 Thank you, Mr. Chair. I have a few announcements. First, let folks know that our schedule for February is set and should be on the, I'm looking at the Christina to make sure it's on the website or it's coming, it'll be out soon. But I do want to just highlight a few of the meetings that were that we have planned for February is a very busy month. On February 5th, we are going to have a Dabbitt Governance Council meeting. That's up on the fourth floor of this building and that is open to the public. Those occur every couple of months. So that is the first meeting of the month. The next day on February 6th, we'll have our regularly scheduled board meeting here in the Pavilion Auditorium at 1 p.m. We're going to be hearing some pharmacy pricing and pharmacy benefit managers information from Blue Cross Blue Shield. Then we're also going to get a presentation from our own staff on an evaluation we did of our great review program. And then the next week is TVD. We will have something on that agenda, potentially some hospital information, but that has not been finalized yet. And then on the 20th, we're going to have a presentation by Diva on qualified health plan design for 2020. And we'll also hear from the University of Vermont Medical Center on their quarterly report for the Mental Health Capacity Project. And then on Monday, February 25th, this is very exciting news because we've been working on this project for a while. We are reimagining and had reimagined our general advisory team. So on the 25th, we will be meeting with the newly formed group here again on the fourth floor Pavilion room from 2 to 4. That is a public meeting. So even if you're not on the general advisory, we encourage the public to attend. We had over, we had about 45 applicants and our goal was really to make it a smaller group so that it was a little bit more manageable to get advice for the board. So we're looking forward to relaunching that general advisory. And then on the 27th of February, we also have a very exciting meeting where we're going to be hearing reports from the fields on the all payer model. And that's going to take place in this auditorium at 9am. And then in the afternoon, we have a qualified health plan and a potential vote for the standard plan. So it's a quite busy month with a lot of projects. But I think that it'll be a busy month, but a productive month for the board. And I believe that's all I have to report. Super. Thank you. Would the board member like to make a motion on the minutes of Wednesday, January 23rd? Second. It's been moved and seconded to approve the minutes of Wednesday, January 23rd. Without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Thank you. I do see the agenda at hand. And it's a workforce is something that I believe is the single biggest topic that we face in health care. I look at the panel over there and I know that we have bright people in the room for this discussion. And it's my understanding that the order that has been asked for is Matt, followed by Laura, followed by Sara Pina. Is that correct? Okay. So, Matt Barowitz, we're going to turn it over to you. A very familiar face when it comes to data statistics on the labor force. And we're very appreciative that you took time to study with us this afternoon. Thank you. Good afternoon. Thank you for having me. Any time I'm starting one of these discussions, I like to first say that this is the start of a conversation as opposed to the end of a conversation. And a lot of ways what I'm doing is preparing information to facilitate discussion and hopefully answer questions in anticipation of those questions being asked. But understanding full well that this discussion or seeing the data that is available might stimulate additional questions. So please know that this is just the start of a conversation and that these are resources available to you as part of the work we do over the Vermont Department of Labor. Excited to be here. Thank you for the opportunity. As you said, I'm Matt Barowitz, Academic and Labor Market Information Chief for the Vermont Department of Labor. The presentation is pretty simple. I'm going to really take through a lot of the breakdown of the data and then do a little bit of a couple pieces about projects that we're doing which are database before we turn it back over to Laura, Sara and Pina down the line to talk more about projects and the works as it relates specifically to work force. So first I do need to do a quick introduction because there's federal pay backing my participation here. So while I am a state employee, me and my division were 100% federally funded. That money comes from the US Department of Labor. 70% which comes from the Bureau of Labor Statistics and they pay us to produce, compile and release data consistent with Federal Bureau of Labor Statistics methodology. So the data that we release is unemployment rate, wages by occupation, employment by industry. Those are the big ones that we focus on and release and the joy of being part of a federal system is that you can be assured that the information we release for the state of Vermont or by county or by metropolitan area, all of that data definition methodology is all going to be directly comparable to the other 54 regions across the state. So we're part of this 54 territory national data system as funded by the Bureau of Labor Statistics that includes the 50 states, DC, Guam, Puerto Rico and the Virgin Islands. And that way if you're interested in saying how many nurses are there in Vermont relative to how many nurses there are in California you're going to be assured we're using the same six digit occupational code for the definition of nursing relative to our counterparts in California. And that's just a little bit of a preamble to kind of take you into the world that I work in because they are federal definitions. And again the good news, bad news about being federal partners is we're very transparent about what we do, how we do it and the definitions we use. We understand full well that there's other people that might have different definitions and this particularly because it becomes of interest in conversations like this because I take for example my job title. Economist or my job title, the economic and labor market information chief. We can all have job titles that we make up, right? Whatever you want. It's got a good word. Right. But an occupation is actually a federally defined six digit code associated. It's a tie to duties, tasks, educational requirements, skills, abilities, all these things. So there's a lot of like say new and emerging like panel manager is a good one. Maybe you talk about healthcare quite frequently. That is one of those ones that's right on the cusp and depending on I've seen panel managers being recruited to have to have an RN or have to have a master's degree or need to have a bachelor's degree. You know that is one of those occupations that's going to fall through the crack at this time because we're still emerging. But we are catching up with some of the newer ones. We are very excited to add in nurse practitioners as a breakout occupation which was significant. I think we did that about six years ago and that was something the states were clamoring for. You can't just let all nurses together that doesn't make any sense. A nurse practitioner has specific and different educational requirements as well as duties, skills, abilities, and as a result a significant difference in differential impact. But the people make it possible for me to be here today is Employment and Training Administration. They say you have a lot of great data and I will talk about it. Answer questions about it. Have a website, do special studies, partner with organizations like the ones at the statement. This is a busy graph and it's always fun to start an economic presentation with a busy graph. What this represents, 2001 current calendar year estimates by employment by industry. Now again, definitionally speaking we're talking about jobs but one job is one job is one job. That means a part-time job is going to count as one, a full-time job is going to count as one. We're not talking about any distribution about full-time equivalents, we're just talking about positions. And immediately you can look, going along the bottom you can see that there's some smaller industries, finance, information, natural resources, natural resources have been trending up, finance has been trending down, has this information a lot of it has to do with consolidation from out-of-state entities. But if you just take away all the noise at the bottom and just really focus on the key five that this graph is really highlighting, you can see just even back in way, you can see right in the middle just by coincidence there's some structural disruption that occurs and really what that is is an economic change in the business cycle. So in 2007 we had an economic peak, we bought in so that means employment hit a high, we went into recession around 2009, 2010 we started coming out of recession. How do you really see how the changes have occurred in the Vermont economy and a lot of these stories are national, these are American stories as well, where that top red line is the combination of education and health and it swims past trade transportation and utilities which is heavily dominated by trade, retail trade, wholesale trade. So going from the number one largest concentration in the Vermont economy by a sheer number of jobs, manufacturing then going down, leisure and hospitality and professional business services on the rise. But this idea of education and health, that's a combination of two very different sectors. You have NAICS code 61 and NAICS code 62 that often get aggravated into the super sector and so we'll break this down a little bit more but it's basically a five to one ratio for every five people in health care there's one person in education. This is private employment as we're looking at it. So the bulk of this trend is coming from, or the bulk of the employment is coming from health care. And when we take it forward to say, you know, well let's break out, let's start breaking down education for health. We can see even at the top line, if you take it down a little bit, Clarina did occupy our industry code, health and social assistance. Now we've got a new friend attached to health. We've got a new friend, social assistance which we'll break out as well. But health and social assistance have outpaced growth between 2010 and 2017. So this is basically the period of economic recovery since the recession, since the Vermont economy bottomed out whereas growth occurred. And it is interesting to point out that when you look at that trend line at the top, education and health, you don't see a dip like some have and no recovery. So during the recession, there was no perceivable loss of employment. It might be a smaller growth rate or stable or flat employment but ultimately it was a pause and then continued growth. So we're starting to try and pair off education services and you can see education services described at education services, not public, have been growing strongly. And both of those are growing strong relative to overall Vermont employment. So the trend line between health and social assistance education services has been very consistent about that five to one ratio. So of the 60,000, 50,000 are in health and social assistance and 10,000 employees or workers are in education services. But as we start breaking down, let's see at the three digit level what's happening within health and social assistance. You can see that the growth rates there are a couple that are jumping out. Hospitals and social assistance are jumping out. And we can see that social assistance represents about a quarter of this population. So when I talk about 50,000 people in health and social assistance you can take a quarter of them out. I'm not sure what the board's interests are in social assistance. It would include things like personal care attendance. So that's a tough one. That's again where you're talking about an occupation and depending on how grant funded might change how the occupation is defined between a home health aide and a personal care attendant. Because a personal care attendant, 50% of them are found in social assistance industries. So there's a high concentration within social assistance. But just looking at the growth rates, you see ambulatory and health care services has had strong growth, 1.5 a little under two times the growth rate of the overall Vermont employment since the recession. Hospitals leading to nursing residential facilities has growth rates about the same as Vermont employment. What percentage of the total is the social assistance? Social assistance would be about a quarter of the 50,000. So we're talking in the neighborhood about 12,000, 13,000 employees. And on my walk over here I had one of those aha moments because I was struggling with my federal partner's website to get the data that I was looking for to calculate the location quotients which are there in parentheses. And I realized I'm going to have to reissue this because those location quotients are not calculated correctly and if my hunch is correct they're understated. First let me tell you what a location quotient is, make sure I'm on the same page and then we can talk about why I think it's understated. A location quotient says it'd be great if I said that 10% of all employment in the state of Vermont is in manufacturing. You could easily say, well is that good or bad? And then you could look and say, well at the U.S. 9% of employment of the U.S. economy is in manufacturing. So a location quotient takes an area and tries to standardize it because the scale of Vermont economy versus the U.S. economy is totally different. But if you looked at the relative shares of 10% being Vermont over at 9% being the U.S. if you divide those two percentages so it's basically a ratio of a ratio of a ratio. A ratio divided by a ratio, equaling a ratio. It gives you like a relative strength and a lot of times you say anything below one means that you're typically importing those services or doing without anything over one you're exporting those services where you have a high concentration of them. So we know and or we believe to be true that health care is a high concentration in the state of Vermont, some of which has to do with, as I'm told, the large trauma-run hospital in Chittenden County which does provide services to upstate New York. That would be an example of how potentially we have higher concentration. But it also could be due to public policy or whatever the fact, because we have heard in other states that they are actually trying to build up health care faster than say Vermont is and it's because we have more industry in place. The reason I think he's wrong is because when I did the calculation for the government I included all ownership types including local state and federal government and the numerator only includes private employment here in the state of Vermont. So I'm believing that the numerator and the numerator needs to go up which would mean that these might even be low. But I don't think that's going to be too significant but it will push these numbers up. So when I say that ambulatory health care services have a 1.09 location quotient we're saying there's about 9% more on a relative scale employment and ambulatory care here in Vermont than there is in the U.S. economy. So just something to think about. Social assistance, you can see that big number 1.5, I mean, you know, it's a pretty significant, a very large location quotient. And I don't know how other states structure their like home health care programs but it becomes very interesting for our data when you look at personal care aids or home health aids depending on how they are, what their work week looks like it is possible that if you had say five clients who did five home visits to five different people that you're receiving five checks. And each check represents an employment opportunity so that could be why our social assistance looks a little higher relative to others if they have it more in some sort of clearing house way that you get one check based on your hours as opposed to based on the number of clients you had. Does that make sense? Yeah, it does. Have you done a chart that would compare this one to what total wages are in each of those components? No, I could as opposed to look at the breakdown of wages by these industries and then wages relative to the U.S. Is that what you're thinking? Yeah, I could. I have not done it for today though. Other thoughts, questions? We're going to make enough about that. So this is a slide I use a lot of times to actually kind of cut out some of the stuff we've done when I talk more universally to other groups. We do occupational projections. We look at 10 years in the future and say these are what we think the occupational demands will be in the Vermont economy in the next 10 years. And so what was interesting about the last 10 years is that the growth basically mirrors what we're projecting to continue to occur. This continued shift in the economy away from manufacturing which just got the significant down. Some other pieces kind of staying stable but this core three that's really driving the employment shift being professional business and technical services education and health services and lesion and hospitality. We're projecting significant growth to occur in those industries. I will point out that growth because department of labor we're always concerned about jobs and employment opportunities. Growth is only one way that job opening can occur. Another way that job opening can occur is retirement or natural job churn where people are quitting or getting fired. And so though we highlight for growth purposes significant employment increases in those three age and hospitality professional business and technical services and education and health, education and health being the big one in the middle of those three. We also highlight or I also highlight when I talk about the significant number of openings that are going to be in construction manufacturing and healthcare specifically because we have an understanding of the demographics of the people in the positions. We know there is going to be a significant amount of migration of employees in those three industries construction manufacturing and healthcare just due to demographics. So let me ask this. Is it possible that that column that includes healthcare is understating the problem because here's my hypothesis and you tell me where it brought. I look around and I see institutions of higher education struggling, places like Greenmont College closing, fewer students also there's pressure to downsize some of the staff. So if we were to separate those out, would healthcare even be a bigger one? I think that's a fair assumption. I haven't looked at specifically for the growth piece, but as it relates to the profile and the replacement due to typical job churn or retirements, yes. We're seeing a higher demand in that particular industry over private education. So this would just reflect job openings due to growth and then when we look at our occupational breakdowns we actually start looking and unfolding in the demographic pieces and we start talking about openings and we divide openings due to growth and openings due to separations and replacements. So I highlight that here because you will hear the Department of Labor talk about the significant number of opportunities in manufacturing and you could look up here and say well last 10 years it's been taking it on the chin and the next 10 years but even though an employer might be going down in size of number employees, if they were at 100, they might be losing 20 to retirement, they need to replace 10 of those and they know it. So there's a significant amount of openings and that's what you're going to see in healthcare as well. The tightness of the labor market because they overlap between not only growth but demographics, the demographic profile of the workers healthcare is the only one that had both of those criteria. Significant growth and significant demographic challenge. Then just kind of taking a step back we know because what these are are projected openings and projected openings only become filled positions if you have the people. So now I'm kind of taking a step and switching away from industry data and starting to talk about labor force data and so this is a projection that the Bureau of Labor Statistics created. But it represents, it's too small, it's the 1950 to 2060. It's basically a long term not only all the history but a long term projection of what the Bureau of Labor Statistics sees for the United States economy, not just by gender but also by age, we're going to look at age in a second and what the Bureau of Labor Statistics is saying is that labor force participation rate of Americans is going to go down. We're projecting it to do so. Not just men, not just women and you can say well, we've talked about Vermont as a little bit older workforce and Vermont's a little bit older than Americans but Americans are aging as well, we know that. But when you break it out even by age you're seeing it's the same thing there. So it's something more than just demographics and there's lots of economic research was started because of these graphs and it certainly was a kick in the pants for the Department of Labor to get on board because when we to change the course because when we were looking at this data, the bottom line is that we're going to talk about opportunities or how we're looking at that population of serving them. The blue line is one that really started my division working and how can we ensure that the workforce or labor force participation of young people doesn't decline because it's so important. A lot of economic research showing that the early enter, the early you enter employment the better off you'll be in the long term because you learn, I think the upshot is you learn so much about yourself, your preferences, your likes, your dislikes your work environment and those soft skills you have an opportunity to adapt those early and often that you might be able to make better choices for yourself as it relates to education and future careers so that declining labor force participation among youth is a big shocker but also the one that really started a lot of the national research is the projected decline in labor force participation among 25 or 54 year olds and that's a really interesting one because that's considered the prime age for people to be working and to show that it was being projected to continue to decline just like what's going on there, we need to look into this and a lot of the research actually points to more rural parts of the country and specifically the population of white men 25 to 54 so this idea that there's downward pressure on the labor force not just due to demographics but also due to socioeconomic factors which are a myriad of factors that are going on but putting pressure on the labor force participation rate itself plus you have ongoing economic expansion meaning the labor pool is short and shallow as it relates to available labor we're seeing this tight labor market manifest in many different ways for several years now lots of employers have been calling the department to say I'm looking for workers, can you help us and this spans more than just the healthcare conversation but across the board and other industries as well Can I ask a quick question before you move on with respect to the labor force participation and the downward trend in that there's also analysis on preferences for hours worked among upcoming generations in terms of not unwillingness less willingness to work 70 to 80 hours a week so I guess it's going to participate in the labor market but 40 hours is going to be more than normal I haven't seen any research on that I certainly could dig into that to see because this is well the underlying data this is household based data and the way I think about your question in the modern light of how the younger generations are looking at work more of that gig economy or more like short term opportunities or project based work because this is household based survey data the individual would hopefully respond that's the theory that they would respond to the employee but to the extent that this would put pressure on it a modern economy or technology I think it's also from what I've heard about the millennial generation and other generations that follow is that there's a more preference for quality work by balance so to the extent that there's not going to be willingness to work in 70 hour or 80 hour weeks this might be an under us in the issues that we're going to be facing in terms of labor force True Good point Other thoughts? Questions? As I mentioned the labor market is creating this opportunity and that's where the department my division thinking about how do we get people talking about the conversation of skills and how skills translate to wages and employment opportunities so I did I have a couple and available but basically this is our third version where we partner with the McCourt Foundation to highlight the employment opportunities in the state of Vermont for many years after the recession we were hearing in the public discourse this idea that there was no jobs in Vermont and that just frankly wasn't true as I said we were hearing from employers saying we're trying to hire, we can't find people and as a result this is one of the opportunities that we found to partner with McCourt Foundation because you have a lot of great data but it's not very attractive or easy to use for people who don't like Excel so we partnered with them and we divided the employment opportunities and we identified them just based on a sheer criteria and I could cut the data any way the group wanted but basically at least 250 openings in the next 10 years and at least $20 for a rate of pay as a result when you cut the data there's about 600 to 650 occupations in the state of Vermont when you cut the data with those two criteria a critical mass of openings plus a wage rate of at least $20 we ended up with 62 occupations in the Vermont economy and to be 62 that we could highlight they're divided by Haaland Code to try and be more interactive and Haaland is a researcher who kind of developed this profile of occupations to kind of group them by skills ability but also like preferences and there's this one category which embodies a lot of the healthcare and our conversations about it here today do you like to observe, learn analyze and solve problems and that's the group where you're going to see all the healthcare occupations and so this is the way we look at occupations these are occupational titles so again we go back to federal definitions individuals might have job title preferences or emerging jobs that might not be accurately captured here but you can see of this grouping there's a heavy component of healthcare including dental so this was just one of the tools to create, try and partner and create outreach and support education institutions who want to have these conversations with their students so we've done a lot of outreach about this in addition the department expanded direct services to recovery centers and just anecdotally and based on some preliminary research we're finding people coming out well hey we've heard that a barrier to sobriety can be gainful employment can be very helpful and a job giving similar roles, responsibilities we're finding that people coming out are actually looking to get back into it on the service delivery side so there's a lot of conversations right now of people coming out and then wanting to get back to the organizations that help them so much so I think this is not only demand of services related to career services and the recovery centers themselves but potentially supply we're extending our public outreach and partnership with the libraries I guess there's a population of individuals who are finding it more comfortable to go into libraries and ask for job search help and they feel comfortable going into a government agency so this spring we're actually going to be doing a train-to-trainer model with librarians and if you ever want to see a more willing excellent group of participants that love resources like giving this partner librarians they're fantastic because they love resources and information we're excited about this it's an opportunity and we're basing this outreach on some work we did on career technical education attachment areas trying to help local career technical education centers understand where the industry compositions are what the industry compositions are their local area and with that that is the end of my piece so I'll just pause see if there's questions for me otherwise I will be here for the rest of the discussion okay we're going to move to Laura Laura has a very good perspective she represents hospitals and nursing homes and one of the things that we saw would be heard from Mary Ann Chan from the talent pipeline with the need for the role of the third and nine hundred nurses in the next couple of years that that included a few nursing homes but not all of them and I certainly believe that it's probably a bigger number than what was pointed out in that research so Laura we're really excited that you're here today to share with us your perspectives well I'll start by just saying a long time since I've been in front of this board and I really appreciate the opportunity my name is Laura Pulosi for those of you who might not know me and I represent the Vermont Association of Hospitals and Health Systems the Vermont Health Care Association which is the trade group for long term care facilities which includes nursing homes residential care homes and assisted living residences and I also represent Bayotta Home Health and in that context certainly we've had conversations with Jill Wilson at the ENA to talk about these issues as well this is across the spectrum for health care providers and I want to really state that I really appreciate that the board is looking at this issue I've been working for the nursing homes in particular for quite a long time about a little over a decade and when I first started working for them their main issue, my first day on the job was regulatory agencies you've got to help us with the regulatory agencies today the number one issue when I go to anyone of our nursing homes residential care or assisted living facilities the number one issue is we cannot get workforce we are in a crisis we need to be able to take care of people so just kind of piggybacking on what Matt was saying in terms of our demographic challenges we've got stagnant population an aging state where the third oldest state I'm sad to say I am now slightly over that median age the percentage of individuals number 65 has increased and we expect the trends to continue with respect to an aging demographic this means we have increased demand for healthcare and long-term services and supports and yet we have a declining workforce our data tells us that the labor force has declined by 15,000 workers since 2009 the declining workforce has an especially adverse impact on healthcare providers you know I've been spending a lot of time trying to pound the drum on this issue right across the road here in the legislature and one of the things I frequently hear is well we hear this from every sector every business sector whether it's retail whether it's manufacturing whatever it is and what I keep saying to legislators and others is we're not like other industries this is people taking care of people we can't reduce staff we can't cut hours we can't install a self-checkout kiosk those are a lot of the strategies that a lot of employers and businesses are able to employ to deal with the declining workforce we don't have that flexibility telemedicine things like that are certainly helpful but at the end of the day we need people providing care so we're increasingly left with no choice but to hire agency and traveling nurses to adequately staff operations and I'll get into some detail on the impact of that and a few slides some of the data that we've collected in my office on behalf of our group of healthcare providers is board of nursing licensing data you're very familiar it sounds like with the Vermont talent pipeline survey you're very very familiar with hospital budget submissions and then the AHS division on rate setting which is able to give us some data on the expenditures and nursing homes for traveling nurse staff I'm going to show you a series of graphs and charts but I just thought it would be helpful to give you a couple of quick summary points and takeaways from these I'm going to switch to my paper because it's easier for me to read my mother told me I'd get to a certain point where I need glasses and this seemed to be different for everything she was right so licenses there are nurses, RNs APRNs LNAs and LPNs that run on a two-year cycle takeaways here the number of new RN licenses defined by 69% from 2007 to 2014 there was a 66% increase in the number of expired RN licenses during the 2012-2013 renewal cycle and while we've seen a slight uptick in the number of new RN licenses since that period of time we believe it represents traveling nurses who have to get licensed in order to work in the state of Vermont while they're here the percentage of new RN licenses with out-of-state addresses has increased from 58% to 86% over this period of time so that correlation leads us to believe it's the traveling nurse population and there's been a stark decline in licensed nursing assistant licenses and a significant increase in the number of expired licensed nursing assistant licenses and those folks are critically important to the daily operations of any health care facility any home health agency or personal care attendants as well can I ask a quick question I'm just wondering having these traveling nurses come to the state we've been hearing a lot about more board meetings over the years obviously the problems are so much more expensive is there any data on the conversion rate of somebody coming here the traveling nurse with an out-of-state address to connect to your filing or two years later filing not that we've been able to tease out from the data that's available we looked at that and we can't tell from the data anecdotally what we know just from talking to providers that doesn't seem to be happening you know and it's interesting I've done the rounds with a number of nursing homes on this issue and they say a lot of them are younger they like the idea that they're able to travel experience new places maybe try to figure out where they'd like to you know to dig some roots so to speak so I think it's a demographic shift there in terms of the business model I don't think this implies where they would well that's you know I think we need to do something to make Vermont a place that is attractive for our providers to come and work here we did have an end goal situation just last week at the UDM practice where traveling nurse practitioner and psychiatry ended up choosing to stay here if we had more success stories like that it would be great it's what we need to do obviously we're going to need to bring people into Vermont to build this workforce in order to be successful so I want to spend a lot of time these are just the graphs that demonstrate those takeaways that I was showing we can see a decline in RN new licenses decline new licenses new licenses is there anything that you can attribute to the increase between the 2004 and the 2006 2005 the big jump yes it wasn't like a new loan program or anything like that I don't know we haven't done that deeply into it maybe the answer to that isn't that about trying I remember Governor Douglas had the Blue Cranche for help on nursing were some of those initiatives spurred that jump? I suppose that's possible but then there was also I said Governor Shumlin's commission on nursing which would have been after that when we've seen so I don't know the answer to that but that's a good possibility some limitations in our ability to explain but you'll see continued declines and increases in the number of expired licenses so people that are just not renewing their license to practice and then the percentage of new RNs without state addresses looking at the Vermont talent pipeline we have a lot of member certainly hospitals some of the home health agencies and a few of the nursing homes participate in this it was an excellent work product the survey offers job end data for the period April 2018 to April 2020 and that demand captures two things and I think Matt referenced the two ways you capture that forecast new jobs forecast represents planned or anticipated industry growth and then replacement jobs forecast represents attrition turnover and retirements so based upon that survey there's a demand for over 3,900 nursing related positions by April 2020 so quickly approaching so while you're on that statistic in Matt by the dry rooms of the conversation because of your chart you looked at a 10 year period and it looks like if you add up the 3980 and then go down to nurse practitioners maybe you're it still seems hard to believe that in the talent pipeline identified 100 and they didn't survey everyone is this just an immediate demand that levels off or that's a good question you don't have been asked to look at them they're such different methodologies that they're really difficult to compare they're the only thing I can think of is either definitional issues where we're actually looking at the occupational codes so while we might have say 8 different types of nurses or 3 different types of nurse practitioners I don't know how their survey was organized they might just be saying what are your nursing needs or they certainly came up with a much larger number than we did our number is based on it starts as a U.S. forecast of all the industry growth for the United States that's protected by the Bureau of Labor Statistics they provide each state the national model and then each state takes the national model and calibrates it to our local economy so it's for us because we have such ceilings on our economy basically as imposed by population and labor force growth it's difficult for us to get any one piece to get relatively out of scale not to say that an employer in the health care industry could use all these people but there's going to be a growth limitation in our model well that gets to an interesting point because we've been talking with providers trying to get a sense of what their needs are it's actually way more complicated than I thought it was going to be because I'll give you an example I had one provider say to me well 30 vacant positions right now in the nursing professions and I said okay but that's just what I reasonably think and yet I'm not even posting positions for things I really need to have he said I could probably take 80 to 100 so I think the way they're looking at it on some level is what do they actually think they might be able to go out and achieve right now versus what they truly might need so that was interesting for me so we're trying to drill down on that a little more we're not there yet to really kind of capture what that need might be and this slide just drills down on that pipeline data a little bit to show you where the needs are in sort of ranking order or upcoming positions so RNs at the top and licensed nursing assistants again I can't stress enough the critical need in that licensed nursing assistant area and they identified in ranking order the top eight critical nursing jobs that you see there and I just want to point out especially working for the hospital association and the nursing home association it doesn't address the needs of the primary care workforce at the physician level which is a real challenge hospitals struggle with this everyone struggles with the issue of attracting physicians nursing homes really struggle to even get a medical director or physicians to come into the building to see patients they're just not available they're stretched very thin it's a real challenge nurse practitioners have been something that has you know alleviated some of that pressure but I just want to point out that that is also critically important and the pipeline report does note that it doesn't address the needs for rehabilitation professionals ptotslp that's a huge area in and of itself our focus here really is on the nursing professions but those are also critical areas and we obviously know mental health practitioners we could use more and more of those as well it's all part of the bigger effort so providers are using several strategies to recruit and keep higher retention rates increasing wages offering time on bonuses referral bonuses loan repayments tuition assistance reaching well beyond their geographical region I've got facilities recruiting Canadian nurses who are really challenged to get those work visas processed in an efficient way that's a lot of work for a facility to try to take on I've got a provider that's gone as far as we could go to recruit nurses and highly specialized nurses there's a lot of time and money that goes into this recruitment effort not to mention nearby states so I talk with a lot of desperate providers on a daily basis about this issue so the traveling nurse numbers and you know this very well when it comes to the pressure you're seeing on the hospital budget side but I think some numbers you're not aware of is what we're seeing on the nursing home side and I got this data from the division of rate setting at the Agency of Human Services in FY17 nursing homes spent close to 12 million dollars on traveling nurses that's 145% increase from fiscal year 2014 so just in 3 years roughly half of Vermont facilities used travelers in 3 years ago and now we've got over 80% of facilities using traveling nurses I was talking with a provider of nursing home administrator on Friday and she said my family's run these nursing homes for 40 years I never thought I'd see the day I was going to have to pick up a phone and call a traveling agency to get nurses into my quality award winning facility she said but we just don't have the people that we need so in terms of the impact on cost I think that's pretty clear the impact on cost that that's having you know especially when you're a facility that is 70 plus percent Medicaid that's an impact to Medicaid and there's an impact on quality and that's not to say that traveling nurses are not high quality nurses and that they don't do a good job but you know whether it's a hospital whether it's a long term care facility you know whether it's a home health agency you know they're not incorporated into the culture and climate of the institution they're not you know used to working with that team of folks it does have an impact on quality in nursing homes you know when I first started working with them the culture change movement has been huge in nursing homes with the idea being that you try to move your care you know to look more and more like a home like environment you try to address resident need you know ahead of time so that they don't have to express need through behaviors that are challenging and one of the keys to being successful with the nursing home population particularly with dementia and Alzheimer's residents is consistent assignment of staffing so that they have a very limited number of staff that they're interacting with who get to know them really well who understand their needs who can anticipate their needs and can serve them and when you've got high turnover rates when you're using traveling nurses we're not getting you know our ability to sustain those efforts becomes challenging we've kicked around as a group you know what might we be able to do we don't have this there's not a silver bullet to this right this is a national problem we recognize that it's a problem across many sectors in Vermont we recognize that but we need to do something so we think about things like financial incentives targeted specifically for healthcare workforce a few licensing reforms some educational initiatives and targeted marketing and recruitment specifically for healthcare workforce you'll see later my last slide we sort of highlight some of the things that are in Governor Scott's budget initiative around workforce and I think it's great he's got quite a bit of money going toward workforce initiatives you know we would love to see some of those dollars targeted to healthcare workforce and a lot of the idea is you know you're gonna go out and market and bring people to Vermont but we need to be able to offer them something when they get here and so that's where you know some of the incentives, licensing reforms and educational opportunity come into play so that there's some other reason that they want to come and live and work in Vermont so on financial incentives piece again Taylor toward healthcare workforce we don't have we're not claiming we know the answer to this but other states have done some pretty bold things that won't necessarily be the right step for Vermont but I think we need to be thinking about the fact that our neighboring demographics that are very rural like Maine are taking some pretty bold action with respect to trying to draw younger people in particular to their state so we are talking about the Maine education opportunity tax credit that was enacted in 2008 it is tied to tuition based income credits our concern with that is that it wouldn't capture non-degree folks you know like our licensed nursing assistants like our personal care attendants and as you saw in that social assistance category those people are going to be critical if we're going to take care of our aging demographic so it's not necessarily you know the golden nugget but the point here is other states are doing some things that we should be looking at and also considering employer tax incentives a lot of employers are providing loan repayment tuition assistance you know they're paying for credentialing they're paying for licensing programs so to help them carry that burden and to provide those types of programs maybe we could do something on the employer side as well can you look at the Maine program that's been in place now since 2008 I mean can you is there any correlation to look at their traveling nurses and seeing you know is it a lower percentage so theirs is not geared toward healthcare workforce they've got a stem focus it didn't start out that way but now they've separated it so they provide refundable tax credits for stem fields and non-refundable tax credits for non-stem fields so they've got a slightly different focus you'll see like Oklahoma, Oregon they all have a particular sector that they tend to be focused on with their financial incentives so we haven't looked at it from that perspective what I can say is they've expanded I think three times since they put it in place in 2008 most recently I think in 2016 and you know one of the concerns that gets raised every time I talk about this is well that's a tax expenditure you know their dollars it's revenue that the state's not collecting if we're providing a tax credit and my response to that is they're not it's not revenue that you're seeing right now these people are either not here unemployed or underemployed and they're not generating that revenue anyway so if we can find a way to get them here and get them in good paying you know quality jobs over time they will be contributing to the economic base that's just my non-economist, non-layman lobbyist response some licensing reform so last year we worked with the administration and the legislature to allow for military medics to go straight to licensed nursing assistants based upon their training without having to go through the time and cost of the LNA training program some other states have had similar programs in place for LPNs so some of the things that we're talking about are a bridge or apprenticeship program for our military medics to LPN just to try to put some more qualified folks into this workforce and we do, we need to join the interstate nurse licensure compact I'm hoping we're going to do that this year that allows for reciprocity across states for our nurses that would help hopefully things that you I'm sure hear all over the place strengthen lower payment programs increase the number of admissions into nursing programs to do that we need nurse educators a lot of what I hear is that our nursing programs don't necessarily have the master's level RNs that they need to teach the number of folks who would like to role in those programs I think we need to promote the value of the LPN and the ADM programs which are career ladders to an RN we've got a lot of folks particularly in nursing homes nursing homes run on LPNs and these folks are working they often have families and young children and it's tough for them to pursue a four year degree so we need to do a better job of marketing the value of that LPN scope of practice identify and remove barriers to accessing educational programs some of the prerequisites to LPN programs coming out of my school can be somewhat challenging I think we just need to take a look at that and then again we've got the life work school balance issues we need some more online offerings probably and again some of these career ladder type programs to allow some of these folks some greater opportunities to access nursing programs and then really market for what healthcare career opportunities but again I feel like if we're not providing some of these other folks who want to join the healthcare workforce we're not going to be as successful as we could because they're really hard jobs and then again I think and Sarah can correct me if I'm wrong I don't know if I've got them all here but these are the ones that we've identified in going through the budget it comes close to nine million dollars and I think this is great you know recruitment grants contracts regional relocation and recruitment initiatives but again I feel like there's got to be a reason for somebody to want to come here and be a nurse over somebody you know over wanting to go anyplace else to be a nurse or main where they might have the main opportunity tax credit program help them on their state income tax so I just feel like we need to find a way to distinguish ourselves and make ourselves be more appealing for healthcare providers to want to come here that is the end of my so I'm just curious which way the tide is flowing here and whether this is in terms of your experience you know Canada, Puerto Rico, neighboring states trying to entice people into Vermont are these other states my impression is that these other states are in the same situation this is a at least regional or national issue and so that as we ratchet up our programs other folks are ratcheting up their programs and are we just kind of not getting any kind of relative advantage that would be one question and the other is what does the great mind say of people who are leaving healthcare not renewing their licenses a 66 percent rate what do they say is it are they saying it's just not worth it it's not a good place to work or is it demographic what kind of message are they passing down among their individual networks that might set a tone about a negative tone about working in these professionals so I guess I'll start with that one and I work with and talk to a lot of nurses every day it is an aging workforce there's no question about that and I don't have the data to sort of back up what's happening with the exploration licenses but my strong suspicion is they're retiring largely I saw emails from seven facilities this week saying our director of nursing is retiring by the end of 2020 so we know that that's a demographic challenge for the nursing population during the recession a lot of them stayed on worked longer like a lot of people did so I think we're starting to see that impact of sort of pent up retirements waiting to happen on some level but by and large I have yet to meet a nurse that doesn't say what a wonderful profession it is so I don't think it's that they're sending negative messages to younger folks I think a lot of folks don't want to work third shift or second shift I grew up in a house with a mom who worked second shift in the hospital for 42 years sometimes third shift worked for our family my dad was home at night my mom was home during the day there was always a parent on top of us but that doesn't work for every family particularly every single working mother which we see a lot of in the nursing profession so I think there are a lot of just lifestyle considerations there as well with respect to your first question if I've got this right we'll never know until we try I guess is my response if we continue to walk the path we're walking and not try to do something we're never going to know if we're going to be successful we're never going to know if we should be losing hope I'd like to think we're not going to lose hope and I'd like to think that Vermont can distinguish itself in some way because of our quality of life if we can combine that with some financial and educational opportunities for people I think we have a decent chance at success so Laura thank you this is helpful and I just this is probably the typical conversation you're talking to a lawyer well that's on health there are several solutions and they all sound really interesting and there's different costs associated with each of them some of them require monetary outlets some of them are tax revenue not coming in some of them are just legislative changes of licensing so different costs and I'm wondering presumably they also have potentially different impacts on the labor force so is there any analysis that's being done with potential initiatives in terms of what's the most cost effective we've looked around and kind of kicked around and done a little bit of our own research we don't feel like we're necessarily in the best position to do that what we're trying to do really is say here we are at a critical point we need to bring together the policy experts we need to bring together the tax experts the financial folks the economists to help us figure out the best path forward so the role that we've taken on behalf of the providers is to say this is really important and you can't not pay attention to it but I don't necessarily know what is the most effective tax policy that we should or shouldn't have in place or where we're going to get the greatest bang for our buck I can just tell you based upon chatting with providers these are some of the things that their staff say to them these are the things that matter to them and when you start talking about dividends and licensed nurses AIDS and LPNs there are even bigger nuts to crack around childcare, affordable housing and transportation those are all elements of what makes it challenging in a rural state to get healthcare work for so I don't know where we're going to get our biggest bang for the buck I don't know what's most effective I wish I did this is going to be a risky comment so I'm looking at the numbers here in the Governor's proposal and it's somewhere around $10 million and as I've kind of come to know hospital budgets I see that there is there is free care in hospital budgets I think that's like $45 million a year and the bad debt is $79 million a year but a lot of that is because that's charge master numbers it's something lower than that but it's I've mentioned this to a few people and I'll just offer it up publicly and take the negative feedback if I have to the state has a program called the offset program which allows and states use it very much we're not a agency state ESAC VEDA the folks at AHS they use this to collect bad debts and I'm just wondering if some kind of connection here in terms of helping to raise money for this purpose at the hospital level by having hospitals which are budgets are regulated by the state be eligible to participate in this well established program this is a program that's been around for years it works very well and my guess is that some good healthy portion of that $79 million in bad debt could be collected through that process and used to help with the cause that you're making there I know there's arguments about that there is free care people will say we don't want to go after somebody that's not paying the deductible to their co-pay but what that means is some of the others are paying their deductible to co-pay and I just think it's an asset that the defendant general uses child support uses and it's an asset that you folks might be able to use to help raise a significant amount of money in the context of the numbers I see here thank you I had not thought about that I'll definitely put it on the I've written it down and I will take it back to the hospital association to get their thoughts around them okay thank you Laura so next on the panel we have one of my old dear friends and I'll tell you that when you're a legislator it's hard enough to get anything through your own chamber you didn't have to worry that the other chamber will even take it up and I can tell you that looking back on some of the bills that we were able to get passed it was so great to be working with Sarah whether it was early childhood education or what have you because you knew that your job would get documented Sarah we're lucky to have you working on the work force issue and welcome thank you, thank you and this mutual is working with you in that way but maybe we have a new way of working together here there you go I'm going to start just briefly because I don't know how much you know about the capacity for the Vermont Department of Labor to contribute to this problem so I just want to just let you know that I'm Sarah Buxton I am the Director of Workforce Policy and Performance in the Department of Labor it was a position that was created about a year and a half ago to really work on labor force expansion issues for Governor Scott and part of my role has been to look at the resources available to the Department of Labor and all of the employment and training programs and the federal ones that come in across the state and see how we can better blend and braid federal resources and the goals of those programs to support the labor force needs in the state the Department of Labor we are 98% federally funded so there are connections to what we can do but I am happy to tell you that today I'm going to give you some ideas about initiatives that we're working on that some are funded some are not funded and they're just going to be partnerships with different organizations some of which are represented here to try to chip away at this issue and to Dr. Holmes point about what is the return on investment I think it took me maybe about two weeks so it was a little bit of time to move from a legislative role where you'd like to really think about process things and analyze whether or not you're making the best decision to being on the executive side where I think what we realize with the labor force challenge is there's no wrong path to getting better we have to we have to pick a path and if someone else wants to say you know I think if you move over in this direction you could get more bang for your buck I know that at least in our department and I could probably speak on behalf of the administration where we welcome that advice but what we don't want to do is continue to stall for lack of wondering which direction to go so this is particularly relevant to this conversation because I don't know one occupation or one employer who would say nah put me at the end of the line you know like they're all clamoring for support here so with that I'm going to give you a few slides that are just an overview on how we're approaching the labor force challenge and then I'm going to identify for you some of the strategies that we're implementing to try to highlight the ones that are related to healthcare labor force so as you know the governor's top priority has been for the last few years to grow and strengthen the labor force and he is directing all of his agencies to work together last year in August I began pulling together an interagency team across all of state government to begin working on labor force issues and seeing if we can better align and support one another's programs and we are making significant headway on all those fronts the very specific goal is to increase not only the number but the skill level of available workers in Vermont and there are three ways even though it says one one and one there are three ways to achieve that but I guess that represents that there are no particular all important the first is to increase the labor participation rate within the state of Vermont and so Matt touched on that earlier in his presentation and Laura actually Laura touched on all of these points in her remarks as well so we have some strategies that are related to trying to support Vermonters or residents here in the state in participating in the labor force overcoming barriers attaining the skill level that they need the credentials they need to become employed to meet those employers and to have employers be willing to hire different types of workers the second strategy that a lot of our activities fall under is to recruit and relocate more workers to Vermont so I'm excited to tell you in a little bit some of the activity around that I just want to highlight that our plan in front of the legislature this year and the way that we're talking about this particular strategy is to emphasize that it isn't just recruiting but it's also relocating so to someone's point about the traveling nurses I think what we found in learning from other states and learning from some private head hunter like firms is that you can attract someone to a position or to a place but there is a separate process that takes place in that decision making to actually take action and move or to take the job and so at the Department of Labor we see our role along the lines of the relocating part because we have some expertise in employment support and other referrals to support services and we also have built a pretty strong network with partners for everything from child care to transportation so we're proposing that the activities are both recruiting for positions and for people and then having a singular support mechanism to help relocate those individuals to Vermont or wherever that may be and then the third is assisting employers in accessing and retaining qualified workers so that again it reflects I think a change in both of our approach for a long time we had very well we had higher unemployment rates and so employers had a different approach to accessing workers now with very low unemployment rates workers are in higher demand and we have an aging workforce so retaining qualified workers paying attention to what which our workers need is certainly something that we're working with employers on so in trying to address all of those strategies we're doing everything that you would think one would be doing with varying levels of energy and success I talked a little bit about an interagency labor force expansion plan that we launched last fall and we ticked off some successes there we've made some progress in trying to identify discrete initiatives that can help move the needle forward we're trying to target investments both state and federal resources specifically on workforce expansion the training when we talk about workforce in general there are many different parts of building a workforce there's the educating component there's an identifying component which is like identifying recruiting there's a matching component there's an upskilling component and then there's a retention component and so activities in state and federal programs private and public programs sometimes touch and overlap on all those different pieces and so trying to help everyone know where expertise exists or where will exist among public and private partners has been really important to try to like I said make some headway in the outcomes focusing our priorities coordinating efforts aligning our work engaging partners understanding where employers needs are is important but again whether it's the talent pipeline data that says we need a number of nurses or it's Bureau of Labor Statistics data that says we need a wide number of nurses we know we need nurses and so we know we need them in hospitals and in other private care settings so I think our job is to get nurses and figure out how to bring all those partners together to find some sort of collective impact so strategy number one was increasing the labor force participation rate over monitors so these are activities inside the state and they're most likely going to be around training and removing barriers to employment what I've done is I've highlighted a couple of the ones that I think are most relevant to our conversation around healthcare so in Rutland County two years ago the Department of Labor funded a pilot project to see what it could look like to do some career coaching in Mill River and in Otter Valley and see if we could help build bridges between students who are still enrolled in high school but weren't planning to go on to college and put them into these right in Rutland County and luckily there's a great partner there, Rutland Regional Hospital who is working with the local Workforce Investment Board and the RDC to support this real careers in Rutland County program we're going to be finding it again and for one more year until we figure out we're working on a sustainability plan but they are looking to expand to other high schools so we're trying to see if this career coaching is something that can help us find that exists right in the local communities in the state expanding adult training opportunities at CTE centers this is another area where we've invested more money in the Department of Labor through the WEC Fund which is the Workforce Education and Training Fund this year in the governor's budget not only is there over a million dollars in new funding for non-degree grants but we've also increased our support from the Department of Labor's perspective for infrastructure at adult CTE centers I believe every adult CTE center has an LNA program and they are always looking for funding one of the ways that we've also began to narrow our priorities is to limit when we put out our RFP for these small grants is to limit the categories of training and so this year it's limited to health care construction manufacturing transportation and business services so that's one way we started to narrow down focus on our priorities you may not know about return shifts but this was another program that came out of the last legislative session a return shift is like an internship in that it's a limited duration on the job work experience but instead of being for someone who's new to working like a typical college maybe a full secondary internship might be this is for someone who is returning to the workforce or is changing their careers so this is everyone from a veteran to a parent who's taken time off to raise some kids or taking some time off to take care of a relative or has been in prison or has been in recovery and so these are opportunities to work with employers to get back into the workforce again just removing some of those barriers so for any employer right now this program has just lost officially in the last six weeks for any employers who are interested in offering these experiences work with the Department of Labor and we'll get you hooked up and we'll see if we can start getting folks in for a return shift and you may find that these individuals are people you want to offer a full time job to skipping down just to the highlighted ones we already noted the importance of ensuring that we have child and elder care so you'll see that elder care is both a workforce need just in general because we need everybody in the labor force so having someone come and leave the labor force to take care of someone in their family is difficult but in addition we need more people taking care of older people in the work in that specific occupational space so we've talked a little bit about Vermont college graduates we're still struggling with how to best help Vermont college graduates stay here we've turned our internship program on its head a little bit and focused the performance more on the number of jobs that are offered at the end of the internship program I think formally internships were viewed as an opportunity to just do some job exploration and so we're trying to focus our dollars on having those internships mean something in terms of offering a job and using that as a pipeline for some employers before the grants went out this year I did touch base with some of the home health and hospice organizations around the state and visiting nurses and I believe we had a few applications to try to support the college graduates who were moving into that field the biggest piece of news I think I have for you today is the progress with me since I last saw you on expanding apprenticeship opportunities we applied for and received a grant from the federal government in May to increase the number of apprentices in the state partnership with CCB and VTC we applied for six we're writing a modification to get a seventh of those three of them are in the health care field so you know four of them are we're changing one so you'll be happy to know we're developing with VTC and LPN apprenticeship we are developing a medical assistant apprenticeship through CCB and that's modeled after the program they had piloted with Brownville Memorial Hospital and we are offering a CVS pharmacy has internships in all of our apprenticeships in all of the New England states in a variety of different ways we're using a model that Rhode Island use and we're expanding pharmacy tech apprenticeships with CVS as our employer sponsor we're very interested in continuing to expand apprenticeship opportunities so I think if we were to talk about initiatives moving forward Yale has an interesting program for RNs an apprenticeship model where you may get a certificate which is similar to an endorsement that would need to be recognized by hospitals or by employers but to be able to train higher level nurses on the job that's something that we're looking at and seeking funding we're waiting right now for the federal government to announce what the next round of apprenticeship funding is going to be we think that it will probably be formula funding which will change a little bit our approach to how we expand apprenticeships in the state but again I can't tell you how important it is for us to be working with employers in this realm because understanding what a good quality apprenticeship program is is really important to ensuring that those opportunities are successful and yield quality employees down the line and so I already mentioned increase of funding for tuition and cost of non degree credentials so that's a sampling of the in-state training opportunities that we have before I go to the next slide and I want to talk about other strategies for supporting the workforce in-state or make recommendations for things that you thought you would see here or you don't see here one thought but I'm not sure which bucket it's from but it was a thought actually when Tiramon mentioned green mountain college and I thought as that institution is closing which is probably some significant high skilled labor force there I was wondering is there any effort that's made to go in there and say hey you have connections in the lot how do we redeploy you in the state so you don't go to New Hampshire or Massachusetts and I was just wondering as larger institutions are producing their workforce and close them all together and I'm not sure that falls into this bucket or another bucket I think this is the one because it's in-state and it's retaining people here we did send our staff down this week to meet with green mountain college I do understand that there was some partnership with Castleton to for some of the students I think one of the important things in higher education in this does fall in an organizational role for the department of labor under the workforce opportunity workforce investment opportunity act we're supposed to coordinate these career pathways in a recent trip down to Castleton I did meet with the new president and understood some of the programs that they were looking to expand and was pleased to learn about her connections with UVM and other other training providers up and down the career pathways so I introduced her to some folks at Stafford Technical Center so that she sort of have a pipeline of some workers in trying to align that but we also wrote Castleton College into another grant we were doing to try to promote better return to work outcomes for musculoskeletal injuries in our workers' compensation division so we received that we hopefully can work with Castleton and any other partner that they have to be able to put more resources into things like occupational therapy, physical therapy assistance and any other type of program they want to develop in the healthcare world that doesn't really answer every mountain college issue I'll say stay sure to do that That's a great answer to another question that's helpful but I'm just wondering how do you retain the workers that may be being laid off within Vermont? Well if there are workers that are being laid off we have federal rapid response dollars and those are incredibly valuable to us we can both do layoff aversions but then we can also very quickly go in and help new jobs we can also if the layoff is due to it's become certified as an action that resulted from a difference a change in the trade the federal trade act permits us to go and help layoff workers retrain for new jobs and there's some significant funding there we don't have a lot of those instances Yankee was the last one that I can really recall but thank you that's helpful so the second strategy is the one you've been hearing a lot about lately recruit and relocate more workers to Vermont so I started talking about this first initiative that can cost money or it cannot cost money depending on how we proceed with this Wisconsin has recently discovered that if they send employers to military bases when the service members are separating and those employers are willing to make job offers on the spot that they are finding some success with those military members and potentially their families moving back to those states and taking those jobs and so working with our jobs for veterans staff in the Department of Labor we looked around at some of the bases in the country and as you may know Fort Hood has a high percentage of medical professionals that are trained in Fort Hood and I think they have somewhere around the 80,000 service members in and around the base that includes their families and so I've started met with the HR directors for the designated agencies last week and I've floated this idea just recently to Laura to maybe work with some of her associations and again try to try something and see if it works but trying to work with some of these organizations who are able to make a job offer on the spot or at least come really close and work with our National Guard who's also interested in doing some recruitment and going on to bases whether it's Fort Hood or Benning or Campbell they all seem to be the name of Senators or Trump and going to see if we can recruit some of those folks to come to Vermont so that is something we're going to try in terms of funding one of the designated agencies the HR director said to me you know for the flight down to Texas in an overnight hotel stay even if I didn't get a single bite it probably I would be no worse off placing yet another ad in seven days and getting no responses so to me that sort of made me think maybe we can just do this without sort of organically and try a grassroots effort to see if this works if that sounds interesting to any of you or to anyone in the room and you say I want to get in on that I'm starting a team so we're going to do that last year we expanded the availability of in-state college tuition to members of the Guard and as I noted I noted the on-base employment events and Laura already mentioned reducing barriers to occupational licensing we did make some headway last year but I still think finding those discreet issues in those problem areas something that we can take and work with the legislature and OBR and others on trying to mitigate those barriers the other under targeted outreach and recruitment campaign we're looking to work with our partners at ACCD to do some targeted recruiting with the help of actual healthcare professionals who know what would be an attractive tactic in recruiting healthcare professionals but we would like to try to target some of the college campuses and the high concentration healthcare workforce areas potentially in Massachusetts and in New York and we'll see if that makes a difference it's something we can track a little bit better actually going out and trying to physically recruit a person and bring them here relocation assistance I mentioned that the Department of Labor feels that we could be really supportive in an effort we're calling relocato to where anyone whether you're a bi-state primary and you found someone that you have recruited for hospital for a position and they may have a spouse or a partner who's coming with them and you really don't know how to help them find a job the Department of Labor can sort of set up a system of being able to help by providing labor market information other types of valuable information at the local level information on schools and taxes and house sale values and see if we can't help you make that whole complete in addition there are a variety of incentives that were offered last year for remote workers the governor's proposal is to expand that to people who aren't just working outside the state but were moving to Vermont to work inside the state so there are some incentives before the legislature now for them to consider that kind of describes the activities around recruiting and relocating more workers to Vermont are the things that you see that strike you or that you are surprised that you don't see on that list so Sarah as you know sometimes I'm very slow okay I can't know that I want to answer your question but I'm going back to strategy one because I think that we're missing a key component in that we have a false narrative in the state of Vermont the narrative is that you achieve a successful career you have to leave the state and we know that's not true because we know for example in health care that these are good thing jobs with good benefits that will allow you to have a good career and you'll be happy in your career because you're always helping others and you'll be able to retire with dignity so the strategy I don't see on here is reaching out and I think it has to start middle school working with guidance counselors to start to get Vermont's youth thinking of the possibilities within our borders rather than believing that they have believed to be a success that's great I will add that to the list we are about to change one of those you'll be familiar with it we're going to ask for a waiver in the use of our wheel of funds we're supposed to use 75% on out of school youth 25% on in school youth we're supposed to bump that down to 60 because we have a high high school graduation rate in the state of Vermont that allows us to go in with resources like that into schools while students are still in school and be able to start to do some of that work along with the work based learning coordinators and others that hasn't taken structure yet the approval hasn't been granted but I'm going to add that to the list so that we don't forget to keep coming back to that okay, anybody have some help on strategy 2? I'm going to skip strategy 3 and come back to it because Ina has to leave and I want to give her a chance to talk because we've talked a lot so after Ina speaks I'm going to talk about a little bit on strategy 3 and then just the health care related initiatives and that's all I had left so I'm going to let you just speak thank you I'm sorry that I have to scurry off what I think is really exciting is something that we've been working on Sarah, myself and others to talk about how what has been a separate and distinct workgroup, the health care workhorse workgroup can be unfolded into the larger workforce development initiatives in the state and specifically the state workforce development board what we envision is a way that the health care workforce workgroup can perform or behave as a subcommittee of that board with those connections being stronger the connections of the initiatives and the priorities of that workgroup which would be a committee or perhaps a task force and how they would be married to the broader overall workforce development efforts and I think that's very exciting because as you fully appreciated today health care is very much a driver in our economy it's a growth sector and it is it should be appreciated as a part of the broader workforce and that's really what I'm excited to talk about and share with you and we can talk more about that now if you have questions about what that's going to look like it's kind of a slow transition but I'm very excited for our first question will be centered in charge of the health care workforce plan what's the timing what will we see a revised one that's a great that is a good question and I don't I can't give you an answer for that right now I have an idea so my world is in the state workforce development board somewhat although I'm not the executive director that's another person the the workforce when Ena and I were talking about this the state workforce development board has to every four years put out a state workforce plan and our plan is due to the feds in 2020 and one of the things that I think is really important in bringing having the governor bring the health care workforce work to the state workforce board nominate some members of the health care community and then charge the board with addressing some of the priorities of the plan is that this will help ensure that components of the health care specific priorities can be included in the overall statewide workforce plan that will come out February I think the first draft we're charged with having ready by February 28th of next year so just about 13 months from now if the if this board would be interested in particular parts of that I think we would be very open to receiving those recommendations or some of those charges and ensuring that specific priorities are addressed in that planning process and in any other type of planning process that this health care committee would have on the board to report on regularly or to take action on so I would pass the block to the Robin because it's my understanding that there's a requirement for a separate health workforce plan and that at some point this board would have to approve it, am I wrong? No there is a statute that requires a health care workforce strategic plan that is proposed by ALA I think it says in the statute but now I think that would be AHS to the this board for approval but I think you could accomplish that same objective by having a unified planning process you just have to I think you would have to be willing to go through this separate step to meet that statutory requirement to fulfill both both requirements so I mean I don't know what the federal requirements are for you and whether that there's a conflict there but I could see how you certainly could unify that planning I think it makes a lot of sense given the focus now on workforce generally to ensure that the health care priorities are unified and incorporated into that focus I also think it whereas the health care workforce development strategic plan doesn't have a date for it to be renewed or revised if we are to be in a marriage so to speak with the overall workforce development initiatives then that's a great avenue for us to make sure that we're refreshing that kind of planning whereas the plan now is I'm sure you're interested in when it's going to be renewed because it's kind of static What's the date of the existing plan? I believe it's 2013 Yeah The workforce workgroup is working on revisions but those revisions I think never really completed to the point that it came The other value that I really see in that is when we do workforce activity I'll be honest I stopped on the employer bucket but we aren't really I don't think we're including employers in our workforce conversations as much we tend to gravitate toward retail, hospitality manufacturing, construction and I know why there are some tensions there in terms of the impact on the economy but from someone who's trying to from the position of those who are trying to change the system it's hard to have one set of conversations to say this is really important and then have another set of conversations about what's really important and then what's happening is we aren't making progress anywhere because they haven't prioritized and had to have that hard conversation about what comes first so does anybody want to ask anything okay thank you I'll just say that once we formalize the relationship we can come back and talk about that and what that structure looks like and what our expectations are alright I talked about most of these but I'm going to touch on one or two little pieces just so that you know what they're happening I talked about targeting workforce education and training funds even in making those awards right now in statute we're supposed to be the Department of Labor consults with the State Workforce Development Board having the healthcare voice there at the table would be another example of where when decisions about targeting funds where they could really add some value we talked about expanding apprenticeships so building employer coalitions for recruitment the idea that in many industries there are industry organizations that are focused really well on training for their participant members I'm thinking about the Association of General Contractors for example AGC yeah and so with some of the healthcare employers especially recently we've sort of talked to them about formalizing the way that they are coming together so that they're easier for us to work with as the State in some of these recruitment initiatives so for example if we're going to be building a video an outreach video whether it's to middle school kids or it's for something that we're going to put on a Facebook ad down around Mass General Hospital having some input from a coalition if we're targeting a particular demographic is important and useful for us the direct employer assistance with posting and recruiting we've just, I've discovered in the last six to nine months that a lot of employers don't realize that they have some free resources at the Department of Labor so we've instructed our staff to start compiling some lists because again employers usually are the ones who are thought of in the community as your manufacturing industries so I think this is going to make hopefully a little bit of a difference we're also trying to impress upon employers the importance of putting a salary in their advertising we find that a lot of job seekers are unaware of what they could be making in these advertisements so with a little bit of coaching and help from us we think maybe we can get some a little bit of traction there Career Policy Development I also wanted to highlight that we are aware of a need to be even more mindful of how we work with higher education in the state colleges particularly and the degrees and the credentials that they're offering that employers are in need of so in some cases there are credentials that are only offered at northern Vermont University but that's really difficult when the credential is needed down in Brattleboro so part of our role the Department of Labor is to facilitate the development of those curve pathways and that includes having the conversation of both ends Ina talked about that healthcare workforce task force and again I already mentioned expanding return ships in the state and the parting question I have is the case for prioritizing healthcare workforce recruitment and retention efforts and resources this is about finding the will I think we've all decided there's an issue here but others are also competing for the same resources and the same individuals in the labor force and so I think our collective challenge is to really hone in on what our case is and then identify the resources that we need in the state and become really clear about that they don't have really perfect resource some more training is better than no training so that's what I have so are you looking for any answer? yeah do you have one? so what's the case for prioritizing healthcare workforce since Joel Olson is in the crowd I'll quote my friend Ron Jaffe at the B&A's and hospitals of the southwest region who I always would say to me when I was a legislator that sooner or later I'm going to get your tired old butt and a paraphrase account because he was quite as nice with his language but the reality is that healthcare affects each and every one of our lives and I would argue that in some ways I never want to make an argument against another industry because of course we need economic development across spectrum but if you're making a widget that may not impact each and every one of us sitting in this room but if you're providing healthcare it is eventually going to impact each and every one of us in this room and so it's about taking care of us and so I would say that I believe it's the highest priority in the workforce Kevin I would also chime in and say that I think Matt's charts early in the presentation about the employment by sector and the slope of those lines is a pretty compelling case that out of the sectors in Vermont that are increasing healthcare is increasing as fast and not faster than the rest so it is going to be an area of great need and I bet if you compare salaries as well the salaries in healthcare for many not all of course would be so I would chime in with those arguments you know the argument that the response to that that I heard, I'm not saying I'm making the response but I'm offering the response which is that healthcare doesn't have the same market pressure there's always going to be demand there's always going to be demand and so even if we try to meet the demand there will be increased demand and it would only be something like a green mountain care board that would have the power to change the pressure in that direction which they are doing totally understood and I think that may account for some of the variation too in the surveys that went after the Vermont talent pipeline I mean the realities if you ask me how many people I'd like to hire in their department of labor state policies aside I would give you a number but then I have my appropriation and things have to be tweaked that the reality of those hires is different also and these are the conversations I think we have to wrestle with and those are the ones that having that at the state level, at the state workforce development board level or in a committee room they need to have that at the same time but keep in mind that if we are not able to provide an adequate workforce in healthcare someone would also want to die so I'll just keep hitting home at that point I just wanted to add one of the issues that we're consistently facing across the continuum is right here at the right place at the right time and if you're in a hospital and you're ready to be discharged and a nursing home can't admit you because they don't have the staffing levels to take care of you or a home health agency can't staff the services that they need to staff at home because they don't have the people someone sitting in a hospital when they don't need to be there or someone sitting in a nursing home that could go home but the home health agency can't respond and there are so many impacts from not having an adequate level of staffing from a quality of care perspective to a cost perspective so I don't want to lose sight of that and when we're paying travelers 200% of what it would cost to employ a rematcher there's a huge economic impact on rematchers because that's a driving force of health care I was just adding one more thing in prioritizing these fields is that you can't attract people to come to the state in other fields if they think the quality of health care is not good so that's something that would at least say hey if I want to get people here I need to make sure that there's quality of health care and then one other thing I think you could try to do in some of your recruitment tactics is really looking at trailing spouses as well so really showing that there are employment opportunities for everyone in the family when they come here so if you're targeting health care but their spouse is working in something else how do we attract that because that's always been an issue certainly on the corporate side to attract people what's their spouse going to do when they get here and so having support in order to be able to place another person as well you know it's really important I'm just going to echo that I'm sitting on two search committees one for computer science at Middlebury College and one for economics at Middlebury College so I've interviewed a lot of people in the last month and the trailing spouse issue is a significant one so I think there's probably opportunities there but I also just wanted to say this is thank you for your creativity and your energies it's nice to know that different people really think inspired or even inspired so at this point we'll open it up to the public for any public comments or questions of the panel yes Dale that's an excellent presentation it's worth going forward but it's a very plain how would I explain to somebody the cost of living the situation like you mentioned put in there how much you're going to make but how do I take that further and explain to them that they can afford to live in Vermont on that salary wage for the next five years as much as you can predict something like that the other one would be I know this is an issue in schools to people and that one you really do want to explain to them as in you practically want to promise them as long as your children are in school you're going to have good schools because hey if you're a parent that really matters let's see oh this is my daughter's not mine she asked me this I bet 13 years ago and we've been going back and forth I'm thinking of this one as well because I saw with 60 below that Minnesota is going to have they showed the indoor climate control living and I thought for sure I'd get a phone call from her she saw that I did get a text message because that's the kind of thing that she has brought up in our just back and forth discussions is why Vermont doesn't have initiatives to develop those communities Montreal has them I know I mean that's one of the things I loved about them in the 70's when I went up there even Minnesota as you can see has do you think there's anything there I'm beginning to wonder myself is there something to that for that bringing in another force climate control there are places in the north that do that do you declare a climate control what to what it is I'm missing the last point about the climate control don't help me understand what you're referring to it's a climate controlled environment where you have housing and you have walkways they can be above ground or they can be underground and you're connecting the buildings so like when I'm in Montreal if they get three feet of snow and it was zero degrees out it's my option if I want to go outside and walk two blocks in that three feet of snow and then I can go right back inside and walk ten blocks the other way to go to work and I don't have to go back outside again thank you for clarifying that or coffee or a restaurant you always have a choice you can live outdoors or you can gouged mercilessly so that higher up people can make tons of money can make these huge two and a half million dollar salaries that was not touched on here although salary requirements or incentives were but this is a huge problem I hope we look at this another idea is education and that's a great thing but you can't access education unless you have a hundred thousand dollars that you can part with the new inspection laws for instance for vehicle laws hit poor people the hardest where you have to buy another car every year to pass inspections so I think you've got to start thinking of systematic wages don't pay enough to live there are other countries where minimum wages are much higher college education is more is free at the point of delivery you pay for it out of your taxes early all of that how is it that they can do it and we can't and I think the problem is is that we still think of the buy low sell high model of capitalism and that labor is something you buy low so you sell your product higher and most wage earners in Vermont are not thought of as people who are assets to an organization they're expendable and I've been a personal victim of this you get benefits at a company and the first thing they want to do is fire you because you're being paid too much that's the reality of what most Vermont wage earners make and face every bloody day so excellent comments well I didn't see a question in there so Jill I saw your hand up yeah thanks I just had a couple of comments I wanted to make I really wanted to thank the board for its attention to this issue I think it's actually deeply tied to health care reform as I talked to my members about our role in health care reform and how we might migrate some of our care away from our more expensive settings and into the home which is really a great idea and a great solution the first thing they always say to me is where are we going to find the staff to do that work so it's really I think we're going to bump up against that as we try to make those migrations because we're experiencing that nursing shortage just like everyone else I really also wanted to really thank your panel the Lawyers Association has really taken an incredible lead role in articulating this problem and I think that it's everything that she said really I think would resonate with my members too we're really struggling in all of the same ways and when you get to that PCA workforce in particular a whole other set of challenges and it's not a primarily education solution because it's not actually it's not a workforce that requires higher education it's really a much more complex set of circumstances and the last thing I wanted to say is I really want to support the idea of bringing the healthcare workforce group which has been floating into the broader workforce board I think that's the right direction I do think that board will need some healthcare folks on it in order for the subcommittee to make any sense and link back but I see bright people nodding yes and I can tell you that I have members glad to serve if you were looking for people so I think that's a great idea and definitely the right direction and the last thing I just wanted to say Sarah I love the pick a path we're just going to pick a path and go because I do feel like on this issue in particular we have done a lot of studying thinking, talking, reporting and not enough doing at least in the time that I've been looking at this issue so I really appreciate that sentiment and I think that's a great question right on. Thank you, Jill. Thank you and thank you for the conversation I think it's a very important subject it's been one that's been discussed for many, many years and obviously needs to be discussed more because the solutions aren't totally apparent I had a couple of thoughts and ideas that I just like to ask the panel particularly to respond I think there's going to be two ideas and I'm not sure which one will be most unpopular so let me just lay out the idea and it really stems from an incident I had about four years ago, four and a half years ago I was at some kind of social gathering party and I met the person sitting next to me and we got talking and I asked her what she did and she said she was visiting nurse so you know always wanting to learn more I after talking to her for about 15 minutes I kind of came to the conclusion of one that this is a very highly competent nurse and two that she was being extremely well paid as a traveling nurse and so and the other part was she was working at the new psychiatric hospital in Berlin so I did ask her you know what would it take for her to not be a traveling nurse but to work here and she kind of laughed because she had looked around and she said you know the salaries are really not very attractive and that's just a global statement whether it's accurate I don't know but she would know more than I certainly would know so part of my question really relates to the question of would an increase in salary we're particularly talking about nurses a lot in the presentation so I was just looking at that you know and to some degree many of the settings that we're talking about could redistribute some of their funds to elevate the salary of nurses and other areas so one idea I had which will be very unpopular in some quarters would be to tie the percentage increase for nurses to the same percentage that administrators get at Uman hospitals which I think has been about 5 to 10 percent over the last three years and I think that kind of increase would have a startling impact on the recruitment of nurses over a few year period so that's the first question the other is has any thought been given to what I would call sort of change through radical disruption and I'm particularly talking about the issue of visiting nurses I was in some ways astounded at the amount of money Vermont spending in health care on visiting nurses I don't know what the figure is but it's a traveling traveling nurses traveling nurses excuse me so suppose someone or the group here recommends that Vermont in the next two years mandate a reduction in this type of nursing procurement by 50 percent and my argument is it would take that kind of radical radical action to perhaps encourage and incentivize the governor the legislature the green mountain care board to really take major tangible steps in this area because in the absence of doing that it just seems like the system sort of drifts around so those are the two ideas both of them are suspect but wanted to get a reaction I'm happy to take that one first move to your second suggestion of you know, mandating a reduction in the use of traveling nurses that would be great if we actually had nurses that we could backfill the work that those traveling nurses are doing the reason we're hiring traveling nurses is because we don't have an adequate number of nurses in Vermont to provide the services we need them to provide I would really worry about the consequences of doing something like that we don't have bodies and that's the problem we've got to attract nurses to the state increasing the salaries you know, correlate that increase with increases in administrative positions what I would say to that is you know I don't care if you're a nursing home, a hospital you know, a DNA you know, Bay Atom Health you're benchmarking your salaries so that you are as competitive as you can be and depending on where you're recruiting from that's either a more local benchmarking, a regional benchmarking a national benchmarking so you know, I'm not sure that that necessarily gets us anywhere because we are providing what we need to provide to be able to be competitive the bottom line is we need nurses we need primary care physicians we need bodies in Vermont so I definitely appreciate the creativity in your suggestions but that's at least my initial reaction Is there other public comment or questions? Yes Ideally, you want to be able to grow your own nurses but part of the problem is that interchange between the education and the apartment graduating so you have nurse faculty that are hired at less, we're talking at state colleges, at less than the median for the nurse salaries you have recruiters that are trying to get nurse faculty trying to recruit from hospitals those nurse practitioners that are earning $100,000 per your statistics so you're asking them to take 30, sometimes $60,000 paycheck to go into education which is problematic you also have on the other end the students that are having huge tuition problems dropping out of, with an educator 15 years in nursing and you're seeing your students that are dropping out because they can't afford the tuition and thank God for the higher education funding that's coming in so we don't have to raise the tuition more for these students I love the idea Laura had about recruiting veterans and the nursing that are in those kind of states I have concerns about the compact that have been raised about the disciplinary not being at the local level that's the big concern there so I want to make sure that if we are joining a compact then we are having it not losing our disciplinary capability at the board of nursing level but we can, there are a lot of incentives that people want to become nurses but what happens often when they become nurses and they want to go in there and nurture is the staffing is inadequate, they're burning out I've heard stories of, I mean I've heard horrific stories from nursing students and people that are working LPN going into RN programs of their staffing issues and trying to medicate to many patients worrying about their license and that being part of why they're going out of here even sometimes nurses that have been at like the biomedical center going into like the, I went in my online class right now that talked about going into juvenile corrections because it was a much better environment for her and that's not to mention that nurses are attacked more than the police officers in professional guards so thank you for what you're trying to do great comments, thank you anyone else so with that under all business we had promised at the last meeting to talk about the moratorium on CONs for home health I know that we're being pressed out of the room but we're going to try to do it quickly so Jill do you want to address anything before we have a conversation I guess I could just say a couple of things that's helpful, one it is going to the senate floor tomorrow so if you want to weigh in it will be I think in the house because the senate has zipped right along but really I think what you'll hear on the senate floor when the bill is discussed is that the reason that there's a suspension of home health CONs currently in place it was for three reasons to let health care reform have a chance to grow to see what impact we have actually had from the statewide CON for Viada in Vermont and oh the third one is just escaping me oh to allow time to actually go back and look at the CON statutes and the ATRAP so last year we did take a look at the ATRAP and I know that you guys worked on a bill with the legislature and now you're hard at work on the ATRAP but that really won't be finished until our moratorium is up and then you won't yet have home health guidelines so we really want to make sure that we've got good solid guidelines in place before we start having home health CONs and then the other piece that we're concerned about is that health care reform has really not fully come to the home and community based services yet the plan for that isn't even due until next year and then it's not supposed to be implemented until the next cycle of the all-care model so we really want to make sure that we have a certain amount of stability in our very planned system before we start having any significant changes so I think that's what you're going to hear on the senate floor tomorrow really we're hoping if the court is neutral on the bill I think that that will be actually enough for the for the house what we really are interested in is that you are not opposing it because I think that will make things a lot more confusing as one board member that I personally support the moratorium I think that it makes sense and I don't think that we are in a state with a significant significantly large population that allows for work in some cases cherry picking so that's my own personal stance but other board members can I agree I'm with you Kevin I'm supported with the moratorium I think especially given some of this is timely to talk about in the context of workforce and all the workforce challenges as well I don't see new entrances helping with the situations board feedback I'm certainly not opposed to it the board doesn't have to take a position on it either we do we did before watch this get extended once so I think what's pretty clear at least so far if I haven't heard anybody say they're opposed I hope they would take this opportunity to step up and speak if they are but at this point I believe no one on the board is opposed thank you very much you're welcome is there any other old business to come before the board if not is there any new business to come before the board I just had a very quick piece of new business which relates to the legislative there's been people know a contingency planning group around the cost sharing reduction issues that the federal government has raised last year we heard legislation passed allowing the board to silver load premiums to offset the funding that wasn't coming through for the cost sharing reduction program that that contingency planning group has some recommendations to broaden and make the board authority more flexible so that we aren't required to necessarily always do a silver load for example right now there was some concern that the federal government might disallow silver loading and then our legislation would put us in kind of a line because it doesn't really allow enough flexibility to do other things so the new language would simply provide us more flexibility should that even come into eventuality at some point to address it essentially so I wanted to let folks know that that recommendation is coming out of that workgroup and similarly I would assume that we would not be opposed to ensuring that we get the flexibility to do what we needed to do if there's an unexpected federal change and I should say it's clear now based on some federal guidance that was issued that silver loading is still allowed for 2020 so this is not an immediate issue but would address potential issues that would come up in a couple of years so again I don't think there's any opposition but this is the opportunity for any board member to say if they're opposed to that but I think that it's the right thing so I just have a question sure so I'm looking at the language paragraph 3 here where it says the Green Mountain Care Board shall ensure the funding to offset the loss of federal cost sharing reduction payments is included exclusively I'm just I don't know how we ensure funding other than to make insurance companies pay for it somehow or something so I'm right this paragraph basically expresses a legislative preference for silver loading if there is not federal funding for cost sharing reductions which is what we did last year in our premium rate setting process so this would be something that we would consider as part of the premium rate setting rate review process and Tom that would be to maximize those subsidies the silver loading does that so that's the preferable group that the group has discussed and that's all that really does do so we are not able to do so under the federal whatever federal change comes on down the pike we'll do something else we have flexibility but this just says as long as we can maximize those under this plan so my way I take that is that silver loading has allowed us to accept the advanced premium tax credit and it was kind of a zero sum game and so if the federal government takes away that opportunity this would mandate us to find