in connection with participation in a bonafide religious, spiritual, or ceremonial activity. And we would appreciate if you would identify yourself for people around the road and to comment. We might have a question or two. Certainly. My name is Rich Holtzschu. I am a resident of the Son of one House of God, which we know is right over from Vermont today. I serve on the Vermont Commission on Native American Affairs. And I work with the non-community, contemporary community in the state, in their interest, particularly with items such as this, where there's an interface with a regulatory body or an agency. And so I have received and read over the proposed amendment, which pops my attention by a percent of Tina. And I am fully in agreement that there should be awareness of religious practices with respect to this. It's a minor amendment. It would be with regard to possession only for those purposes as we've stated, bonafide religious spiritual, ceremonial activities. I don't see any need to to step in and have to amend the proposed change on sale of products. I understand that points of sale regulations need to be easily understood and enforceable. So requiring a separate system of identification at that point could be cumbersome. But the possession part is much too broad and is twice in the face of the American Indian Religious Freedom Act of 1978, which does recognize that there are practices such as this. The recognized, from your perspective, does the American Indian Religious Freedom Act protect abnormalities? That is a federal act. And as with all federal acts, it applies to federal interpretations of who is a native person in their eyes and that is federally defined as a recognized tribe. So the spirit of the law of the letter of the law does not. And are the Abnaki in Vermont a state recognized tribe? There are four state recognized bands of Abnaki people in the state of Vermont. Okay. And can you very briefly describe for us what would be in any of those tribes, what would be a bonafide religious spiritual or ceremonial activity related to tobacco or tobacco paraphernalia? Sure. And this is in my word, so I'm not positing myself to be all and end all. But the use of tobacco in these practices typically consists not of smoking, tobacco itself although it may, but typically does not. This is simply a possession of and policing of tobacco as an offering or a recognition in spiritual practices. So there actually is absolutely no health risk involved. This is merely holiness and putting it down to that. So we're talking about a leaf or a stem? Yes. This is generally speaking about tobacco in its raw form. It could be, and at least it could be ground, but it's not the tobacco substitute. It's not a processed product, or manufactured product, I should say. But it could be roll your own. Sure, that's raw tobacco. But again, I'm talking about possession, not sales. And generally speaking, these practices would be under adult supervision, although I don't think that that is necessary to be included in law. There are children that do follow these practices as they are taught by their elders. And where do these bonafide religious spiritual or ceremonial activities take place? They can take place anywhere. The world is our relative, and so when we are interacting with aspects of the world, it could happen anywhere. Okay. We have a couple of questions. Carl Rosenkrist here from the audience. Would non-native Americans enter into these ceremonies or essentially ascribe themselves to these practices, or is that prohibitive? I would see, hello Carl, that's a good question. I understand there's a bit of difficulty in interpretation here. I would see the prescription of non, non-native people or non-recognized people wherever you want to draw those lines. I would see that prescription as another entrance and counter-legit freedom. I don't think it can be restricted to a particular group by ethnicity, that's discriminatory. And so, whereas the effect is probably going to be most greatly felt by, in my opinion, the Native American people, I don't think it should be restricted to that. I think you're starting to go down a road that's going to raise more problems than it will fall. Absolutely. I'll call up, yeah? I'll follow up then, so to then. Let's just assume then that the non-native American decided to use this as cover to possess tobacco products so that they would not be fined. I can't see how that would be protected in this amendment. Are not all city and city, the overall intent of this law would be protection. Protection of traditional religious practices. And it's not for me to say who's doing those practices. However, it's a proposition that if it was decided that somebody wanted to question whether someone was actually participating in a bona fide religious spiritual or ceremonial activity, I would think that the answer to that could be gotten to very quickly. Especially if there was component of the gold supervision. Again, I recognize the inherent difficulty in defining this, but I don't think we can throw the baby out of the bathwater, so you would try and pray. It just happens to leave villages that you can't possess tobacco, you're not smoking it. You're putting it down as an offering. Mary Beth and then Tom. That's Mary Beth Redmond from Essex. Just a quick question. I'm curious, how regular is this practice? Is it something that happens once a month, every now and then? Every now and then, I'm thinking of like, at any rate, that's the question basically, like how ongoing is this for a young person? How often would they participate in this kind of worship? I would say that there's no periodicity to that because that's following a calendar such as the Sabbath is on the seventh day or the first day where we want to place it. According to your case, it's a practice with interaction with the world around you. And so it could be once a year, it could be once a week. I'll give you an example. I don't know if Representative Kina mentioned this, but I was with Chief Roger Longtoes. They all know about the Naki tribe on Friday at fellow's fault and we were meeting some students from Dartmouth who were participating in a project for their anthropology class. And we were at the fault and when we're at the fault, this is a sacred location. It was incumbent upon us, it's our responsibility to recognize where we are and to leave a recognition of that often in the form of tobacco. And so we did that, the two adults that were there, the two young ladies, the three young ladies that were with us, who I don't know their age for sure, but they may have been underage before we sued to this act, this proposed act. I offered them tobacco for them to leave an offering which they accepted and which they followed through with. Now under this law, I would have been in violation. But what they did was the appropriate thing for that place and it was of the moment, it was not planned. But that kind of speaks to, here's an opportunity. Thank you, yeah. Dartmouth, you have a question. Then we have someone else who would like to weigh in. Tobacco power finalia. Why do you need that? Sometimes there is a high ceremony which may involve smoking. I would say that that is the exception and it is always under supervision because you're going to be doing that with one's elders. Will that make that? Yeah. Yes. Okay, thank you. There are other questions. Thank you for being available at the last minute. I appreciate your input into this. Thank you very much for your time and consideration. Absolutely. Thank you. Thank you. And now we have on the phone, shortly, the director of compliance and enforcement from the Vermont Department of Liquor and Latter. Can we hold? How old are they? About seven months. You're so good. What is their name? Their name is Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Fia. Skylar, can you hear me? I can, yeah, man. This is Representative Ann Pugh. You're in House Human Services and I do want to apologize. We have two seven-month-old babies in the room and some of our attention is being diverted. I may not be obligated, but you're very precise by CATA over for Fiat. Okay, thank you for being on the phone. We are, I believe you were sent by email a copy of the proposed amendment to the tobacco 21 bill and that would exempt from the word of gen go. It exempts it from what? It exempts from the restriction on possession, possession, underage possession. So, okay, and it adds, so you've got that, from underage possession, a person in possession of tobacco products, paraphernalia, et cetera, in with participation in a bonafide religious spiritual or ceremonial activity. And some of our questions relate to prior to this proposed law, it was a person under 18 and so we're wondering what your enforcement plan is, has been for people under 18 and et cetera. And if we were to change it, what your, that's, so. Right, so contextually, in my experience with the department, we have never dealt with an issue of spiritual or religious use of tobacco products by anyone under the age of 18. I'm not aware of any departmental position on that. It is just simply an issue that hasn't been brought to the department's attention. I do not believe that the department takes the position where we would oppose this amendment. Essentially, we just haven't had very little experience or have very little inquiry about the application of federal government in regards to, again, that spiritual religious or tribal use of tobacco products. Tapper. We understand that this can take place at any time, any place. How could you monitor these activities? To make sure. What? I mean. Yes, sir. I think that it would be, it would pose some difficulty. I don't know how to put a liquor investigator or any law enforcement officer in Vermont, in particular in the position of judging what is the, what is the, again, a tribal religious spiritual use of the tobacco products. I do anticipate some challenges there to find what that is and what that looks like. I can't provide much more in the way of a response there. I just certainly see some challenges. Again, I guess we don't have a lot of context that we've met, not done with issue historically. This is Representative Theresa Wood. So any challenges that you might predict as a result of this actually already exists today? Is that right? I'm sorry, I didn't quite hear that. So any challenges that you might have in determining a religious ceremonial activity, essentially we have those practices happening now and theoretically for people under the age of 18. So it has not been a large problem for you, is I guess my question. That's absolutely correct. I just, again, I struggle with the scenario at which law enforcement will encounter that per se, in my 13 years of law enforcement, I certainly haven't encountered any youths in possession during some sort of bona fide or any sort of against spiritual, religious, or tribal purpose. I'm not certain saying that that doesn't exist. I'm certain if I'm confident that it likely does, I guess what I'm saying is that there's been little cause for law enforcement involvement to do that. We've got no complaints. Certainly not interdictive of youths in that context. Thank you. So, yes. This is a new amendment to us. Thank you very much. Is there other questions for the Department of Liquor and Lottery and the tobacco control people? Go ahead, Carl. Someone along the lines of what I asked before, Carl Roosevelt's from Georgia, Vermont. But it just seems to me that this opens the door for a person 18 years of age, let's say, who currently supplies vaping products, or, well, okay, I'd take that back, actual tobacco products to youngsters that are younger than 18. And at this point, the law of wood farming, the law we're proposing, would prevent them at 18 years old to possess this substance and distribute to people younger. And by virtue of this exception, and the gentleman we talked to, the Native American we talked to previously, said he couldn't see that the religious practice could be prohibited for people that are not Native American. So it seemed that somebody could use this as a reason they possessed this product and to be exempted from punishment and fine. I certainly would, I see your viewpoint would agree with you, Representative Roosevelt. Again, I do see a huge challenge in the fact that in the amendment, I certainly don't see any definition of a religious spiritual tribal purpose that would lead a law enforcement officer in the position of determining what is and what is not. And that would be a very comfortable position to say the least. So in that regard, I certainly agree and accept your viewpoint and concur. Thank you. Other questions for Schuyler? Schuyler, thank you very much. I appreciate this. Yeah, you're very welcome. We're just gonna queue at any time. Thank you. Bye. Bye now. I don't know if there's anyone from tobacco 21 who wants to comment on this amendment or whether I'm offering or whether the health department would like to comment on this amendment at this point in time. The health department does not. I'll be very brief. Jennifer Hesta, government relations director of the American Cancer Society Cancer Action Network. I will be speaking on behalf of the Coalition for Tobacco Fever Maud, which is Cancer Heart Law and Law Medical Society. While we sincerely appreciate the spirit of this amendment, we are opposing it. Because we feel that enforcement would be incredibly difficult and it might, unfortunately, just be a loophole for exploitation. Good thing there was last night. I don't want to stand between you and lunch. I'm not Jennifer of the other gender. Yeah. Jen, can you remind me what the definition of tobacco products is? I know there's a specific definition. A-p-o-l. Bye. Bye. I wish we were free right now. The Caribbean Legislative Council tobacco, tobacco products, yes, cigarettes, little cigars, rolling around tobacco, smoked cigars, used milkless tobacco and other tobacco products was defined in tax law. So it doesn't include, I was having trouble remembering the sort of broad definition that included the other stuff, like jewels and things like that. That's tobacco substitutes. Substitutes, okay. That's not included in that. Okay, all right, thank you, that's all I wanted to say. And so, is a tobacco leaf a tobacco product? I'm not sure, I know how to answer that question. Who else is supposed to tobacco? I don't know. Well, there's another tobacco product. So I don't know what new smokeless tobacco is. Was it tobacco? Yeah. We can look at the definition in the tax law of other tobacco products particularly this time. Product manufactured from the right front were containing tobacco that is intended for human consumption by smoking and chewing or in any other manner that does not include all the things that are included in the definition of tobacco products. And so, up above I may really see what new smokeless tobacco is. I'm not sure that is a tobacco product. Oh, it does. Any tobacco product manufactured from the right front were contained tobacco that is not intended to be smoked as a particular moisture content or is offered in individual single-dose tablets or other discreet single-use units. So tobacco that is not a product containing tobacco that is not intended to be smoked with arguments could include raw tobacco, but it could also be more specific about unprocessed tobacco. It seems like from what the man's name. What please speak up. It seems like from what we heard on the phone that they're really talking about a leak or a stem in its most raw form is not included in this bill. I think you could get there but I think you could be more explicit about it. You might think you can potentially get there through the definition of new smokeless tobacco but you may want to be more restrictive than that. If your purpose is really for, I think you heard it was the leak stem or the ground form, but it sounded like the unprocessed nature of it was and you know, without making a thing. It was a stewardship. But it was smoked, it was also, it is smoked in some ceremonies. It sounds like you were right. We're talking about under 21. I guess for me, this is a bigger discussion to not have in this short period of time, I worry about enforcement and opening the door to a whole new, you may have looking at smoking or not or rituals. What I'm wondering is if it makes sense for us to do what this community wants to do. What has historically done, which is to send a letter directing a group of people to look at or issue and come back with more clear direction. And so that would be the health department. And for the last commission on Native American affairs, the amendment as it is proposed does not limit it to Native American. And so whether or not there are other spiritual, whether or other, but to actually ask these people to have a full and robust discussion about and try to, in fact, both support what is clearly part of what we've heard testimony and what we heard on the phone, part of the Native American ceremonies. And we've heard from the proposal of the amendment that they did not want to narrow it to that, but to more broadly spiritual and others. It just seems, picking up on what you said, sometimes good legislation, sometimes bad legislation gets put out when we haven't had the opportunity to really define and look at things. But a good point to be heard from the tobacco 21 people that they appreciate the concern, but that they're concerned about loopholes will heavily balance that. And that seems to be a part of a longer discussion. And the paraphernalia is part of a long discussion, too. Because if you look at the definition of paraphernalia, it talks about bombs and other kinds of stuff. I don't know where other people are. I'm not for them. Well, I would entertain a motion so that we have a position. There's a motion to approve the amendment on this draw. As a further discussion, two of us, three of us, four of us have said, make some comments, whether I'm in what happened. So I feel very mixed about this. Because, you know, we have a stipulation or a monstatue for sacramental wine, you know, a stipulation there. But I do agree that we need more information. Like, I don't feel like we've had the proper time to really get this and look at this. I feel like the language in that is very expansive. I feel like it needs to be narrowed so that we don't create a loophole. But I really do feel that it's important that we, you know, we honor the rituals and ceremonies that are not familiar to us. Maybe a last phase for that. So, you know, I feel very mixed about it. Topper. So my recommendation along the lines, what the chair is saying is let's get the thing done right. The way it is now, I can't vote for it. There's too many unintended consequences. I respect the religious piece of it. If it was worth it just that way and very narrowed to it, I'm gonna have a problem with it. But it's too expansive at this point. Right, because one of the things about spiritual wine, it's always in a church setting. And so maybe there's a way to look at setting as well as there's just so much that maybe the commission. Is it a commission? Well, I mean, I'm not sure that, I mean, we would ask you to come back tomorrow or with a letter that we could, sorry, we haven't, that is where people went because I'm picking up from what you said and others, which is how do we both honor and at the same time not undo what we're trying to do. And I would push back on the church thing just for Native Americans, the whole world, the entire church, yeah, so. I think so, all right, all right, so. So it's in any way. So can I just ask, the letter you're talking about would be just advisory in nature? The letter would be to the commissioner of health, probably to pull together. But would be outside of the bill that we are passing. And as to come back. Yes. And ask them to come back by January whenever 4th, 5th, whenever the first day is with a recommendation on how to marry the importance of honoring spiritual, religious practices for honoring you and as well as keeping tobacco out of the sickness of it. I had participated firstly in several sweat lodges, get the others with different groups of people. And usually it's the burn of the baccalaureate and just make the odor of the baccalaureate in the lodge. And then they may pass around a bite as well. I mean, that's the way I've seen it. It's important that I point out that it is currently illegal under current law at 18, below 18. So we're not just talking about the effect of this, of the bill that's before us, but we're talking about a change to existing law. Right. So I think that we've done some more homework on it. Is there anyone else who would like to comment on the motion that's on the table to accept the amendment by Brian, by representative Gina? Okay, all those, your motion was to support show of hands, all those who support representative Gina's amendment. The first two, I don't know why I say this. Why am I like that? I know, you support you. All that's to support your proposal. Okay. Choose one. Choose your proposal. Okay. Choose support in the nine of those. So the position of the committee is not to support the amendment. All those who support, I would entertain the motion to direct legislative council to write a letter requesting, because I guess we can't demand it. Right, you know, they will. The department of health, the commission on Native American affairs, director of compliance and enforcement and tobacco 21. So I move to amend, I mean actually to send a memo to not to look into how we on a five minutes. So I'm all right. Further investigation. Further investigation. Motion put forth by Jessica. Oh, that's what it is. Motion put forth, sorry. I couldn't remember that before. Motion put forth by Jessica. All those in favor? Okay. Can I, can I change my vote? I'm going to join the others. Okay. Thank you. Yep. The others. What? In approving and supporting the amendment. So it is now on the paper. Three. Three votes. Three in favor. Three in favor of the post. I believe that the speaker specifically asked when we've reported that it report, we report that the committee does not approve. That's no matter how the motion is made to speaker in attempting to have us all know what we're voting on. Okay. Thank you.