Vermont Legislature SmartTranscripts:

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Alright. Alright.

[Rep. Alyssa Black (Chair)]: Welcome. Thanks. From Blue Cross Blue Shield. Wanted to know if you wanted to comment on well, I'd like your take on a lot of the changes. I do want to, if you could, you've testified already on Sections one and two, if you could just sort of, I think weigh in on the difference between two picks by the governor or one pick by the governor in the legislature. That's really I mean, you have already

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, I can do that pretty quickly first, and then I can go on to some of the new stuff. Yeah, absolutely. For the record, Courtney Harness, Blue Cross and Blue Shield of Vermont. Just some words that I heard as the committee was discussing the differences in some of the language with how people get appointed or who. One word was precedent. And so just want to make sure that the committee is aware that the reason that there's no language for any of this is because it is the first time anyone's ever done it. And it is, in fact, unique and is setting precedent for the 6,000 plus other nonprofits that exist in the state of Vermont. So if I were them, I would be really scared about this. And I'm sure that they are. So the precedent was number one. Related to the process, this would be my opinion on a nomination committee. Frankly, that's our preferred method. But that would more than likely require money from the administration. Because my understanding is the Green Mountain Care Board nominating committee gets a per diem and a stipend. So if we were looking for affordability, that would probably not be the best pathway. It would be the most fair, but probably not help us on affordability. I think another word that I heard was competition. And I can say pretty confidently that if Blue Cross and Blue Shield has board members appointed by the governor, if I were a competitor, I wouldn't be super psyched about jumping into the Vermont state market. So I would just maybe say that on competition. I heard the word transparency. And I would ask what information anyone will get that they can't get tomorrow from these two provisions. Because if it is ordered, we have to provide it.

[Rep. Alyssa Black (Chair)]: Go ahead, Allen.

[Rep. Allen "Penny" Demar (Member)]: Quick question. How many other nonprofits would be in this situation setting a precedent?

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Well, I'm just saying there's about 6,500 nonprofits in the state of Vermont. If we wanted to look at the financial performance of all of them Yeah, okay, absolutely. Thanks.

[Rep. Alyssa Black (Chair)]: Could I Yes. I'm just wondering how many of all those nonprofits are equivalent to your role in the state, which is pretty unique in your relationship to Vermonters.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, I would speak more to their size and scope for the communities that they serve. So I have a history in the mental health and substance use disorder space and Recovery Partners of Vermont were in the cafeteria this morning. They're pretty close to my heart. I would say that for the people that they serve, they're equal. And our budget size, any quasi public status, any financial stress is not any different than any other nonprofit in the state of Vermont. So from when I say precedent, that's what I mean. Because I don't believe that size, scope, or anything else is taken into consideration in the current language of the bill. So the process is another one, and it dawned on me as the committee was having this discussion with the FR that I'm not sure that anyone has actually heard our process for either board recruitment and vetting or our current we already have a compensation committee. But it occurred to me that the committee has not heard our full and complete process, which, by the way, is also being updated as we speak for the last two months. Not to say I'm not going to dive into that now, because I did promise I would be brief and then go on to the other portions of the bill. But if the committee were interested in learning what we actually do right now and the technical rigor behind it and the lengths and depths and money that we spend to make sure that it is independent and accurate, we'd be happy to do that. I would also say, lastly, if DFR does decide that it's not sufficient, we would ask that there's language put into the bill around who helps them decide that. Because there is decades of experience and costs that go into deciding that. And we don't do that. That's why we hire someone to do it. And if they decide to hire someone else, I believe that's an RFP process. If it's hired through the state, which will also cost money, which I have a hard time understanding how that helps affordability. In any case, I'll say on I think the two new things the whole sharing plans I think we're really interested in just learning more about. I thought that discussion with Mary last week was really, frankly, interesting to me. I learned a lot about that. And relative to out of pocket maximum, of course, something that we support from the perspective of it does allow us some flexibility in benefit design. I think particularly what I understand from our actuaries is that large groups in particular would really appreciate the flexibility that this particular component of the bill would allow us. In terms of actuarial value or what it does on premium, my understanding is that it's negligible. But it's more about and Commissioner Sampson did a really good job of talking about this when he referenced benefit design just some flexibility in different options for folks, just some ways for people to better pick and choose and decide what fits their needs, I think would be really good.

[Rep. Alyssa Black (Chair)]: Good question about that. Do you mind that I am not an actuary in

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: any way to promote Me either.

[Rep. Alyssa Black (Chair)]: Biocurious. Out of court.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah.

[Rep. Alyssa Black (Chair)]: So, you know, they come up with kind of the value of a plan. And so if one would, and I'm thinking about this in the most simplistic terms and I'm probably wrong, But I am thinking that if they're coming up with the value of a plan, they have to sort of measure what the average out of pocket will be. So, one, like the prescription deductible is 1,200 and the medical out of pocket deductible is, or the, not out of pocket, but the deductible is say 3,500 or 3,000. If they're both equal, would that allow trivially total out of pocket or deductible to come down? I mean, if they met in the middle, wouldn't there be It wouldn't be like you're just putting everything up to the top. You would have to actually reduce. So could that possibly reduce out of pocket for everyone, not just a few?

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, I'm glad that you asked it the way that you asked it, because that's exactly how I sound when I ask our actuaries And that so The answer that I got was there's little change to the actuarial value, and because of that, there's negligible difference in premium. Negligible doesn't mean nothing. So, there may be some slight downward movement. I think the word from our actuaries is that it just shifts the cost sharing because people will pick different plans based on the design, to your point, of what the deductibles and out of pockets are. So, it's a good thing that we actually think, like I said, opens up flexibility and options for people. And frankly, where we are now, we agree with DFR. If that's all we give to people is better options for them personally, we're in a pretty good spot. So we're happy to support language that does that, absolutely.

[Rep. Alyssa Black (Chair)]: Leslie, there any examples of other Blues in the country who do have a process of a governor or legislative body appointing board members?

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: No. In fact, all of the other states that have ever brought forward any legislation remarkably close to this have been never passed. It's a good question. Glad that you asked it.

[Rep. Allen "Penny" Demar (Member)]: Me too. And

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: as far as physical therapy goes, we actually see this, and we heard the testimony from the owner. I think she was from rehab gym. And we see this as a low risk way. And so we've talked to the hospitals a little bit about this. We see it as a low risk way once to do a little bit of shifting where we might be actually able to elevate some of the reimbursements for independent providers or off-site locations and kind of compress some of the not inpatient, but in hospital outpatient settings. We talked with folks about this a couple of weeks ago. And talking about the implementation, we feel like it's a pretty quick turnaround. It's not anything where we think. Vas might completely tell me I'm crazy on this one, but it doesn't seem like it would be something that would be detrimental to hospitals. But it's enough where we could gather some good data and feedback to report on in March of next session to then whether or not we wanted to go further with other options. And so we we put some data together. And again, this is just Blue Cross. So there's 400,000 other Vermonters not covered by us. But we offer, I think, 30 visits in all of our plans for physical therapy. So most people use all of them because if you got them, you should probably use them. And most providers prescribe to them, which they should also do for better health. And so in conversation, we used this as an example of sharing some data. And it just seemed to make sense, frankly, in terms of where we can have an impact, where we might be able to support independent providers, and where we can collect some really good data so that we can come back and say, here's an example of the type of impact or influence we might be able to have on this type of billing behavior. I think if we were going to guess and again, this varies based on how the final language of the bill ends up, but we could see anywhere from 3,000,000 to $6,000,000 in savings on physical therapy line of service for Blue Cross and Blue Shield members statewide. So like I say, enough to give us really good data to say whether this works, enough to hopefully have the owner of Rehab Gym come back in and say, We really like this. This is working out well. And enough hopefully to not put hospitals in a pinch with it.

[Rep. Alyssa Black (Chair)]: Does Blue Cross Blue Shield have data on the disparity between the sites?

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, we can give Would you

[Rep. Alyssa Black (Chair)]: be willing to share that with the committee in written testimony?

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, and I can certainly share. And again, I'll give you a range just based on a story that we've shared in testimony previously and how the physical therapy example itself actually came up. One of our executive team members went to a hospital owned off-site physical therapy location, and the professional fee schedule for that location was about $85 and his bill was for closer to 400 because it was billed as an outpatient setting of that hospital because it was a hospital owned location. So when we talk about numbers, we go, Okay, that's $300 over 30 visits for one person. It really adds up over time. And I could certainly get you much more that a lot of it is hospital by hospital with fee schedules and contracts, but I could certainly write that example into a written testimony.

[Rep. Alyssa Black (Chair)]: So it's not that you don't have a negotiated fee with the hospital for the provider, it's that it's being billed as a hospital outpatient service,

[Rep. Allen "Penny" Demar (Member)]: which is a different negotiation. Yeah, correct. We have

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: What we're

[Rep. Alyssa Black (Chair)]: trying to do is get everybody so that they're billing the same way.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: I think the word was parity that we used. We have an independent hospital owned professional fee schedule and then an outpatient schedule. And so I think in this particular example, we could navigate some pathways to get those all closer to one.

[Rep. Allen "Penny" Demar (Member)]: Allen? No, on my phone. So sorry, Pitchlow, question.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: It's okay. Exercise. I think the other stuff in here is we've already set our support for whether or not there's any positive or negative outcomes. I think we've already testified to that stuff. So I'm happy to say more on any particular pieces of it if anyone is feeling really interested.

[Rep. Alyssa Black (Chair)]: Any questions? All right. Thank you. Thank you. Yes. And if you could share written testimony with us on that, that would be helpful. Absolutely.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Is the example, just the one example okay,

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: or would you prefer a broader?

[Rep. Alyssa Black (Chair)]: Just sort of speaking to the physical therapy piece and why we decided to collaborate on that. Absolutely.

[Rep. Allen "Penny" Demar (Member)]: Thank you.

[Rep. Alyssa Black (Chair)]: Anybody wanna come on up? In

[Devon Green (Vermont Association of Hospitals and Health Systems)]: the right order. If I'm out of order, let me know. Just This is order. It's next. Thank you for having me here today. Devin Green, Vermont Association of Hospitals and Health Systems. I'm guessing you would like me to talk about the site neutral piece. I did receive it yesterday evening, and so I haven't had the opportunity to go back to my members on it to, you know, get fully informed about the impact. But I would say that I appreciate this board narrowing the scope from a very broad scope that would have a big impact on our hospitals to something a little more targeted and providing the opportunity to study the impact. Thank you for that. I would also, just wanna say too that as we move forward, I'm trying to think of so we are doing reference based pricing. To me, this is similar to the reference based pricing piece. It would be helpful to remain consistent on that path going forward because the hospitals are locked into the affordability piece. That is the direction that they're going. And I think they want to continue going in that direction. And this is not inconsistent with that, but I do just want to say that it would be helpful to stay on that path.

[Rep. Alyssa Black (Chair)]: Go ahead, Chittenden.

[Rep. Allen "Penny" Demar (Member)]: May I ask what is concerning to you? Well, just

[Devon Green (Vermont Association of Hospitals and Health Systems)]: site neutrality, I think, means different things to different people. There is a space where it means that independent providers get more reimbursement and are brought up. There's another space where hospital services are just brought down to independent providers. And so if you're looking at affordability, then you would bring hospitals down, not bring the independent providers up. There's just a lot of things to think about there. So as we move forward, we need to keep in mind that doing one thing over here may impact the reference based pricing efforts over there.

[Rep. Alyssa Black (Chair)]: I agree with you on, you know, we are already on the reference based pricing train, which means adding site neutrality. It's like, oh, let's hop over to this train too, and which train are you going to be on? I believe we did, and I agree with you, by the way, on the whole what does site neutral mean, because who's neutral? Don't give me one of those questions. Who's neutral? Much like what we did with the HAP on ASP, we sunset that for when reference based pricing would determine where it should be. I I like this because I personally have concerns that essentially one is being billed as a facility as opposed to a professional fee. But if we could get the reimbursements to actually sunset once reference based pricing is in effect And then keep the sort of a continuation of ensuring that things are that there's not a facility fee. Let's just call it a facility fee. Would that be?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: So Sunset it once the reference based price is set for it. Yes, let me take that back. I think that sounds helpful, and I will let you know.

[Rep. Brian Cina (Member)]: And that just got me thinking too, that if that specific strategy of a cliff of sorts where it just ends, doesn't make sense, it would be helpful to hear any proposed transition that would promote affordability between the two. In other words, maybe it's like just ending one thing and having the other thing begin is not feasible. Maybe it's like a crossover.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I think this language is flexible enough that it allows for that.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Okay.

[Rep. Alyssa Black (Chair)]: Great. Was there anything else you to weigh in on the reporting that sharing plans would have to do to the state?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah, I think we would be interested in understanding the activity that goes on in Vermont and the impact that it would have to things like our uncompensated care and those sorts of things. I think this is a good step towards getting there. So we are supportive of that piece.

[Rep. Alyssa Black (Chair)]: It would be nice if you would poll your members to see what they do. Yes. And when presented with some of these things, no. So we

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I got information.

[Rep. Alyssa Black (Chair)]: We have more information and see if we really want to get more information. Yep, Happy to do that. Okay. That would be helpful. Any other questions for Debra? Also, sorry. No. The question that I posed to Commissioner Sampson regarding the AHP plans and sort of the TPAs and what kind of contracts you can also poll your members as to kind of

[Devon Green (Vermont Association of Hospitals and Health Systems)]: what they see in that space. Yes. We would need to be delicate in that situation. We can't collect hard data about reimbursement and contract terms, but we can ask a general sort of lower or higher question to them. Happy to do that.

[Rep. Alyssa Black (Chair)]: That would be great. Thanks. Great. Mr. Fisher? Can I make an amend? Legislative Council, can we table five seventy seven for the day? And I think we have plenty of time to gear the amendment on May. I had anticipated that appropriations would be I had anticipated that appropriations would be voting on it, but I think they're tabling it. We're not going to see it for a while. We have time and we need a break. Okay.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Good afternoon, Mike Kisher with Care Advocate. I know that I testified on this bill early on. It may have been one of your first witnesses. So it is interesting to see how it has evolved, and I think I can go fairly fast. But I'll just touch on on the different things. I support the board members on the Blue Cross Blue Shield. I also don't believe it is a make or break huge thing will have any big impact. I think it to me feels, I think, more important in symbolism than in having any real outcome. And I totally understand why the legislature would say, hey, Uptu, there is balance of power there, but I don't think I would bother with creating a big nominating committee or anything. Think you wanna do it with just one member from the executive, one member from the legislature, in my opinion. Disappoint the exec mhmm.

[Unidentified committee member]: So what you're saying is a board member from the legislature and the administration rather than just let the governor No.

[Rep. Alyssa Black (Chair)]: No. No. Picked by the administration and picked by the legislature.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I guess let me say it again. I support the concept of putting public members on there. I understand why the legislature would say, we wanna choose one too. I am not gonna put a lot of weight into that distinction. I will I will say, because I've been around this business for a long enough time, I wouldn't put a lot of energy into creating a nominating committee. If you wanna do it, do it. Have the speaker and the pro tem nominate

[Rep. Brian Cina (Member)]: without any guidelines?

[Rep. Allen "Penny" Demar (Member)]: I

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: think that when you're appointing somebody to a position, you're expecting that person to nominate, appoint someone who is good for the job. That is the system we have.

[Rep. Alyssa Black (Chair)]: I think there are guidelines in this bill on what their charge is. So, go

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: ahead, Brian.

[Rep. Brian Cina (Member)]: I was just going to say, if it's not clear, would have hurt to add a few guidelines in that section of the bill and just say, one member appointed by the governor, one by the legislature that meets the following criteria, and then at least it's clear somewhere in statute. I mean, I know that I get to hear your point that we would expect them to know. However, my experience in the political world is that when you don't set guardrails and people can do whatever they want, sometimes they do. And we don't know who's going to be elected in the future and what their priorities will be, and they could come in and just be like, this is our chance to just do what we want because there's no guidelines. Then, I'm sorry, I just don't trust politicians. No offense, everyone.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I very know well. Yes. I I don't have any opposition to that. That seems fine. I'll just also note, I've seen process where with a ton of guidelines and a ton of process and a nominating committee result in wide range of appointments?

[Rep. Brian Cina (Member)]: They still do what they want. Yeah. Absolutely. Yes. Yes. It's frustrating. Thank you.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: It is. I support the executive compensation section of the bill. I think it's important for DFR to know the parameters of how executive compensation is set. I am supportive, happy to see the age rating section come out. And I would add, I said this directly to the commissioner, I'll say it again here. The HCA would be happy and eager to partner in understanding. We have a model where we build, where we look at how changes would impact people, and we'd be happy to work on that. It's not like hiring an actuary, we're a little cheap. Oh, you already paid for us. Well, maybe you did.

[Rep. Alyssa Black (Chair)]: And especially thank you to your queen, the HCA, who very quickly started modeling this and were surprised at some of the outcomes that this would not what we intended to

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I mean, I'll just say, when I uttered the words in here the last time I spoke on this bill that we could see people's out of pockets, their premiums, their family share for their premiums go up if you reduced the premiums, I got scared because I thought, oh, I hope I didn't overstate something. We went and modeled it, and for sure, there's dynamics that play out in exactly the opposite way as you'd predict. This is complicated. And I would be happy to walk through individual memories about just how that can happen, but it really can.

[Rep. Alyssa Black (Chair)]: It's sounding like silver loading.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: It might have something to do with that. No surprise, I am very much opposed to the AHP section and the short term limited duration section. I think I heard from a number of committee members expressing similar views as I would express. I'll just say, to the extent that it works, to the extent that small groups can form together to save money, that will harm the QHP, the small group marketplace. It's not a maybe, this is math, this is sort of directly taking lives that are lower risk, lower cost, and moving them out of the pool. And there's some dispute about whether it will actually work, whether they'll be able to organize themselves to actually do it. Sometimes I've seen things like that work, and sometimes I've seen people form buying pools that absolutely don't work, and I'm mystified why they do it. I also understand the impulse. I heard the commissioner say, wow, this is not working. I agree. We have deep problems with what we're doing right now. I would argue this will make it worse. It is cannibalizing the small group. If we're gonna do that, we need a strategy for the small group, and I don't have one. Knocks it out. Also concerned about the short term limited duration section. We see people make very bad decisions for themselves in this space. This maybe goes a little bit to section 10, say both at the same time. Also very much support the getting data on health sharing ministries. People love their health insurance. People who have no claims only care about how much their premiums and love their health insurance if it's cheap. And that's and so you you interview people and you say and they say, oh, my health insurance is great. And then they get some claims.

[Rep. Alyssa Black (Chair)]: Make it suck.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And they find out, wow. The plan I have really doesn't work for me. And so we have that experience. We regularly hear from people who have bought sometimes crappy plants, sometimes illegal plants, sometimes scams, or have gotten into a plan that they didn't exactly understand. It's a plan that they didn't exactly understand, which wasn't really insurance. So very much, I think that's great to put that in there. I'm gonna just do one more. The prescription drug coverage change. Madam chair, here is another place where you get to say.

[Rep. Alyssa Black (Chair)]: Did you do this?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I was chair in 2012 when this happened, and it was motivated by a particular senator who was very sick and had very high drug costs. And so I suspect that the HCA is going to oppose this change. But I I agree with the commissioner. It's complicated. We need to model it. I need my team to take a minute to understand who are the winner. There will be winners and there will be losers in this, and we need to measure that before we can say exactly the degree of support or opposition.

[Rep. Alyssa Black (Chair)]: Would you you I wanna say, would you agree with the concept or would you agree with the statement? But would you acknowledge that as it is now, that it is inequitable for one person to be paying the exact same premium as another person, and yet based upon how they utilize healthcare,

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: one person pays more out of pocket than the other person. Would you say that's equitable? So the question I'll ask back is, is there something different about high prescription drug costs for people who have ongoing chronic conditions from other types of healthcare? There is a different dynamic. There are people who enter every single year, they live with it, they know it's coming, they have crazy high costs to stay healthy. Prescription drug costs. I know that there's healthcare conditions that do the same thing and people have episodes, and it's hard for me to compare it exactly. But I think there is something about ongoing maintenance medications that are very expensive that plays, that has a very predictable role in their lives. I think we just have to weigh it. I don't think this will reduce premiums. I do think it will allow for some more flexibility and plan design to assign out of pocket costs in different places. And I understand the motivation to do that in terms of an equity lens, but I also totally understand the dynamic of wanting to protect people with high prescription drug costs for the rest of their lives.

[Rep. Alyssa Black (Chair)]: I don't want ask you this question, but I would open this question to anybody else. And I don't know who to ask this question to that would actually know the answer, but I'm going to ask it anyways. Do you think that sometimes people make decisions about the prescription drugs they use, particularly if they're on something for a long term medication that they have to be on, that oftentimes they may pick a more expensive drug than another one that might also be a high cost, but not quite as high cost because they know they're going to meet that out of pocket max anyways and then insurance picks up the difference.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: You think people make choices about which pharmaceuticals they use? I'm not sure about that, but I think where people are in meeting their deductibles and out of pocket max has a huge impact on people's healthcare decisions. I know it. I've seen it. I've experienced it myself. Already met our deductible. There's no reason not to get the care this year. So I think that plays out all over the place in our crazy health care financing system. Does anyone else want say

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: a story? I would just add, and you see that in our financial year every December, that So

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: claims go up through the year. The last quarter is particularly high. You know why? People met their deductibles. Well,

[Rep. Alyssa Black (Chair)]: using that using that you know, what you just said, it would wouldn't it stand to reason if people make decisions on whether or not they've met their out of pocket costs, Would it stand to reason that if you know that you're going to be on an expensive medication all year long, you know you're going to meet that. But if you're incurring medical, do you think you delay medical care or avoid medical care because it's an unanticipated and you know that it's going to be out of pocket?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I'm not sure if

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: I could share. I

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: think it plays out in different ways in Vermont families today. I think the dynamic that you're describing. I'm not sure that people choose a different medication that's more expensive, I'm not sure I would go there. But I think people live with the realities that they're on expensive medications than they will go through their deductibles in three months or something like that. And people, of course, buy plans that they do their best, hopefully, to buy plans that meet their needs.

[Rep. Alyssa Black (Chair)]: I think the point I was trying to make was if people make decisions about their care around knowing that they will have out of pocket costs, that it's easier to avoid medical care and not seek medical care than it is to avoid a prescription that you know that you have to take. I think that was the point I was trying to make.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Think the one thing I would add in this conversation is we talk about these two types of care is very distinct. I think a lot of people who have very high prescription drugs have very high medical costs. Great, thank you.

[Rep. Alyssa Black (Chair)]: All right, great job for the day.