Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Welcome. This is afternoon of what day? Because my computer just died. April 7? No. April 9 afternoon and we have Addison McCracken back. We are moving to S-one 54, which is the biomarker that we heard from at 9AM. Feels like I almost said last week. So thanks for being with us, Alex. Get your perspective from the diva side of things on 154.

[Alex McCracken]: Of course, of course. Happy to be here. Thank you for having me. For the record, Alex McCracken, Director of Communications and Legislative Affairs for the Department of Vermont Health Access, and I use sheher pronouns. My comments today on S-one 154 will be very brief. I can speak for the department to say that we appreciate the changes that were made by the Senate from the as introduced version to the current version before you. DIVA is happy to produce the study that is referenced from the Agency of Human Services and the Department of Vermont Health Access, and we can do so within our current actuarial contract structure. So we would not require an additional appropriation in order to do that work.

[Alyssa Black (Chair)]: Okay, that's great. So we heard from the Department of Financial Regulation this morning that they had recommendations really more around how much it would cost and the deferral is that the word? Defraile. Defraile, sorry. And they had recommended that we remove some of this more particular stuff around what the tests are and all of that. If we remove those things, would that hinder D. Va's ability to do your piece in number two at the end? Would you have enough information to go on, I guess, is what I'm asking?

[Alex McCracken]: I think we would, madam chair, and I think that we would seek out the information required and have our contractor do the same in order to conduct the analysis. So I don't think we have issue with that language being removed.

[Alyssa Black (Chair)]: Okay. Hey, Alex, does Medicaid cover currently any sort of biomarker testing? You know, in particular, and we're going to get some information on biomarkers because we really haven't gotten a lot of testimony on that, but do you cover anything now?

[Alex McCracken]: Yes, I would have to circle back with the clinical team to give you a list of what exactly we do cover, but I know that there are some biomarker treatments that we do cover as a Medicaid program. I think I would have to get back with you on a list of any more specifics, but there are some that we do cover, yes.

[Alyssa Black (Chair)]: Okay, great. We'd really appreciate that. We can at least get a landscape of current practice. All right, any other questions for Alex?

[Mike Rollo]: All right.

[Alyssa Black (Chair)]: Well, for joining us again. And sweet.

[Alex McCracken]: Thank you so much. Alex.

[Alyssa Black (Chair)]: So we have two witnesses from Alzheimer's Association. We've got Jenny and John. Are you guys testifying together or separately? Whatever works best for you,

[Jenny Horgan]: Madam Chair. All right.

[Alyssa Black (Chair)]: Well, that's one and then off to the other.

[Jenny Horgan]: You're okay? Yeah. Perfect. So thank you, Madam Chair, members of the committee. For the record, my name is Jenny Horgan. I do our government relations work here for the Alzheimer's Association in Vermont, and I appreciate the opportunity to come before you all regarding S-one 154. So just for some background, this is a bill that we're working on in coalition with the American Cancer Society, who I believe you'll hear from later, a bunch of other specialty organizations. We are excited to talk about biomarkers myself specifically in relation to all timers. To give you the landscape, I do have some facts and figures regarding Alzheimer's and dementia and the state, the costs and challenges associated with that, as well as the spouses initially introduced did require coverage for biomarkers for public and private. So this one pager I thought will be helpful. It's reflective of the bill as it originally stood, but it will give you some good information about biomarkers and why we think it's so important in order to expand access. Thank you so much. So currently, there's over twelve thousand eight hundred Vermonters living with the disease and or another form of dementia, and that's representing almost ten percent of the population, 65 years of age and older. And the figure is likely higher as many people face significant barriers when accessing a diagnosis that is timely and accurate. And so as the Vermont population continues to age, the impact of disease will only intensify, placing increasing strain on families, caregivers, healthcare providers, long term care system and the state budget as a whole. So currently Alzheimer's is often diagnosed only after cognitive decline has occurred. That means that significant brain damage has already occurred at that point. But scientific advances are incredibly exciting right now that show that biomarker testing offers one of the best ways to get a diagnosis along with a cognitive assessment and medical information from your doctor. So this is especially critical as we now have FDA approved treatments that slow the progression of the disease. But those treatments work best at the earliest stages of the disease. It's critical that people are able to get a diagnosis quickly when they are facing this disease so that they can look at accessing treatment and they can look at making the best choices to increase better patient outcomes. So an earlier diagnosis, it enables earlier intervention, more effective care planning, improved quality of life, and it provides families clarity and access the ability to access support services. So when you can access treatment following a diagnosis early detection can reduce those long term care costs and ease the strain on the long term care and healthcare system in the state. The national analysis estimates that an earlier diagnosis of Alzheimer's or dementia can save per person $63,000 So that's $30,000 in Medicare savings, 20,000 in Medicaid savings, and $13,000 in other savings. There are huge savings in an earlier diagnosis for someone in the state is already facing very high costs in terms of caring for people of Alzheimer's and dementia in 2025 alone in order to care for people living with Alzheimer's and dementia Medicaid spent $150,000,000 in providing that care and support. These costs are only going to continue to rise as the prevalence of the disease increases and the cost of health care increases. Oh my gosh, of course. Yeah.

[Alyssa Black (Chair)]: Some So of the numbers. Yes. 12,800 Vermonters. Yes. Over the age of 65. Yes. Do you have a little bit more aggregated breakdown of the ages rather than just, 65?

[Jenny Horgan]: Yeah, so regardless of the way that we access that information is through Medicare data. So that's only applying to people 65 and older. So that means that we are that the prevalence of the disease is higher because it's only pulling data from there. And

[Alyssa Black (Chair)]: you indicated that, well, it says on your an early and accurate diagnosis of dementia can improve access to care and support services, enhance quality of life and reduce financial impact. Yeah. Is there anything that we can do currently to stop the progression?

[Jenny Horgan]: Yes. So there's two disease modifying treatments that are FDA approved currently, Kinsula and Mackenzie. And so they slow the progression of the disease in the earliest stages. So when you get an accurate diagnosis, if you're able to utilize and access those treatments that can slow the progression of disease. Also, The US pointer study that was released last year talked a lot about preventative steps and ways that you can protect your cognitive health, including managing high blood pressure, exercise, cognitive engagement, managing diabetes, good sleep. And so all these things can help manage the disease and improve patient outcomes.

[Alyssa Black (Chair)]: If you control the progression, slow

[Jenny Horgan]: the progression, slow the progression of disease.

[Alyssa Black (Chair)]: Stop the progression.

[Jenny Horgan]: No, but we are in a really incredibly exciting time when it comes to research and treatment. There's a lot of trials, lot of exciting research going on. So we're very hopeful that in the coming years, there is going to be better treatments and potentially a cure that comes down the line. We want to make sure that Vermonters, when that happens, can have a diagnosis and access that as quickly as possible.

[Alyssa Black (Chair)]: I'm just trying to tie together, if you can slow down the progression, stop the progression, then how do you arrive at a figure that it saves? Because it may save it one year, but isn't that Right. So we see that as individuals are slowing the progression of

[Jenny Horgan]: the disease, they are less likely to they're able to delay entering long term care or entering the need for higher care, higher costs in healthcare because you're slowing the progression of the disease throughout the course of it.

[Alyssa Black (Chair)]: Go ahead, Vam. The medications, I don't

[Jenny Horgan]: Yes, Leukemia and Consula. Yes. Are they accessible to everyone? So, know, that is an interesting question. It is treatments that have come out in the past couple of years. So, it is certainly something that we believe that people should have access to when it's appropriate, but we are certainly that's something that we would like

[Alyssa Black (Chair)]: to see in the future. I'm sorry that I interrupted.

[Jenny Horgan]: No, oh my gosh, no problem at all.

[Alyssa Black (Chair)]: You're throwing a lot of notes out there. I talk

[Jenny Horgan]: so, so fast. So I'm sorry. I'm sorry.

[Alyssa Black (Chair)]: No, please. Like the narrative. Absolutely.

[Jenny Horgan]: Please feel free to interrupt me at any point inside. So I'll just wrap up that, you know, really focusing on that in the insurance coverage is not keeping up with the pace of scientific process. We do see this report as the first step forward in our belief that moving towards Vermont towards more equitable access when it comes to biomarker testing and a coverage landscape is really important. So we hope that you guys will look favorably upon this piece of legislation. And I'm happy to answer any other questions that you have. I do want to flag that we have an FDA approved blood test now that helps to diagnose the disease. That's incredibly exciting and is very different than the more invasive biomarker tests that were available previously. So we're seeing again so much exciting research and treatment and everything is happening really excitingly in that space. So we want to make sure that Vermonters can access that and to get the best care not only to improve their lives but also to reduce the strain and burden on the seeds.

[Alyssa Black (Chair)]: You indicated that there's now a blood test as well. Is it just as effective in diagnosing as a biomarker testing?

[Jenny Horgan]: It is a form of biomarker testing. So it's a blood test that does. And so when you get when you're getting a Alzheimer's diagnosis, it's not just simply relying. You go to the doctor, you get a biomarker, you say memory concerns or something like that. And, you know, ask for a bio protest and the bill itself also had very significant limitations regarding medical, you know, utility for whether or not it would be covered. It's not just you go to the doctor, your doctor says, let's give you a bio protest. Let's cover it. For this specifically, you're getting the diagnosis for Alzheimer's, go to your doctor, they review your medical history, they give you a cognitive assessment, they would do a number of other things and then potentially also include a biomarker test as well.

[Alyssa Black (Chair)]: You indicate on this one of your handouts twelve thousand eight hundred homers living with Alzheimer's, but as many as half of them are not formally diagnosed. So if they haven't been formally diagnosed, how do we know they have Alzheimer's?

[Jenny Horgan]: So, that's data that we're pulling, there are we believe that there are significantly more people without a formal diagnosis. So, that is people that are facing significant barriers to accessing the diagnosis, whether that's because they can't access it by finding a provider that's able to provide that to them or if they're struggling to, you know, providers don't feel comfortable making a diagnosis. So that's where we come to that.

[Alyssa Black (Chair)]: Questions. Don't want to go ahead, Wendy. So the biomarker test is to definitively diagnose.

[Jenny Horgan]: It's to assist in giving an accurate diagnosis. Again, it's not just the biomarker test that gives you a diagnosis when you go to the doctor. It's part of a comprehensive exam of your physical, mental health and all of those things that then lead to a doctor providing the diagnosis.

[Alyssa Black (Chair)]: And to get those medications, that's

[Jenny Horgan]: not very exciting. Yes, you have to have a diagnosis. You cannot access the medications without a diagnosis.

[Alyssa Black (Chair)]: What's the cost for bio? How much does that It's very

[Jenny Horgan]: hard to break down that to be very honest because it depends on the agreement that the insurance company has with the biomarker testing company, depends on the type of insurance you have. So, there's a lot of factors that go into that. I know that the American Cancer Society has some information specifically on the cost of cancer biomarker testing. But again, it's a really challenging thing to nail down in terms of what the cost would be for, you know, whether it's a PET scan or a blood test.

[Alyssa Black (Chair)]: Do we know the range? We have a range?

[Jenny Horgan]: I don't currently have one right now, but

[Jen Harvey (Office of Legislative Council)]: I'm happy to go back

[Jenny Horgan]: to our team and see if I can find that information for you. But I think it's definitely this bill right here, this reporting bill would provide a lot of that information that you're looking for. It would provide information regarding how it would impact premiums, how it would impact the cost of the state for Medicaid. So I think that this bill actually would be incredibly helpful in pulling exactly together what it would impact the Vermont Medicaid program and the insurance providers in the state.

[Alyssa Black (Chair)]: Just follow-up real quick. Yeah. Lung cancer, ovarian cancer. Cologuard is now doing all of that. I just thought it was just for colorectal. It used to be just for colorectal. Now it's doing all of these other screenings. Now I just wonder, like, with the advancement, like, will there be? So on

[Jenny Horgan]: the federal level, we are advocating with Medicare for it. And this is going to get very into the weeds with stuff. So to be very brief, this is specifically for diagnostic, you have to have symptoms. If this were something that the state would want to implement screening wise, the FDA approved blood test is only for diagnostic. It's only if you have a symptom and then the test is approved to help identify whether or not you have the disease and give you an accurate diagnosis with screening. The FDA has not approved a blood based biomarker test for that yet. So, on the federal level, it's definitely something that we see very exciting coming down the pipeline. And again, we think it's going to be incredibly impactful on the research and treatment landscape to really give us a better understanding of the disease, a better understanding of how to treat the disease. So very excited on that front, but that is not quite where we're at yet. Yes. Okay, thank you.

[Committee Member (unidentified)]: Go ahead. And can you just explain what happens now to a person that believes they might have Alzheimer's and they go to

[Jenny Horgan]: their Yeah, so you would go to your doctor, would have a conversation with your doctor discussing your family history, provide a cognitive assessment, which is a written test that you take as well as an examination of your health overall because there are a number of diseases that can present as if they are dementia, but they're not. It has to do with something else, which again is why we think that biomarker testing is really important because it kind of prevents the situation and helps prevent the situation where a misdiagnosis occurs. Right. So, doctor would do these cognitive assessments with you and then if biomarkers would pass and again some insurance coverage does cover certain types of biomarkers, but this is about equity and access ensuring that all Vermonters would have access when appropriate not just you go to your doctor you say I didn't have any memory concerns.

[Jen Harvey (Office of Legislative Council)]: I want a biomarker test. Yes,

[Jenny Horgan]: so you would review your medical history, provide form of physical exam, cognitive assessment, all these things, and then potentially a biomarker test that your doctor would then take all of that information and provide you with a diagnosis or not a diagnosis.

[Alyssa Black (Chair)]: So, I have a, I realize and we're going to hear from

[Committee Member (unidentified)]: the

[Alyssa Black (Chair)]: American Cancer Society.

[Jenny Horgan]: I'm

[Alyssa Black (Chair)]: curious as to the advocacy from the Alzheimer's Association, and I do realize that oftentimes that people are diagnosed before the age of 65, but we're really talking about the Medicare population here. So I'm wondering why the efficacy for Medicaid and commercial So

[Jenny Horgan]: we should see that it's not just, right? You think Alzheimer's. You think someone that's much older. We are seeing Alzheimer's show up in a number of people we have that are before the age of 65. Know, I know a number of people personally that were diagnosed in their 50s. You know, we see reports of people getting diagnosed in their 40s and even younger than that. And so you also have the situation with the disease where the disease is progressing, but you're not showing symptoms. So we think that it's really important that if you are having concerns and you do want to get an accurate diagnosis, that is this is the best way to ensure that information with your doctor reviewing the relevant information that you would be able to access this. So again, you can get a diagnosis and it is definitely a disease that impacts people.

[Alyssa Black (Chair)]: I do know that. My husband's family has a very, very strong family history and they were all diagnosed in their fifties.

[Jenny Horgan]: I'm so sorry to hear that. It's so awful and challenging. Sorry.

[Alyssa Black (Chair)]: Go ahead, Karen. I don't want to get into defraud and simplifying the language or not necessarily it's done. Don't we ask, we could certainly ask on the suggestion by Department of Financial Regulation to limit all of this other stuff and whether or not they just

[Jenny Horgan]: Find that. The DFR was in this and they There's

[Alyssa Black (Chair)]: a lot of specificity in there, and they said it sure would help us with our work if it wasn't something specific, so we could kind of figure out what it would cost because there's this frail aspect to it that they also need to analyze. Of course.

[Jenny Horgan]: They feel like they have

[Alyssa Black (Chair)]: a lot of access to information, but this might pamper their abilities. How would you feel about that language?

[Jenny Horgan]: So the language that the Senate passed took directly from the guardrails that were in the bill regarding who would be when a biomarker test would be covered, because not just blanket coverage, it would be based off of the FDA, you know, scientific evidence medically medical utility involved in it, right. So that's where that language come came from, you know, certainly I'm happy to talk to our team, you know, I know that that came up earlier this morning. And if it is something that we have concerns about, would be happy to reach back out to you and share what our concerns would be

[Alyssa Black (Chair)]: if that would be appropriate. So what you're saying, because we weren't in the Senate, so in the original bill, it had coverage. Are these requirements, but it was when it was coverage? Exactly. Now it's just really a financial report back to us.

[Jenny Horgan]: Absolutely. Okay. Yeah. So that's where all that kind of language came from, because that was the real guardrails and meat of the legislation as it was originally in the Senate.

[Alyssa Black (Chair)]: Thank you. Thank you so much.

[Courtney Harness]: Is it any physician that is able to diagnose Alzheimer's or do they go to a specialist?

[Jenny Horgan]: So you can go to a specialist to get a diagnosis. A lot of primary care physicians are not comfortable making a diagnosis. They don't feel prepared to, they don't feel like they have, you know, the knowledge and the training necessary to do that, but they certainly could assist in making a diagnosis. But we run into that challenge.

[Courtney Harness]: Is the biomarker company does a variety of other tests as well or is this a specific company for Alzheimer's?

[Jenny Horgan]: So it's a variety of different. So biomarker doesn't refer to any type of company or anything. It's just a blanket statement regarding these different types of tests. It's not one company that's doing all of the tests.

[Alyssa Black (Chair)]: Guess just I keep asking this question. Yeah. There been any research done on the cost benefit for this in Alzheimer's or the return on?

[Jenny Horgan]: So that national analysis of $63,000 per person is what we really see as the potential cost savings. So that's $30,000 in cost savings for Medicare, dollars 20,000 in Medicaid and $13,000 and other savings. But we also think that it's really important to recognize that if you're delaying someone entering long term care, they're also reducing the burden on the long term care system, reducing the burden on the workforce. And essentially allowing someone who's caring for someone in their home living with the disease. If you're slowing the progression of it, they may be able to continue to engage in the workforce and do all of these other factors that really ripple out and impact. Caregiving is incredibly challenging and hard. And anything that we can do to delay and slow the progression of the disease really reduces some of that strain that we see across the entire state in so many different ways. Thank you, Jen. Thank you for all your information. Thank so much. Thank you. I really

[Alyssa Black (Chair)]: appreciate the time. You barely looked down at your paper. Thank you so much.

[Jenny Horgan]: Hi, John. Hey. How are you? I'm alright, thank you.

[John Bouten]: Thank you all.

[Alyssa Black (Chair)]: Thank taking

[John Bouten]: a few minutes to hear what I have to say. If you don't mind, so I did pen in testimony. I'm gonna add a few pieces and talk freely a little bit about, okay? If that's all right, great. Again, thank you for seeing me. My name is John Bouten. Live in Hartford, Beringer, White River Junction. My wife Judy Simon Bouten died almost three years ago from complications of Alzheimer's. Relatively quick kind of thing. But she was, among other things, a guiding parent, master elementary school teacher, reading specialist, lifelong learner, lover of performances, lover of art, lover of color. This was one of her scarves, and I wear it whenever I'm politicking or doing whatever this is called to celebrate her life. At her celebration of life, her friends filled the UU church in Woodstock with quilts that she had given away, and we requested that people wear colorful clothing. The place was filled, which was just she would have loved it. It was great. We had music and all kinds of good stuff. Complications of dementia, which was probably Alzheimer's, entered life about two and a half years ago. I was a caregiver for several years, as this terrible disease took away her enthusiasm, her ability to socialize, and she was a very social person. Lost her ability to cook, lost her ability to put together fabric and make quilts she liked to make quilts. She got to the point where she was actually afraid to leave the house, paranoid about me taking the dog out for a walk, because she was afraid something was going to happen to the dog. She had a seizure one morning. We'd gotten to the point where I was brushing her teeth. She had a seizure one morning, fell over backwards, mangled a couple of vertebrae, and for a 72 year old woman that has dementia, you don't invest a whole lot of money in life threatening surgery. So we went through some rehab and that sort of stuff, but it was about three months before she finally succumbed. But the whole time she retained her cheerfulness, knew people, but was just kind of going downhill and stopped drinking and eating. I want to talk a little bit about her diagnosis, because you sort of brought it up here. She knew that she suspected something was wrong, and she felt like she wasn't as sharp as she thought she had been. Looking back at it now, I can see that, well, she's a school teacher, so we're talking at this point in time she's 70, so she retired a couple years, but remember going in or having her request that I help her put her classroom together or her workspace together so that she could bring it home and store it, which was so different from when she was younger and would spend almost always, it spent all of August, putting together packages of information that she could program packages to work with different kids at different ages and that sort of thing. So they would be all neatly packaged, and so this was one of the shifts that was happening, and if we were sort of recognizing it then, we might have been more aggressive about trying to figure out, is there something wrong? Quite frankly, because there wasn't really a way out of Alzheimer's, and there wasn't really a way out of dementia. That's probably one of the reasons that we didn't look earlier. I do want to talk a little bit about when we got the diagnosis. We worked fairly independently. She had made the appointment through her PCP, who was a nurse with a master's degree, and in that process she had been suggested that she go and had made an appointment at Darvish Hitchcock, which quite from me is like seven miles away from where we live, but she missed the appointment. It was going to be a Zoom. This is in 2020. I left her with the responsibility, thinking that she could do it, and was actually getting kind of pissed that she wasn't taking care of setting this up appointment. So she missed that first appointment. Saw her PCP, recommended that I go with her, got another appointment with another doctor there, and I have to tell you that within a very short period of time of me and her being in there talking to the neurologist, it was really clear to me that something was way wrong. I mean, some of us have almost certainly, as a kind of a screening test when you turn 65 and you kind of get that first Medicare kind of thing, there's this series of 10 questions where you try to draw the clock and that sort of thing. I mean it was just nothing. It was really clear that something was going on wrong. Her doctor was talking to me and to her and said, Well, I'm pretty sure this is early onset dementia, probably Alzheimer's. I'm not sure there's any point in having a PET scan or something like that to confirm it, and we decided not to do that. I'm saying that because that would have been the next step in trying to confirm that diagnosis, and I can't believe that a PET scan with all of the equipment that goes with that is going to be less expensive than a blood test. Jenny already mentioned so much has changed in the last three years. There are now two drugs that can slow the disease, and now we've got this FDA approved blood test, which has promise. The research is on moving. One thing that I want to say is that I think it's a real game changer from a couple of standpoints. One is that it may, I don't know, but I suspect it would be quite a bit cheaper than a PET scan. Second thing: I live seven miles away from a major medical facility, which would have all of that stuff. Somebody in Northeast Kingdom, somebody in South Central Vermont is going to have to travel some time, perhaps an hour, and that may be harder. It may be harder to get somebody to go an hour or an hour and a half for an appointment. So if there were blood tests that were available, and if eventually PCPs were trained in making these partial diagnosis and wanting to be able to follow-up, then they might very well be able to have a blood test taken, sent to a lab, and confirm their suspicions. There aren't enough neurologists around. Aren't enough geriatric psychologists around. It's big long waiting lists. I also want to say that six years ago, I wouldn't have wanted to know if I had dementia or Alzheimer's. The progress is just incredible. It's so hopeful, and at this point in time I would want to know, so I would be approaching my doctor and saying, Look, I'm and quite frankly I am I'm having trouble remembering names and people's faces. Then I have talked with my doctor about that. We're not to the point where I'm getting referred to a neurologist yet, but it's concerning. I would love to know that there's a fast, fairly effective, and fairly inexpensive way having this happen. So my pitch really is I think that health insurance should cover this. I certainly hope it will, and I understand that we're not talking about health insurance now, we're talking about what the cost is going to be of doing this thing, but I strongly urge you and hope you will support moving Spill forward. Thank you.

[Alyssa Black (Chair)]: Thank you so much for sharing your story and telling us about your work. I do have to say that I laughed a little bit when you said that she worried when you took the dog out because you said she was worried about the dog. I'm like, she wasn't worried about you. Well, that's fine.

[John Bouten]: I'm fine. So I was a forester, I worked for the state of Vermont, and so I don't think she worried about me walking up and down the driveway too much.

[Jenny Horgan]: Actually, I didn't want to

[Alyssa Black (Chair)]: ask you a question, and I know that that's not why you're testifying today, but we frankly in this committee have not really done a lot around this, but you were her caregiver. How were resources for How are you coping? Because we do know that most often this falls upon families and loved ones. Okay. If you wanted to share it all.

[John Bouten]: I could do that, I had a dry run earlier today actually, but I go over. So it was tough. As I said, Judy and I were having our disagreements, and looking back upon it now, I'm pretty sure that some of it was related to her dementia developing. So I really have said this many times: when we got that diagnosis, it was like a switch. No longer are we in this kind of a relationship trying to figure that out, but oh, I've a different job to do now. Changes. The support I got varied, or that we got varied. Again, this was during the pandemic, which didn't make it easy, but we were referred I get a bunch of publications from Dartmouth Hitchcock from the dementia section there. Old enough, clearly I'm only 75 not old enough to go to an aging resource center, but we went to the aging resource center and they had several courses that took Zoom courses for caregivers and for people that were patients. Very, very helpful. Beyond that, that follow-up, at least for me, with support groups on Zoom, again offered through that organization, and they were, boy, they helped a lot. I think without those, kind of locked in a house with your spouse who doesn't want to go out, and I'm not that social a person, but I need something, so getting some of that feedback was just absolutely critical. Judy had a number of friends. They came over, helped sort her fabric, there was a lot of compassionate deception that was going on, which was wonderful. We got good support from Dartmouth Hitchcock. We were seeing a specialist there, again a nurse practitioner, four times a year. Our PCP recognized that we needed a little bit of extra help, and because Judy had some diabetes and her numbers were kind of at that edge, had Judy and me come back every three months so that she could kind of check up on us. That was expertly organized, actually. So she would meet with both of us, say, well John, why don't you go out there, because I really want to talk with Judy alone. We'll talk with Judy alone, then we'll come and get me and we could talk while we're going back to get Judy. So it was very clever and it worked out well. One of the things that we did, because I do want to give some tribute to the Alzheimer's Association, we were trying to figure out how to do this. We didn't know people that had Alzheimer's, we didn't know that many caregivers, but Judy and I were here at the Alzheimer's thing four years ago and we learned a lot from people that experienced listening to people like me talking, and that was extremely helpful, and that kind of got us on the course of doing some more stuff. Judy was more of an activist than I was, and so we actually testified Judy by my side in the Senate health and welfare once. I went back and testified the next time, and Judy had died in the meantime, so that was certainly impactful. I think so I'm giving you a bunch of stuff that was useful for me. It would have been lovely if there had been more stuff that was local. It would have been lovely if there had been a memory cafe near where we are. Have you heard of those? Do understand what they are? So oftentimes a caregiver and person with dementia will go to a place with a number of other people, I mean, as a gathering of those folks, and it'd be facilitated sessions, and the groups may actually get split in two directions sometimes, where the caregivers might get to talk amongst themselves, and the people with dementia might be doing some projects and things. So I actually volunteered to help facilitate one of those in White River Junction. There are two others there, but they would have been great. I know that there's a group that meets in Woodstock similarly, but that wasn't possible, obviously, during the pandemic.

[Alyssa Black (Chair)]: Well, you for doing that now, and thank you for helping others.

[John Bouten]: Yeah, well, it's what I do, it's purpose. It's a good thing.

[Alyssa Black (Chair)]: Thank you so much, thanks for testifying. I really appreciate it and sharing your story. You. Yes, sorry about Judy. Thanks. Okay. So we have Michael. Oh, Michael, you're on Zoom. I'm sorry. I thought you were in the interview today.

[Mike Rollo]: I apologize, madam chair. Thank you for accommodating me. I wish I were there, actually. Some of you may know I I cover New Hampshire and Vermont. So, it's our cancer action day in Concord today. So we had our volunteers there, which reminds me of it before I get to my testimony. We have Vermont's Cancer Action Day, also known as our legislative ice cream social. You may remember that we host every year. It's coming up on Wednesday, April 22, from one to four in the cafeteria. More Give us more things on the way for ice cream. Ice cream is on Wednesday the twenty second.

[John Bouten]: So Okay.

[Mike Rollo]: Anyways, thank you so much for for allowing me and accommodating me. There's no way I could get back from Concord. It ended half an hour ago. So anyways, so thank you for that. My name is Mike Rollo. For the record, I am the government relations director for the state of Vermont and for the American Cancer Society Cancer Action Network, also known as ACS CAN. ACS CAN is the nonprofit, nonpartisan advocacy affiliate of the American Cancer Society, and we advocate for evidence based public policies to reduce the cancer burden for everyone. And as the nation's leading advocate for legislative solutions that are helping to defeat cancer, ACS CAN ensures that cancer patients, survivors, and their families have a voice in public policy matters at all levels of government. And it's in that vein that on behalf of ACSKN, I want to take this opportunity to submit the following testimony on S one fifty four. With the understanding that it's no longer what it was when it was submitted in the Senate. So, but timely access, to guideline indicated, comprehensive biomarker testing will enable more patients to access the most effective treatments for the disease and can potentially help achieve the triple aim of health care, better health outcomes, improve quality of life, and reduce costs. Now the original goal of this legislation was to ensure that Vermonters covered by commercial and Medicaid, commercial insurance and Medicaid, had comprehensive access coverage to comprehensive biomarker testing when medically appropriate. Now that the bill has been replaced in its entirety by an actuarial study and analysis, we still support the legislation as we see this as an appropriate step in ensuring both expanded access to important testing slash monitoring tools. But also in ensuring the solvency of our healthcare system. We look forward to working with the members of the of this committee and others and with regulators to ensure that the language of, the bill as it moves forward, achieves those goals. Now I I did listen to I was able to listen to, thank goodness, to Zoom, able to listen to commissioner Block this morning. And we're completely fine with with with the changes that she suggested. The question was asked, where did where did this bill come from? Came from the American Cancer Society. We've been and and we partner with you you just heard from from from John. It's, it's never easy to follow John, but it's always uplifting too because he is he's not my volunteer, but he is an amazing advocate. He does an amazing job. Jenny is very lucky to have him. But, we we do support that. But the reason, though, those basically, the Senate, when they decided to move this to a study, took quite a bit of the existing language, like definitions that we had in our bill this model legislation that we have that we've used successfully in 23 states, I believe, now that have passed this. They those those things that are are very specific that she objected I don't what's objected to, I guess, maybe it's the best way to put it, to having to to study that would, you know, be more cumbersome, I guess cumbersome rather, I guess. Those are put in place to ensure that we'd I wrote this down because those were hard words to safeguard patients and payers for fraudulent testing. We we we don't want that. We we are very much in in in lockstep with with with with commissioner blocking not wanting that to happen. That's why those those are in place. For her to do that study, and I I I may have missed I think I missed, DIFA. They, they do not have to do all of those things to do the actuarial analysis. That doesn't need to happen. And there are other studies from other states. We have provided information to help guide that process in a multitude of states, and we are more than willing to help to do that in Vermont. One of the things that not saying Vermont is doing this, but other states are being have been hung up on when they look at the, the fiscal note, that's attached to the bill, and when they do when they do actual analysis, they don't always take into account the testing they're already doing, the services they're already covering. They just see it as a a large mandate and and look at which is appropriate. One to look at the worst case scenario because someone's gonna be on the hook for paying this, and I get that. But we've helped guide those discussions in other states to show that might be a little more nuanced study that they may want to do and unless it just help guide that. The best product can can can be developed because our goal at the American Cancer Society is not to not to destroy the health care individual health care market in any state. If our patients, the people we advocate for don't have access to health care, no one is served. So that's why, you know, as much as we wanted to see this policy move forward because we've seen it be successful in other states, Have there been some hiccups like in Arizona? Yes. But we we we see this as a natural progression, then it makes complete sense to us that you would wanna do an actuarial analysis. You want the best information to make the best decisions possible, and we are more than willing to do that. I I I I can go into more detail about what biomarkers are. I don't know if you really want that this afternoon. But, basically, just so yeah. Just a rudimentary sort of background in it. A biomarker is I'll just read it because I don't want to but biomarker testing analyzes tissue, blood, and other biospecimens to identify mutations that may impact treatment decisions. Basically, they use a person's own genes and proteins to diagnose and to treat diseases like cancer. Mean, it has it has applications for a multitude now of different diseases. You've just heard of Alzheimer's. That's a very recent development. Parkinson's is another very recent development. And so those organizations have been partnering with the Cancer Society. Rheumatoid arthritis is another one, where there are applications that help patients avoid unnecessary treatments. We've had volunteers avoid unnecessary surgeries because they wouldn't be beneficial to their course of treatment. Now before there was a biomarker test available for those types of cancers, for for the I know and it's not for every cancer rather after that. They probably would have gone through a course of chemotherapy in that in that surgery. This one individual just had to have chemotherapy, and she avoided I don't want say just. I don't want to downplay. I mean, it's still arduous to go through that. But she avoided a very invasive surgery that saved her a lot of time and worry, and it saved the system also resources that they didn't have to they didn't have to use. So it's we see it really as a win win biomarker testing. We've seen it be successful in other states. Now that being said, I respect the Senate's decision to turn this into a study. Now would my life be a lot easier if I just pass the bill? Of course. But that's it's not practical, and I understand that. And I would encourage you to, to amend the bill to, to take into account what commissioner, Block said this morning, because I think she was a 100% correct. And and we look forward to to working with with you all and and the department to, to try to come up with, a policy that's going to help the the most Vermonters, but also maintain vital services that people need and the vital access to services. So with that, I think I'll stop and I'm happy to answer any questions, ma'am. And again, thank you so much for accommodating me. Wish I could be there in person.

[Alyssa Black (Chair)]: No, thank you so much, Mike. Any questions? I just wanted to ask Jenny as well. What are we talking about for how much does biomarker testing even cost?

[Mike Rollo]: How is this for a political answer? It depends. There are on the low end, on the average, and I will email you that. Since it had been switched to just a study, I didn't send you the deluge of of of emails and paperwork that we would normally submit. We have a cost share and all of the info on that, and I will send that to you. But on average, they run depending on if it's commercial or Medicaid anywhere from, and these are the negotiated prices. I I believe it was I don't have in front of me, but I believe it's anywhere from $46 to 200 and change. And, again, those are the negotiated prices that the carriers and the Medicaid department would would, work out with with, with the folks that are actually administer these tests. If they were doing it on their own, now that's the average price. Keep in mind. There there are some newer tests that may or may not that more than likely don't fit the the criteria that's laid out in the at the original bill. They could be multiple thousands of dollars. And like I said, they may or may not have a benefit to the patient. And if they don't, we don't believe it's appropriate for them to be getting it. I should have said this from the beginning too. We do not believe it is appropriate for every single cancer patient to be getting a biomarker test. It just isn't. There are a line of criteria that were laid out actually, it's still laid out in this pill, but in a different sense that the commissioner block had mentioned that this is all the things that you're gonna have to look at. Those are put in place to safeguard to make sure that the payer isn't paying for a test that's not not appropriate medically appropriate. But, on average, like I said, between $46 and and 200 and change. I could tell you the New Hampshire Medicaid office guy literally just worked on this bill in Jenny too. Although I think Jenny was in Vermont, and I had to be in Concord yesterday too for it. We we should just swap back and forth. The the Medicaid office in New Hampshire did an analysis, and it was gonna cost on average there. Keep in mind, it's a different system, I know, but I was gonna cost the state of New Hampshire anywhere from it was a $150,000 on the low end, to cover everything. Now they also didn't take into account things they're already covering, keep in mind, up to us. The high end was just under 600,000 on the very, very high end. That's if they they they didn't bother with medical necessity and just covered anything anyone asked for, which would be foolish. And they wouldn't do that, but they wanna do an estimate anyways. So it's that doesn't break down per, per test, but that shows you the, on the on the low end, it's not it's not a lot of money in the grand scheme of things when you're looking at a state budget. And you're and you and you're looking at what this provides an individual and what it provides a system as a whole in avoiding unnecessary treatment. So I think it's it's pretty, pretty low investment per very high reimbursement. But

[Alyssa Black (Chair)]: I think

[Mike Rollo]: That's probably more

[Alyssa Black (Chair)]: of an answer than

[Mike Rollo]: you need a representative. I'm sorry.

[Alyssa Black (Chair)]: All right. Couple of questions. I know Val has one.

[Mike Rollo]: Sure.

[Jenny Horgan]: Thank you. Hi. I'm just curious.

[Jen Harvey (Office of Legislative Council)]: I'm just learning about this now. How does this come up in conversation with your doctor? Is this something that the patient asks for, or is it something recommended by the doctor?

[Mike Rollo]: It can be both, actually. Now, they were one of our volunteers, they would probably ask about it because they know about it. But the overwhelming majority of people don't know. They don't ask for it. In fact, we had if you were you may not recall, but a few months back, we had a a table in the card room, and people were coming up to us. And, a couple of representatives actually came up, and they said, you know, I've had cancer, and and I wonder if I had one of these tests. Well, I don't wanna say which representative, but she went and I mean, let's just say David. That person went and spoke to called their doctor, actually. And long behold, they had had a biomarker test and never even knew it. And it actually helped that individual guide their treatment, help their doctor guide their treatment options. And that's what in the cancer world, that's what it's used for mostly. It's after diagnosis. If there was a biomarker test available and there isn't for all cancers. Like for for certain breast cancer, so if you have a breast cancer that the hormone base, you know, that that would respond to certain treatments based on hormone, there is a biomarker test for that to determine whether or not you would be a candidate for certain treatments. And if and if if it doesn't and I I I'm gonna get it backwards, of course, so I won't say which way. It go whichever way it goes, you can either avoid treat certain treatments or you'll need additional or or or the treatments that they would use normally for it just won't be effective so they don't bother. And it's a standard it's a standard course of of treatment of doing business in diagnosis to use that biomarker test. And I'm sure I don't wanna speak for for Blue Cross Blue Shield, but I bet you they'll tell you that that they cover that already because it's standard of care. What we're talking about is, there are there are newer biomarker biomarker known testing coming online that may or may not be appropriate, depending on the patient and whether or they meet the criteria that they may not be covering now. It's a case of of, of science outpacing. It probably always holds true, but outpacing laws, you know, whether it's insurance laws or anything else. You all do the best you can to to to to make the laws that would be the best that they what can be for the great people of Vermont. But you're only there for a few months at a year. Right? So if something happens when you're not there and then or a bill gets filed, it takes time to catch up. So that's what this is really about. It's trying to stay ahead of of science, but in a cautious and judicious way. But also because if I I get off my soapbox in a moment, just tell me to stop, madam So it's also used to decide whether or not treatment has been effective. There are certain cases where they'll come back for a couple of biomarker tests post treatment to determine whether or not the treatment was effective, whether or not they have to go to a new course of treatment or if there isn't any other options. That doesn't hold true for every cancer patient, but there are applications there. Trying to think if there's any others that I'm forgetting. I will forward all our fact sheets. I didn't do it for today because it was really, because the bill had changed so much. I can give you more about biomarkers than you ever want to know, but, is helpful. I know and maybe not sometimes, because it was this was switched to an actuarial analysis and study, I didn't want to give you the deluge. I'm happy to send them over.

[Alyssa Black (Chair)]: That would be great if you want to send them to our committee assistant. Please have them posted so that we can refer to.

[Mike Rollo]: Will do.

[Alyssa Black (Chair)]: Any other questions? All right, well, we'll let you get back to the answer. I hope you're not doing an ice cream social for them because there's way too many

[Mike Rollo]: of

[Alyssa Black (Chair)]: them.

[Mike Rollo]: You know, now it's worse. It's actually worse. We put a lunch on for them.

[Alyssa Black (Chair)]: Oh my goodness.

[Mike Rollo]: When 400 house members, 400.

[Committee Member (unidentified)]: Didn't know they didn't come

[Mike Rollo]: this year, but when they hear free lunch, they get paid $100 a

[Alyssa Black (Chair)]: year. Yeah.

[Mike Rollo]: To be a rep in New Hampshire. So they they they could be lying down to whoever puts it on.

[Jenny Horgan]: So Yeah.

[Alyssa Black (Chair)]: They're they're gonna take they're gonna take that free lunch.

[Mike Rollo]: They take advantage, but I really hope I'll see you at on the twenty second for ice cream, which I think is a much better offer than than than anyways, personally.

[Jenny Horgan]: I know.

[Alyssa Black (Chair)]: Well, thank you so much for joining

[Mike Rollo]: us. Have a great day.

[Alyssa Black (Chair)]: Great. Thank you. That's always nice being so close today at 04:00. Yes. I wanted to hear it. And very important. My daughter is safe to meet my daughter. Four blocks. Can you join us? Can you stretch it out for an hour?

[Courtney Harness]: I didn't know about the ice cream, so absolutely. Just ask me easy questions, and I'll be happy to stay here until four I know you all do that all the time anyways. Courtney Harness, Blue Cross and Blue Shield of Vermont, and very happy to be here for the second time this week. I was missing you all, so thanks for having me. I want to start by saying, first, very happy that this bill has become a study. And I sent you, and I'm sorry, it's a lot, but if you're into medical research, you'll love it. I think the had asked for some examples of things that we cover. And I think to earlier testimony, it's important to call out you've received two different documents, one updated December '5, so just a few months ago, and one updated January '6. So the document related to prostate cancer, those are biomarker tests that are in the investigation stage right now. And so what that means is that all of the researchers at Blue Cross Blue Shield of America have not deemed those medically necessary yet. I think there's a handful of those biomarker tests. The other document, which I believe is from January, are all relatively new biomarker tests that have become medically necessary. So they've moved from investigative stage to medically necessary, and so we cover them. So I want to make sure that I start by saying it happens more frequently than yearly. But every time a biomarker test in particular and it goes along with many other things that we cover. Every time it moves into that medically necessary category, we cover it. And we just had this conversation downstairs about HIV PrEP and PEP. And I think we kind of threw off some other testimony, because folks didn't know the extent at which we cover certain tests. And it's something that we're really proud of. But one thing that's important to say, and I'll say this about this study, When you say to mandate every single test that's FDA approved, it's thousands of things. Now, I'm going to say this, too, and this is why I might suggest that this study in Vermont is so important. We literally have the highest laboratory cost in the country. I said to this committee a couple of months ago, most of our lab costs at hospitals are 700%, 800%, 900% of Medicare rates. So we're not talking about another state where those averages are 90%. We're talking about 10 times that. And the testimony notes that I sent you, there is some and I'm sorry, I'll have to read this because there are numbers that I want to make sure I get right. Those are from Blue's plans only, and analysis in other states. So I shouldn't make sure that I say to states that are much bigger than Vermont. And even us charging 10 times more for lab tests, we're probably not going to catch up to the population gap. But if you look at a state like Maryland, when they conducted their fiscal analysis for cost to Medicaid so this is not Blue Cross Blue Shield, but this is Medicaid 1% of enrollees in Medicaid in the state of Maryland, if they just get one biomarker test was $27,000,000

[Jenny Horgan]: Wait, can you repeat that?

[Courtney Harness]: Yeah. If the uptake for Medicaid members in the state of Maryland was 1% So if 1% of Medicaid enrollees in the state of Maryland got one test, dollars 27,000,000.

[Alyssa Black (Chair)]: Why the Maryland comparison? Stop talking.

[Courtney Harness]: That's the data that we have. We don't have Vermont data.

[Jenny Horgan]: How many people is that?

[Courtney Harness]: I wouldn't be able to tell you off the top of my head the number of Medicaid enrollees in the state of Maryland, but I could find out for you.

[Alyssa Black (Chair)]: Yeah, because to me, it doesn't mean anything. It's a lot of money. But Maryland is also

[Courtney Harness]: Correct. A big Much bigger. Yeah. I would say, also related specifically to this bill and we've heard testimony from American Cancer Society and Alzheimer's Association there are states that have done this specifically for eitheror or both. So Louisiana is a great example of a state that has done this specifically for cancer. So I think, Rebecca, your question about Maryland is right on. And I would say that that's why the study is important in Vermont. It's not just the cost of Medicaid in the state of Vermont. But when this is a mandated coverage and I know you heard this from Mary Block this morning it's a lot of cost to the state above and beyond that. And so that's why this study is really important. And from our perspective and from the perspective of Doctor. Weigel, who I talked to about this this morning, who you saw earlier this week, It goes both ways with cost too. And I would suggest that we make sure that part of the study is some modeling around both things. What might a biomarker test that's medically necessary prevent or help in terms of the treatment pathway. But also, and you see in some of my testimony notes, what are some of the unintended consequences of a biomarker test that inherently leads to a cascade of other tests that we know are very expensive in the state of Vermont. And so for me, this study is important because our health care system I don't have to tell any of you this is very fragile at the moment. And we really need to know, I think, what we're getting into. And a study might be able to help us slowly wade into some of these waters with specific sets and guidelines for testing. So Blue Cross and Blue Shield of Vermont is supportive of the bill with the study language. I think we would also be able to support in whatever way we can with whatever data and pricing and costs we have available. I'll make sure to follow-up with Mary and let her know that. But we should just wade carefully into this one.

[Alyssa Black (Chair)]: So you do have, if it's medically necessary, by the way, I just learned. So the Blue Cross Blue Shield Association actually does medically necessary and then farms it out to all Blue Cross Blue Shields?

[Courtney Harness]: Well, they're the host, right? So there's

[Alyssa Black (Chair)]: This is not pertinent to

[Courtney Harness]: the battle. There's a variety. So part of the benefit, there's a blessing and a curse to all associations, but part of the benefit of being part of the Blues Association is that we get access to a number of things. And a lot of them is research and data relative to testing.

[Alyssa Black (Chair)]: Didn't know that. Interesting. However, you do cover some medically necessary Are these, and I know so little about this, particularly around cancer, are these something that any normal lab like a Quest or even UVM, they would do, or are these specialty labs?

[Courtney Harness]: I think it's a good question. And so if you look at the list that I sent you, and there's a lot of them on there, and it's dozens of pages. Sorry for that. But there's some pretty specific tables in those about what the test is, what is it indicated for, whether it's like a biopsy or a blood test. And so relative to the Vermont market, I'm not sure. I don't think Quest is all the way into a biopsy market. I could be wrong. I would imagine someone would choose a hospital setting for something like that. But I would imagine the blood tests could be done in an independent site.

[Alyssa Black (Chair)]: I just didn't know if they were specialty pharmacy, I mean specialty labs that did this, sort of that you send stuff to. That's what I was

[Jenny Horgan]: referring to.

[Courtney Harness]: Oh, the actual test. Got it. Go

[Alyssa Black (Chair)]: ahead, Karen. Just following up on costs a little bit. There are all these different specific oligarchy tests. Do they cost different amounts be processed?

[Jenny Horgan]: Is that

[Alyssa Black (Chair)]: fair to say?

[Courtney Harness]: Yeah, on the processing end, so on the hospital side, I probably wouldn't be able to speak to that very well. But yeah, we have a few scheduled for all of the tests. And that's why when I say in a specific language, the way it's written now for FDA approved, it's thousands of tests. And so as we begin to pare it down and we say this, and you've done this on other bills. As we say, I'll look to five eighty five even in the PTOT athletic training. If we take this big thing and really want to narrow focus to see whether or not it works, that's a really good example of something we've talked about in here this session that would work. And I would think that to be able to tell what the study should be done as a whole, it should really study how the bill is written, all FDA approved, and what would the cost be, and what would we do at 1%, 10%, 25% uptake.

[Alyssa Black (Chair)]: So for example, those lines that we just said, well, we're just going to, just as an example, we're just going to look for Alzheimer's testing. Is that one test or is that

[Courtney Harness]: Not thousands, but it is

[Alyssa Black (Chair)]: a lot. It could be

[Courtney Harness]: a lot. The list I sent you, I had another list which I spared you from, but that was another list specific to prostate cancer. So the list I sent you that's investigated, that's very specific to, I think, even advanced prostate cancer. So they're bucketed by disease state and then level of disease. And the advanced list that I sent you or the list that I sent you that's medically necessary, I think, is only recently approved for advanced cancer.

[Alyssa Black (Chair)]: I guess that's it for now.

[Committee Member (unidentified)]: Yeah. Thank

[Alyssa Black (Chair)]: you. Yeah. Sounds like it's an ever evolving

[Courtney Harness]: I didn't make it to 04:00.

[Alyssa Black (Chair)]: You even showed her that Mary Block today. Oh, okay. Can her. I can take her in fifteen minutes. Well,

[Courtney Harness]: that's why I didn't go fifteen minutes. I could just call on her and say, yeah, thank you very much.

[Alyssa Black (Chair)]: Thank you. Thank you for all the information. 48 pages. Seriously. Weekend reading.

[Jenny Horgan]: It's great to meet Thank you so much. Happy to you.

[Alyssa Black (Chair)]: So I just wanted to get the committee's thoughts, consensus on, number one, whether they're interested in moving forward on this study and the information we heard from Mary Black this morning regarding removing the extraneous things that they're to look at, which it appears as though all the witnesses that we've heard from was like that if the committee wanted to move ahead with that, then I can work with Ledged Council to make sure that we get that. So I just wanted to get thoughts on whether or not anyone

[Committee Member (unidentified)]: Can we talk to Mary again just to see what she meant by all those things she wanted to eliminate, or is it a whole section?

[Alyssa Black (Chair)]: Do you have the bill in front of me? I do. So what she was talking about was on page two, there is that on line 10. So that whole section is essentially what they can do. Then when you start on line 16, it goes through 16 through page three, line five. And that seems to be so it's it's all of that. One, two, three, four, five. And that I think we heard was in the bill because that had to do with coverage criteria. But since it got turned into a study, why would we study the coverage criteria as part of the study when we're really just trying to figure out how much it costs. We don't really need to know that yet. If when they come back to us, we obviously would need them to then develop coverage. But these parameters were about coverage, not about study. Does that make sense?

[Committee Member (unidentified)]: I have to digest this, I guess. So you're talking on page two, line 10b.

[Alyssa Black (Chair)]: Yeah, so 10 would stay, line 10 would stay all the way through page, in line 15. And then everything after that.

[Committee Member (unidentified)]: On line 16, then over to on page three up to number five.

[Alyssa Black (Chair)]: Okay, so that's what she would be. I can ask if Mary would like to work with Legis Council to ensure that we're getting that correct. I feel ready to go with this because it seems that all the folks involved are in agreement right now. And it's very straightforward. I'm always in favor of getting more information, especially when it comes to spending, and that's what this would do. I feel ready to support it.

[Committee Member (unidentified)]: But if you're talking, this is only a study. Just a study. Right now.

[Alyssa Black (Chair)]: I'm not even sure I'd call it a study, more of an actuarial analysis. It's basically TFR will go and they will do an analysis of what the costs associated with a coverage like this would be and how much it would increase or decrease premiums and then or actually, no. The they would they would analyze whether it should be required. Have you been here before? When we've done like a, hey, should we change the benchmark? And we send it to DFR and then DFR does an analysis and then they bring it back to us and we say, Oh, yay, this seems like a great idea. Or we say, Oh, wow, no, we shouldn't

[Committee Member (unidentified)]: do that. And this study is going be done by 01/15/2027? Yep.

[Alyssa Black (Chair)]: And then it goes to AHS. And then AHS just has to figure out whether or not we need approval from CMS for doing that coverage. That's all they have to do. And cost. The cost. To Medicaid. Okay,

[Committee Member (unidentified)]: so we know the cost to medicate.

[Alyssa Black (Chair)]: That's what it's doing. Am interpreting it correctly, Jen?

[Jen Harvey (Office of Legislative Council)]: Jen Harvey, Office of Legislative Council. I think so. The first report or the first analysis by DFR, at least has written, would be how much premiums would increase if Vermont were to enact the covered requirement, but it doesn't actually enact that covered requirement. And then it specifies including the amount of the state's financial obligations to, it sounds like you heard some this morning Debra, to pay the costs of increased premiums in qualified health plans and how much the premium would increase in the state employees plans, or what the cost would be. And then separately, the agency of human services talking about reporting on what kinds of proposals you need from the federal government for Medicaid coverage and what the costs would be to Medicaid.

[Committee Member (unidentified)]: I don't want to sound foolish here, but could you give me the real definition of defraile?

[Jen Harvey (Office of Legislative Council)]: Defraile means like to pay the costs of. Defraile means the state is responsible for paying the costs of Yep.

[Alyssa Black (Chair)]: One of the things Courtney's testimony highlighted is just how expensive labs are in Vermont. And it's not the subject of this field, but it's a very important subject to think about. Think it'd be great to get the information. I don't want to say it's not going to cost them anything at the moment. Something they can do within their capabilities. So it's good to get the information. And they both indicated, particularly DFR, they had indicated that they would not require additional resources. This is something that they would be able to do within their scope that they currently do if was if we included all that extra stuff that they would be needing resources to do that. So should, I just want to make sure, is everybody okay with working with Ledged Council to incorporate those changes? Yes. Okay. Okay, good. Great. We'll do that, and then we'll bring this back on the agenda. Okay, week. Give Jen some time. Okay.

[Jenny Horgan]: All right. So we're done

[Alyssa Black (Chair)]: for today. We are back here tomorrow after the are we

[Jenny Horgan]: back here tomorrow after the floor? Yeah, 10:30.

[Alyssa Black (Chair)]: 10:30. Okay, alright, see you all tomorrow.