Vermont Legislature SmartTranscripts:

[Alyssa Black, Chair, House Health Care Committee]: Good morning, it is May 7 and this is House Healthcare. So we are on 190 today. Specifically, we're talking about reference based pricing. We're going to talk about the amendment that I presented to the committee last week. That is the version that we are working off of with our testimony for today. Is that 1.1? I believe it's 1.1. Yes. Okay. And we're we've got a lot of witnesses, so we're gonna try to get through this really quick. So, Kai. Oh, I'm sorry. Commissioner Sampson. I am so, so sorry. We left out. I I've been working on that. Sometimes it's

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: I still have trouble. Kai Sampson, commissioner of DFR, calling you panic, but you know? That's fine. Rep Demar. Let's call me panic. How's that? Well, I know I know where you're staying.

[Leslie Goldman, Member, House Health Care Committee]: I have your testimony. Yep.

[Jennifer Carbee, Legislative Counsel]: No. I

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: just I just printed it. I get it. I was up at 05:30. Oh. Beautiful morning. Not Montpelier. I walk walk here in the rain. Alright. So, you know, since since seeing this amendment, I just want this moment of, like, zooming out and seeing where we've been on health care, where we've been in the long you know, distant past and where we've been in the recent past. And I think what I wanna spend some time on this morning, I've got a couple comments on the strike call. You all know where I sit in terms of where we should apply savings and why, where the administration feels it should be broad based. I'm not gonna hammer that one anymore. You know where I stand. I've got two more little factoids that I wanna introduce that I haven't before on that topic. But, really, let's look at what's happened in health care in the last twenty four months, year. I looked back at some old Green Mountain Care Board guidance on hospital, total revenue, pricing, and budget. Just two years ago and and probably since the inception of the exchange, the mindset was controlling growth, moderate growth, 3.5% budget growth or pricing growth, revenue growth. That was a mindset of a growth mindset. It was not a reform mindset. Last year and the year before, things changed, and it's good that they changed. We have and and once again, in this year's budget guidance, we have negative revenue growth. Revenue growth is what drives insurance premiums. Pricing and utilization together equal revenue. So I think we should all understand that this ship is turning. And, I have a fun analogy in here. I'll tease of we're all we're all everyone is on this ship heading towards affordability or crisis island. Okay? And we've recognized that, all of us. And everyone's a little bit panicky on the ship, but the ship is turned. And I don't know that there's anyone in this room that would disagree that, the last year or two have shown incredible changes in attitudes, behavior, and actual action and actual real savings. So I mentioned the difference that we see in just in Mountain Care Care Board guidance and actions. They took a decisive action to not only make orders, but doggedly enforcing those orders, reducing hospital charges, compelling savings at hospitals, and those reductions were successfully reflected as real bankable savings in their QHP rate reductions. And there were significant reductions, specifically the Blue Cross's rate last year, and Blue Cross is performing because hospital costs or revenue was was changed as well. So Blue Cross is is recovering desperately needed reserves that that help them and help the state stay stable when we have some in in claims. Legislature passed act 55, creating significant savings that contributed to QHP rate increases being among the lowest, if not the lowest in the nation, outperform you know, yes, they grew, but at a very moderate pace, particularly relative to the national averages. Care Board installed the liaison team in our biggest hospital, and they are now under new leadership, the hospital. And they are under a level of financial and affordability scrutiny that they've exterior regulatory induced, that they've probably never experienced before. And it appears, you know, I'll let let the care board speak to that, but it appears that they are participating in in turning the ship around. Vaz engaged a consultant to identify system wide efficiencies, invited regulators, legislators to to hear what their consultant found. What's significant about that is while individual hospitals have undertaken, you know, cost savings, reviews, and etcetera, this was the first time that the association for all of them voluntarily, from their own initiative engaged in a system wide review. Now I haven't dug deep into that. I've seen the presentation. Many probably believe it should be, deeper, more transformative. But the point I'm making is they they did it, and they're acting. At DFR, we changed. I suspect that insurers have been complacent, in terms of their negotiation, in terms of thinking about affordability up until the last couple years. And DFR has some responsibility in that as well. DFR should have been understanding what was happening, asking what was happening in negotiations, hearing what was happening, and doing everything we could Gotcha. To not only think about solvency, but to think about affordability for all of Vermont, particularly in our insurance percent of the commercial mark. So but now we've intervened the negotiations in a very heavy handed way. Two things happened. Green Mountain Care in in the last couple years. Green Mountain Care Board listened to insurers who reported that in negotiations, hospitals were regarding GMC orders as entitlements. Cats were in regarded as entitlements, and green and our insurers weren't unable to move some of the major hospitals off of this entitlement approach that, hey. I get 3.5% revenue growth. Why are we even negotiating? Chair board said it. Chair board was made aware of that. DFR was made aware of that. Again, liaisons are appointed. We appointed a liaison in August exclusively to to to look at not exclusively, but primarily to look at and bring in an outside perspective on how negotiations work and what the culture of negotiations is at that company. And that's making a difference along with, the work of the regulators.

[Alyssa Black, Chair, House Health Care Committee]: Mister Simpson Yes. In the interest of time, I know you're you're making the argument that the ship is turning around. How how how are you feeling about one ninety one point one? Can you speak specifically to Thirty. Rather than a history of how we got here and how we're trying to get out of it? I I'm just trying to move things along

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: here today. I'll I'll stay under the the fifteen or twenty minutes allotted.

[Alyssa Black, Chair, House Health Care Committee]: Oh, we might have questions.

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: Okay. Mhmm. Anyway, so I will fast forward the rest of this telling of history, which is look around in the room. I think for the first five years ago, three years ago, I don't think that this cast of characters first of all, many of us has changed. I don't think anybody could say that years ago, everyone in this room was essentially thematically aligned towards reforming the system, creating savings. And the point I'm trying to make here is that there's there's a lot of chaos, being caused. You'll hear it from the hospitals. It's not it's not intentional chaos, but, you know, we've got so we pushed very hard, both the care board and DFR, to get insurers to negotiate these savings, to do this in a free market kind of way, and that's working. They have put dramatic initial offers or significant initial offers, but negotiations, I need you to know, are completely stalled right now because there's so many balls in the air between this bill, even our bill with site neutral billing, and and the offers that no one can commit to anything. They need to see where all these things land, yet we've pushed so hard for them to do this thing, and now we've we've created an obstacle to getting it done. And, you know, finally, on the point of where we are, I have zero doubt that, without mandated savings, in statute or splitting the market, that this system that provided that is turning the ship, that system being changes in management, changes in attitude, regulatory direct involvement is gonna continue to produce savings. So the savings are gonna be there, for for affordability. And I I trust that with or without these bills, you'll see the care board doing what they did last year, successfully matching, savings with reduced rates for Vermonters. So speeding up. Two things that that that I hadn't brought up before. I looked through my emails looking at the price impacts of the original s one ninety, and I saw a note from MVP that said, if you're already considering quality of care, you know, we don't have any concerns. I I can't put words in their mouth, but it reminded me that we had talked about that as well internally that if you segregate the market and have this set of the market getting materially different reimbursements from hospital lower, should we consider that those people still get the same attention and care at the providers knowing that not when those providers know there's a different reimbursement rate? And I think there is evidence within the history of pricing and utilization that sometimes high priced items get more utilization. So I don't think it's, a paranoid thing to consider. And then the other one that I hadn't brought up before, obviously, I have brought up the concern that we still don't have an answer to what percentage of these savings in any of these permutations that focus them in on on a certain group. What percentage of them just go to reduce federal revenue? Absolutely agree. You don't you don't not do policy because of that or subsidies. Meant reducing federal subsidies. But one thing to remember is we talked about a thirteen thirty two waiver, and that's now in the big bill, I believe. And, Diva and and asking for authority. A thirteen thirty two waiver is an innovation waiver with CMS. Their skin in the game is, you show us how we save on subsidies. We'll we'll give you a piece of that for whatever, typically, reinsurance. We gotta be careful to if we're going to do things specifically to reduce, QHP prices that reduces or saves the federal government money, we should do that in concert with a plan to file a thirteen thirty two waiver, which, hopefully, this session passes and becomes and we authorize studying and and pursuing a thirteen thirty two waiver.

[Alyssa Black, Chair, House Health Care Committee]: Any thoughts on extending this to VHIP?

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: No no different than they should go ever everyone's suffering. Let's give it to the whole market. And, also, I I ask questions in this testimony. What what is the cost of tracking this for for all parties involved, including regulators, hospitals, and insurers of now, implementing the system changes, not just for QHP, which is a very distinct set of policies, but now QHP and VHI. Complexity, and I guess my thoughts are that, you know, to to to what end are we introducing all this complexity potentially cost, when the ship is turning we're we're getting, technical comments on, the bill. I don't think it's intentional, but, I I've emailed this to to Jen and the chair. There's a section in there, section e on the bottom of page six that, to me, sounds a bit ambiguous about, who has authority over VI rates at this point. Blue Cross of blue I mean, VI is entirely regulated entity forms and rates by, DFR. And I think separating that out, unless there's an intention to have Green Mountain Care Board now also have regulatory authority over their rates.

[Alyssa Black, Chair, House Health Care Committee]: It's not their rates. It's the hospital's rates. No.

[Jennifer Carbee, Legislative Counsel]: He's Manager. Yes. I'm sorry. Jen Carpenter. He he's right. There could be clarification there. But it is about Okay.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah. It's about insurance is

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: about ensuring that the that

[Colin Robinson, Vermont-NEA]: the the insurance is fixed.

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: Right. The section I'm referring to is is ensuring that any reductions Yep. You know, contemplated by this are in fact reflected in rates. Green Mountain Care Board has the authority on QHP policies. DFR has the authority on VHI, and so we suggested an amendment to make that more clear rather than doing it in one sentence that we both do it for both. Let's separate that out. Great.

[Alyssa Black, Chair, House Health Care Committee]: Thank you.

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: I'll take questions.

[Alyssa Black, Chair, House Health Care Committee]: Thank you for clarifying. And thank you, Jen, for correcting me. Any questions for commissioner Santoni?

[Owen Foster, Chair, Green Mountain Care Board]: Thank you.

[Alyssa Black, Chair, House Health Care Committee]: Thank you.

[Owen Foster, Chair, Green Mountain Care Board]: Thank you.

[Alyssa Black, Chair, House Health Care Committee]: You. Chair Foster. Probably in the interest of time, let's contain it to 01/1990. We don't need a whole history because we've been here through it all.

[Owen Foster, Chair, Green Mountain Care Board]: I'm Owen Foster. Nice see to everyone, and thanks for having me. I'm the chair of the Green Mountain Care Board. The Green Mountain Care Board's job is access affordability and quality in connection with our rate decisions with insurers and with hospital budgets. We do consider whether or not our decisions will harm hospital solvency and whether or not it will reduce service lines and access. It's a critical part of our mission. I think in some of this discussion, there has been comment about a concern about is this too much money for hospitals to absorb? That is our job. We have a staff. Some of them are here, incredibly talented. We have PhDs. We have economists. This is what we do. And I will note that there have been hospital closures rampant across the country, and they're still happening. We haven't lost one in Vermont. Thank goodness. And frankly, a lot of it is because of the great work of the hospitals, the insurers, and the Green Mountain Care Board's regulatory efforts. What we try and do is extremely difficult. We want affordability. We don't want hospitals to change. We don't want the insurer broke. That is a massive, massive tension, and at the point where we are in our commercial prices, we are seeing a serious decline in the number of people that are insured. We have to address the prices to ensure hospital sustainability. I believe that. There's a New York Times article this week about this market you're talking about, an S-one 190, that because the prices have gone up so high with the loss of subsidies, hospitals are getting financially crushed. There's a connection between those two. We can't look at it as if we reduce prices, it hurts hospitals. If we raise prices at this point, it hurts hospitals. In Vermont, we're seeing a 15 to 20% decline in the number of insureds in this marketplace. We all know, this committee's heard it many times, we have the highest QHP prices in the nation. We must address it. My point here is I fully support the amendment to S-one 190 to allow the care board to determine the right amount of money that can be reduced from hospital budgets. This is literally our profession. At that point, you can take that savings, and as this bill amendment note contemplates, apply it to two very beleaguered struggling the QHP market and the teachers. Those are really important because property taxes are going through the roof, and we're seeing a decline in the QHP, so I fully believe that it's right to target these two markets. Whether the board reduces the hospital budgets further by $0 for the full amount is something that we will determine based on the evidence that gets submitted to us and the statutory law and charge that we have. I think that if you did this across the entire system, that would be great, but the problem is you're only going to save a little bit of money for everybody, whereas this market is struggling much, much more than other markets. And a really key point that Ms. Berbe made, our director, is that if you do it across the entire market, those savings, the money we take from hospitals, may not stay in Vermont, may not go to reduce property taxes, may not go to reduce insurance rates at all, because you have national providers and insurance providers that will absorb some of those savings. That means those savings could go to dividends, they can go to those insurers' bottom lines, they can go anywhere. We can't control those savings if we do the entire market going to Vermont. If you do it as contemplated here, it will go to QHP and VIHI. We know it will reduce prices in Vermont 100%. That's really, really, really critical. The other point, which I believe our executive director Emily Brown made, and I'll emphasize, is that these plans and programs are not starting in the same place. The markets that are not touched here have more levers and more tools to be able to adjust the prices. They also are not starting with the same pool and the same price level. So this market does not have those available resources to deal with the affordability crisis. That's why targeting it here also makes more sense. On the VOS consultant, I think this is really important for hospital sustainability. Ms. Green is here so she can correct me, but I believe the hospital consultant said they could target, I think, around 125,000,000 to $140,000,000 in savings over two years. 100,000,000 over two years. We can probably get the point. Point is, there's work being done to absorb this financial reality. It's not like there isn't complimentary pieces in action, and to Commissioner Sampson's point, the state has become very aware of the crisis we're facing. We've known it for four years and it's time for action. So the question is, are you gonna take this action now or not? We also have the Rural Health Fund and AHS's transformation work with the hospitals. That will also help us absorb this financial reality. Keep in mind, Wyman, and I don't think it's been disputed, predicted that our hospital system is a billion and a half plus short over the next five years, a billion and a half short for the hospital system to stay the way it is. And there is not a billion and a half to take from Blue Cross, from UVM, from Vermonters, from property taxes, from Medicaid. It's not happening. So that's just a reality we have to confront, and that means there's going to be changes. This change, I think, is really, really critical to stay in this market and protect some of our most vulnerable people. At bottom, all you're doing with this bill is two things. You're accelerating the move to reference based pricing, something I think the whole state has gotten behind, including hospitals, insurers, everybody. This allows us to start it one year earlier in a bit of a pilot as to these two vulnerable markets. That's essentially what you're doing. That's all this really is. And in 2028, the CARE board has already been tasked with legislation to do this more broadly. I'll stop there and take any questions.

[Leslie Goldman, Member, House Health Care Committee]: Was the second thing? One was accelerating reference based pricing and the second?

[Owen Foster, Chair, Green Mountain Care Board]: And in some ways, it actually sets a suggestion, a legislative suggestion, on how deep the care board should go. So I believe, Representative Susie, think you had said something about, well, this might be too much money for the hospitals. We can go lower than this already. We can do minus 20% if we want. We can do minus 10. Without this, we can do any number we think feels appropriate. So in some ways, this is actually a suggestion that the legislature thinks that minus 2.5 is the right amount to do here. But the point is, there's not a limitation otherwise on how far the board could go in a reduction. That's very important. And we exercise that authority very, very, very judiciously because we wanna sustain 14 hospitals in Vermont, and we've gone to pains to do so.

[Alyssa Black, Chair, House Health Care Committee]: Wendy? Just

[Jennifer Carbee, Legislative Counsel]: briefly, I was here last year when

[Wendy Critchlow, Member, House Health Care Committee]: we did this, and it felt like such a big thing. Now it's going into utilization, we, I mean, into practice, and we're all pushing a big, I think, because maybe I'm talking for myself, taking a big sigh of like, now it's going to happen. And we're a little, I don't know, a little afraid of how this is going to roll out, and I see why we're doing it in increments. Can you just address I think it's the utilization that could be the key here, because people are just not using the hospitals because they can't afford to go to the hospital for their doctors. Can you explain the disparity?

[Owen Foster, Chair, Green Mountain Care Board]: Yeah. So hospital finances are made up of three main components. One is the price that people pay, two is how often they use the service, and three is the intensity of the service, how serious the thing is that they need and what the coding level is. And as people have a difficult time affording health care, whether it's their premiums to have insurance, whether it's their co pays, those can discourage people from getting care. If you're looking at a potential bill or just struggling with it, a lot of people at these price points are choosing to struggle with it. We are seeing, at least at UBM anyway, some data and some testimony, I think, in this committee that utilization is going down. If people don't have insurance, if these 20% of people on the QHP drop, there will be a commensurate decline in utilization services. Keep in mind, that's very, very bad for health outcomes. We do not want uninsured or underinsured people. This bill helps protect us from that.

[Leslie Goldman, Member, House Health Care Committee]: Leslie. Thank you. Can you point just I have two questions. The first is, could you point to the language that would help me understand exactly where you're talking? Is it or should we wait for that?

[Colin Robinson, Vermont-NEA]: I think I have it here.

[Owen Foster, Chair, Green Mountain Care Board]: It's page four. So what section? Section three. I missed the sections.

[Wendy Critchlow, Member, House Health Care Committee]: I think

[Owen Foster, Chair, Green Mountain Care Board]: it's section

[Leslie Goldman, Member, House Health Care Committee]: Are we all on draft 1.1? Yeah.

[Owen Foster, Chair, Green Mountain Care Board]: Yes. I think it's section 2B1A, with the sentence that starts, The Green Mountain Care Board shall determine the B1A of the Green Mountain Care Board shall determine the amount of hospital spending that can be reduced for hospital fiscal year 2027.

[Leslie Goldman, Member, House Health Care Committee]: Okay, thank you. And you didn't comment on section 11, which is the critical access Medicare problem that you've discovered, just wondering about thoughts about that.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, this is also another barrier to access and sustainability for rural hospitals. If rural hospitals charge significantly significantly more money to seniors to get care there, and seniors can get care much more affordably at a bigger hospital, I worry people will not use the critical access hospitals as much. There will be people traveling because it'll be a lot cheaper for them to get the care elsewhere. So I do not think we should have a prohibition on trying to solve that problem, either regulatorily or otherwise. We've commenced a work group. We've asked for solutions. We've had a couple meetings. We're having another one next And I think with the potential of regulatory action, it keeps people engaged and it keeps people having pressure to take steps. I think you had asked before about the five time multiplier.

[Leslie Goldman, Member, House Health Care Committee]: I'm really struggling with that.

[Owen Foster, Chair, Green Mountain Care Board]: Agreed. Think personally, what we would like to see the hospitals come to a solution with is a zero, a one to one multiplier, no multiplier. People pay 20% and we maximize Medicare. I think for purposes of this, what this gets at is a situation where people are actually paying more than Medicare. Do I think it should be lower? Yeah, because the lower it is, the more we maximize federal Medicare and the less we make for modern spending.

[Leslie Goldman, Member, House Health Care Committee]: The problem I'm having is in the meantime, I know you have a work group and that's great, but what's the collateral damage to our seniors in the meantime, And how does the population find out about this problem so that they really maybe shouldn't go to the critical access hospital if they're going to be saddled with a huge bill? So should there be language saying that someone, I have no idea who, should be responsible for informing people about pricing and that who's responsible for that? Because it just feels wrong to me. It feels like friendly fire that we're shooting our own people, really struggling.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, so I'll address that. So the first part about the five time multiplier, it's in statute in this bill, but at the same time, the board and the hospitals are pushing and working towards where we wanna be, which is the one to one, not the five to one. So this doesn't take that off the table, that's very important. In terms of the transparency, one of the key, key, key criteria in creation of the care board, why we get paid and exist, a big part of it is transparency. That's how we're structured, that's in our core mission. So, seniors are gonna know this. I am not gonna stop talking about this. I'm gonna make sure they know it, and one of the things that we've been contemplating in the work groups is public notice from the cause that if you come here on this service, your copay will be x dollars higher. Let them choose. Let them know. Let them choose. So if you remove the s one ninety amendment from the senate that prohibited the board from taking action, couldn't purportedly, we wouldn't be able to actually make hospitals do that. At a minimum, we should require hospitals to notify their consumers that if you come here, this service might be x dollars more. People have a right to know that. This is money that bankrupts people. The average senior makes $48,000 $50,000 a year in rural Vermont. These can be many thousands of dollars. So we're hopeful that hospitals will need a provider led solution, but we don't want the regulatory potential taken off the table because it would include transparency.

[Leslie Goldman, Member, House Health Care Committee]: So what's the timeframe for that? I mean, of implementing something like that?

[Owen Foster, Chair, Green Mountain Care Board]: We have a work group meeting on May 13. We received some information back on April 27 from the hospitals. I think the hospitals have come to the table with supporting transparency. I went to a rural caucus meeting, and I believe the association testified to some support that they have for transparency. But I would like the board to be able to make sure that transparency is consistent with what we need to see as a state.

[Leslie Goldman, Member, House Health Care Committee]: So do you think that the five time language needs to be in here? In statute, that's what I'm struggling with.

[Owen Foster, Chair, Green Mountain Care Board]: I don't think it does harm to seniors, and I don't think it does harm to hospitals, because in that situation, they would get every nickel they ever were going to get. We're just not kicking back additional money to Medicare beyond the full Medicare payment. So I think at a minimum, it doesn't hurt the hospitals or the seniors.

[Leslie Goldman, Member, House Health Care Committee]: Well, the seniors are paying this giant amount of money.

[Alyssa Black, Chair, House Health Care Committee]: That's what the board and

[Leslie Goldman, Member, House Health Care Committee]: hospitals need to tackle. So I hear that you're tackling it, but when do you think that it could be implemented? Like months, years, what are we talking?

[Owen Foster, Chair, Green Mountain Care Board]: Well, we don't have all the information on all the challenges. There are challenges. If we could just flip a switch and fix this, we would have done it and the hospitals would have done it, but there are complications and concerns. So part of our job being judicious and trying to watch for the whole system is getting this information all in before we make a decision, and we are not unsympathetic to the seniors. I care about this a lot. I have a lot of rural cousins and uncles all over the state, and this hurts them. I know where they live, I know what their bank accounts can afford this. I am very, very, very sympathetic to those people. At the same time, I personally don't wanna cause massive disruption to the hospitals at the same time.

[Leslie Goldman, Member, House Health Care Committee]: I think I struggled a little bit because we thought when we did F55, there was huge outcry and everything was gonna collapse and it didn't. Or when we had Oliver Wyman, there was a huge outcry. Everything was going to die and it didn't. So I feel like we're just operating. It's like the third time of this, chaos creating that everything's going to die. And in the meantime, the seniors get charged. So I'm just struggling.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, and that's our job to take that outcry, to see through it, and make a clear eyed, correct decision. We can't be flapping in the wind because there's outcry. Oliver Wyman was a lot of outcry. There really was. I was demanded to personally apologize. I did not, and it was right. That report was accurate. So it's our job to bear that and deal with it. There will be outcry on this, there's outcry. Look, when we reduced UVM's budgets $3,040,000,000 dollars, there was massive outcry and there's reduction of really sensitive services. Mike Smith, last week, the liaison came out and said, no, you need to cut 300,000,000. UVM supports it. So, when we cut 30, there's massive outcry. Now, it's 300 and everyone's on board. This is just the environment, and it's part of moving forward and trying to get the system right.

[Leslie Goldman, Member, House Health Care Committee]: So I like what you said about see through the outcry. That's great, thank you.

[Alyssa Black, Chair, House Health Care Committee]: I fully expect in the next week, we will be getting outcry.

[Owen Foster, Chair, Green Mountain Care Board]: Can I say one thing on that, if you don't mind? So the voices you get a lot are ones that are, they represent an interest, and that's really, really, really, really important to get those interests. Are there any patients here? Like people in their own

[Colin Robinson, Vermont-NEA]: individual That's right.

[Owen Foster, Chair, Green Mountain Care Board]: Yes, but individual capacity representing patients, or representing the consumer, or representing the dairy farmers on small group.

[Alyssa Black, Chair, House Health Care Committee]: There's one.

[Owen Foster, Chair, Green Mountain Care Board]: But the voices you get are like this loud from certain industry groups, and those are very valuable, but you're not getting a whole heck of a lot from the restaurant workers who can't afford this. Do you

[Colin Robinson, Vermont-NEA]: have a senior in here who's paying his Medicare co pays? I don't see one. No, but I tell you what, I do get emails.

[Alyssa Black, Chair, House Health Care Committee]: Always say that I'm the luckiest representative in the world because nobody ever emails me about all these other things. My constituents, they email me about the cost of their healthcare and the cost of their property taxes going to healthcare, right? I mean, we do hear from that, we hear very little though.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, so I mean, some people have more access and amplified voices and amplified resources. And when you hear that outcry, you have to remember there's a whole lot of voices you're not necessarily hearing and aren't sitting in this chair. And when I sit in my chair, that's my job, to hear all the voices and protect all the interests as best

[Leslie Goldman, Member, House Health Care Committee]: I can. So you don't think we need to have language in here about transparency?

[Owen Foster, Chair, Green Mountain Care Board]: As long as you strike the prohibition on the board taking action on this, I think you're okay.

[Alyssa Black, Chair, House Health Care Committee]: We'll take this back. We replaced the no action or no looking or absentee, no pretend. Oh, that crazy thing.

[Owen Foster, Chair, Green Mountain Care Board]: Sure, one correction actually, if you don't mind for Ms. Carby as well. In that section B1, page five, You have B1A on page four, then B1B on five, then B1B2, hospital fiscal years after 2027. So we have 2027, and then we have a provision for after 2020 There's already statute for the board to implement reference based pricing after 2027. I think this is superfluous, I don't think you need it. This is what we're being tasked to do. We're actually legislating here what 2028 could be, that's the work we're doing, so I'd actually prefer not to have legislative mandate on this for 2020 after 2027.

[Alyssa Black, Chair, House Health Care Committee]: The striking two. Two, would strike Yes.

[Owen Foster, Chair, Green Mountain Care Board]: You need to come back next year because we don't have it together for 2028, I think that's fine, but

[Alyssa Black, Chair, House Health Care Committee]: I'm sorry, I'm unclear. What words?

[Jennifer Carbee, Legislative Counsel]: I have two. We have subdivisions, lead one, who lead, lead by direct support and its hospital budget orders for fiscal year 2027, and then two has hospital fiscal years after 2027, that the court shall continue doing this work until reference based pricing is fully implemented.

[Daisy Berbeco, Ranking Member, House Health Care Committee]: Okay. Which I.

[Alyssa Black, Chair, House Health Care Committee]: I think the intent was to split this over two years.

[Jennifer Carbee, Legislative Counsel]: Right, and in case, right, over two years and or in case reference based pricing was not up and running, that you've had something and you're still directing the board to continue doing this. Okay. I think it's a policy question.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, don't think it's a huge deal, but you're setting a cap essentially through this on what reference based pricing could be for 2028. And we just haven't done the work yet and completed the work as to what we actually think that cap should be.

[Alyssa Black, Chair, House Health Care Committee]: So you think you would like to strike two altogether? You don't think it's necessary? I don't. Okay. I guess, I mean, that makes sense because, I mean, as previously discussed, the intent was that we would do it over two years, but you're saying you already have the ability to do it over two years.

[Owen Foster, Chair, Green Mountain Care Board]: Correct. We're charged in last year's bills to do in 2028

[Jennifer Carbee, Legislative Counsel]: anyway. I mean, I think subsection C then is also related to that form setting, curriculum that was far as the therapy that we're seeing about a big three point five percent three point five of the percentages. Yeah, I said Hold on one second.

[Alyssa Black, Chair, House Health Care Committee]: Can I go back to if we strike two, it just says that you have to It says that you have to begin reference based pricing? So this is your beginning. 2028, you're not going to be done with reference based pricing. I mean, it's going to take you quite some time. I think the point of this was for these two markets in C and little C fun in these two markets that you would identify savings and concentrate it just on those two markets, not say we're done with reference based pricing, so now they go up to what they were. It was trying to get it so that they get first in, and then eventually everything else sort of shakes out in conclusion.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, I just think we should have a little bit more flexibility for 2028 because we're in some ways, I think you could read this, and I'm curious what commissioner Sampson would say on this, but does this say that this market's gonna get the first dollar savings in 2028 and the others don't? I do agree for 2027 that makes a lot of sense, but I think we should see where things are. The markets are quite dynamic, and I'd rather not be pigeonholed to a dollar amount or a specific market segment two years down the road. And this is the work that we're tasked with doing already. I just worry about a little bit of a legislative limiter that might not be as flexible once we get better information on where Blue Cross is, VHI, QAP, and the broader market.

[Alyssa Black, Chair, House Health Care Committee]: Well, then I'm worried about dramatic increase for '28. So if we take this out for '28, you've artificially lowered them for '27, and then they may have a huge increase in '28. If you're not completed with reference based pricing across the board, which I think you all are doing heroic work, I am concerned that you won't be done by '28. Even absent reference based pricing, we're not seeing any dramatic increases. The hospital guidance for this year is a negative on the commercial side. Last year, we effectively ended up in the negative with the enforcements that we did. I don't think there's gonna

[Owen Foster, Chair, Green Mountain Care Board]: be some swing back in '28. We're like, oh, never mind. We were wrong. There is no affordability problem. Let's go up. Especially with the transformation work and the grants that are being executed on now. I don't have a lot of concern that we would all of a sudden be giving large rate increases even if reference based pricing wasn't we're going, we're flat to negative anyway. We very much recognize that hospital prices are a challenge.

[Alyssa Black, Chair, House Health Care Committee]: Okay, well, that's

[Owen Foster, Chair, Green Mountain Care Board]: I don't think it's an enormous deal breaker, but I just wanted to flag it that I do think there's the flexibility would be a little bit better. And you could always put it in again next year, the exact same provision if you're uncomfortable with where the board is at in reference based pricing work. You could also make it I'm making up language, which is always reckless, but you could add some sort of provision that says, unless the board has not significantly addressed the reference based pricing work or something like that, give us a little leeway. I don't mean to distract you. I mean, the key here is the other pieces.

[Alyssa Black, Chair, House Health Care Committee]: I mean, I guess I'm less concerned about the 2028 budgets and reference based pricing and the implementation of reference based pricing, what I'm more concerned about is volatility in these two distinct markets. If we don't have this in gear, who was it? One of the committee members, maybe Brian or someone said, we're on a gentle, we're on the on ramp to reference based pricing and this is like the on ramp. I worry about getting halfway up the on ramp and then

[Owen Foster, Chair, Green Mountain Care Board]: the road stops. We have a very dogged policy director who I don't think lets off any ramps and they're not always so subtle.

[Alyssa Black, Chair, House Health Care Committee]: She's really good. Maybe she could be somewhere else next year.

[Owen Foster, Chair, Green Mountain Care Board]: I'm gonna do my best to ensure she's not. It's small. You can make and choose. It's not a loud objection to it. I just think balance, I would probably end up there, but it's okay if you don't agree.

[Wendy Critchlow, Member, House Health Care Committee]: Yeah, would it delay moving forward with, I get this, with state employees?

[Owen Foster, Chair, Green Mountain Care Board]: No, I don't think so. I don't think having this would delay us either. I think this is like a downside protection, essentially, is how I would read this, that if we weren't there, you would still have this. So it's a downside protection for this market to ensure that there would still be a potential for reduction.

[Alyssa Black, Chair, House Health Care Committee]: Okay, thank you. That's for you, testimony. Okay. Thank you.

[Owen Foster, Chair, Green Mountain Care Board]: Thank So

[Alyssa Black, Chair, House Health Care Committee]: next up, we have Colin Robinson. How is this twice this year in the house, healthcare?

[Jennifer Carbee, Legislative Counsel]: Hey. It's a good evening.

[Colin Robinson, Vermont-NEA]: You know, there was one little Medicaid One

[Jennifer Carbee, Legislative Counsel]: little beer.

[Alyssa Black, Chair, House Health Care Committee]: So you were sitting over there and

[Colin Robinson, Vermont-NEA]: getting the chair. Yeah,

[Alyssa Black, Chair, House Health Care Committee]: So It's a rare pleasure. Always.

[Jennifer Carbee, Legislative Counsel]: Your

[Colin Robinson, Vermont-NEA]: advisor here. Happy to be here. Good morning.

[Jennifer Carbee, Legislative Counsel]: Good morning.

[Colin Robinson, Vermont-NEA]: These are big, big conversations we're having today, so appreciate that, and I will attempt to keep my remarks within the requisite fifteen or so minutes. So for the record, Con Robinson, Vermont, NEA, for those of you who, just to be clear, who don't know, we represent 16,000 public school workers across the state. And as I mentioned in my testimony last week, the work of this committee and the GMC B just last year realized upwards of $25,000,000 of savings in the Beehive pool. So as I start, I'm going to be speaking to two provisions, one around reference based pricing and one around section four and 4C, the collective bargaining provisions. And the top line is, as I said last week, we support reference based pricing, speak a little more substantively to that, and we are strongly not in support of in opposition to the changes to the statewide health care bargaining process outlined in draft 1.1, which I'll speak to in a in a little bit. So as it relates to reference based pricing for the VHI pool, obviously, as I said, we've been in support of this effort to move towards reference based pricing for many years. That's why we worked with the Vermont State Employees Association on an opportunity report that I spoke to last week and the GMC B completed in December 24 that between those two pools showed upwards of $400,000,000 in savings over the course of the study. In the VHI pool specifically, it would have been $230,000,000 worth of savings. And in 2022, the last full year that data was available in that study was $48,000,000 We can obviously imagine those numbers are bigger now. So I would say we, as a practical matter, support moving forward with reference based pricing for the VHIP pool. I will also say we supported moving forward with the QHP. We supported conversations that we've heard previously about having a broader application of reference based pricing. Forward movement is forward movement, and that is good for everybody.

[Alyssa Black, Chair, House Health Care Committee]: I'm sorry to interrupt you. I really truly am. I think I completely lost the thread of what you were talking about. What study and what was the study looking at? So in What saving you said savings or

[Colin Robinson, Vermont-NEA]: Sure. I'm trying to be brief because some of these people I I spoke to last

[Leslie Goldman, Member, House Health Care Committee]: was like,

[Colin Robinson, Vermont-NEA]: wait a minute. So in the fiscal twenty five budget, we along with VSEA worked with Senator Kitchlow to get funding and language to study what the impact of applying and implementing reference based pricing for the VHI pool, as well as for the state employees pool would look like. It charged the Green Mountain Care Board with looking at that analysis, and they came out with that analysis in December '4. It's a very fulsome report. You can read it. The details about application in the specific pools for state employees and VHI live on page twenty and twenty one of that report. I shared it with the committee. It's on your website last Thursday. But the headline there is across the state employees and the VHI pool over the five and a half years of the study, had reference based pricing been in effect from 2018 to 2022 or 2023, it would have been $400,000,000 in savings.

[Alyssa Black, Chair, House Health Care Committee]: Okay. I have to stop you there because that's kinda where I thought you were going, which

[Jennifer Carbee, Legislative Counsel]: is where you cannot

[Alyssa Black, Chair, House Health Care Committee]: say $400,000,000 worth of savings if we had reference based pricing. Reference to what and what reference? Because that's an artificially made up number to get your 400. Mean, what was the reference? Oh, if we paid 100% of Medicare, sure, look how much money we could save.

[Owen Foster, Chair, Green Mountain Care Board]: I have a report here.

[Colin Robinson, Vermont-NEA]: It's on your website from last Thursday. And that number that I'm citing is based at 200% of Medicare. Are numbers in there to two fifty. I don't remember if 300% is in there. And so in the charts on page twenty and twenty one, you can see the full spectrum of what savings points are. So I'm specifically citing the numbers for 200% of Medicare as GMC B did in that analysis or these years looked at. Make sense?

[Alyssa Black, Chair, House Health Care Committee]: Yes.

[Owen Foster, Chair, Green Mountain Care Board]: Okay, sorry about that.

[Alyssa Black, Chair, House Health Care Committee]: Crush our system if possible.

[Colin Robinson, Vermont-NEA]: Yeah, but my point here is to lift up and not necessarily advocate for those specific numbers, but highlight the work that this draft proposes doing, which is potentially realized savings in a particular segment that you're talking about. Right? I know there are some technical points that have already been mentioned. I would leave those to DFR, GMC, and legislative council to figure out if there is a desire to go in this direction. But the direction that you all move on on reference based pricing, we believe, is impactful regardless of the path. Can I pause there before transitioning to the next point? Are there any questions on the reference based pricing?

[Alyssa Black, Chair, House Health Care Committee]: Thank you for supporting that. We love reference based pricing too. That's why we did it last

[Colin Robinson, Vermont-NEA]: Yeah. Exactly. And we're That's very

[Alyssa Black, Chair, House Health Care Committee]: why we're extending it to be high and

[Colin Robinson, Vermont-NEA]: taxpayers We appreciate this draft. Appreciate. And, of course, you know, that's that savings that is and as you, chair Black, have spoken to, that's real that savings that is to realize to everybody. Mhmm. Right? There's and that's significant, and chair Foster spoke to it as well. Before I transition to talking about sections four and four c of the bill, which touch on collective bargaining, I know you're gonna be hearing from legislative council around that and others, I just wanna remind this committee, in case you're not aware, the VHI board. So, VHI is the board, VHI is the entity that provides healthcare benefits to public school employees. It is a standalone nonprofit that is regulated by DFR and Commissioner folks. It's administered. The TPA is Blue Cross Blue Shield. VHI's board is separate and distinct from the collective art process, but VHI's board is in the process of plan redesign right now. And that plan redesign is intended to be completed and effective for 01/01/2029. So they are looking under the hood of all the plans currently offered in the VI pool and saying, okay. What's working? What's not? What could change? Etcetera, etcetera. So I just wanna make sure the committee was aware of that. Okay. Four c.

[Alyssa Black, Chair, House Health Care Committee]: Didn't you indicate actually in your testimony previously that that process would be starting in the 2026?

[Colin Robinson, Vermont-NEA]: I believe RFPs are out right now to various consultants. Again, I'm not deep under the hood. Would encourage you to have VHI in to speak to that process.

[Alyssa Black, Chair, House Health Care Committee]: You're not in the middle of it right now.

[Colin Robinson, Vermont-NEA]: It is in process, but yes. Okay. Yeah. So who is covered? I just wanna say, often in conversations about health care for public school employees, there's a lot of talk about teachers. I want be very clear that we're also talking about bus drivers, paraeducators, food service workers, other behavioral interventionists, other folks, and oftentimes low wage folks. It's also a profession that is 80% female and teachers as compared to comparable professionals with advanced degrees make 88¢ on a dollar in Vermont. It's also when we talk about health care benefits and collective bargaining for public school workers, over the past sixty deck sixty years, six decades, they have time and time again given up wage gains at the bargaining table in order to protect and maintain or moderate increases in health care costs. And finally, just contextually speaking, I think I don't need to tell you all that the education system right now is in in a seismic transformation moment. And at the end of the day, the 16 plus thousand people that work in our public schools provide essential supports to students. But last year, over 400 jobs were lost. Right? People don't know who and if they're gonna have a job or where they're gonna be working over the next couple years, and that's the work that's being done in September. So collective bargaining, sections four and four c specifically touch on the statewide collective bargaining process. Statewide collective bargaining, which I'll outline in a few minutes and Sophie will speak to, but as a main principle, collective bargaining is supposed to set up a neutral statutory process by which a group of workers and their employers get together to negotiate terms and conditions of employment. In Vermont, there are three main provisions of collective bargaining, one that applies to teachers, one that applies to municipal workers, and one that applies to state employees. Most of these statutes are very mature. The parties that negotiate know the process, familiar with the process, because they've been around since the 1960s. And in a school context, teachers, of course, are covered under the teacher labor law, school support staff are covered under the municipal employees labor law, which has kind of been interesting. People don't actually think that that is the case. From our perspective, the provisions of Section four and C4 are significant intrusion and a fundamental change to what collective bargaining is. Collective bargaining, as I said, is supposed to have that neutral process. It is not meant to dictate terms and condition or impose or imply specific outcomes and the provisions in 4C do that. So stepping back again, the history of the healthcare bargaining process from the 1960s through 2019, it was all done locally. So a local school board would incorporate that conversation about premiums, etcetera, etcetera, into local negotiations around all of the benefits. In 2017, the governor and the school board's association proposed moving to a statewide level. It did not happen that year. In 2018, in Act 11, it did move in that direction. And it created the Commission on Public School Employee Health Benefits, a term that you see in draft 1.1. I wanna be clear, and I believe legislative council will speak to this a little bit later. The term commission doesn't necessarily connote what it actually is. It's a bargaining council. It's a council that is made up of five appointees of labor, four from Vermont NEA, one from AFSCME, five from the Vermont School Board Association. And it sets up a very specific bargaining process, which you'll hear about later. Talks about negotiations, fact finding, mediation, and ultimately binding interest arbitration. These are all normal processes of a collective bargaining process. And again, these are processes that are intended to be neutral to ensure and work to move the parties towards an agreement, not to predetermine, dictate or curtail or expect a certain outcome. And in the first two rounds of statewide healthcare bargaining, we've had two rounds of bargaining, two rollovers, which means the party stopped together and said, hey, let's just do an extension. Both of them ended in binding interest arbitration. They had multi day fact finding hearings. These are experts in labor law do this professionally for decades and decades. You bring forward witnesses, you make your arguments, bring forward your proposal. They also both ended in arbitration hearing. There's a multi day process with dozens of witnesses who are presenting economic arguments, presenting facts, figures, legal analysis to in the last round of bargaining, a penal three expert arbitrators who do this professionally and make a determination. So where are we right now as it relates to benefits for school workers? All teachers pay 20% of their premium towards their benefits. 20%, you all talk about healthcare costs going up, 20 of a bigger number is a bigger number, so our members are paying substantially more year over year. Prior to And our members over the past seven years since the first round of statewide healthcare bargaining are not only paying more because healthcare costs have gone up, but because actually their premium contributions have gone up as a result of healthcare bargaining. So as a practical matter prior to the first round of statewide healthcare bargaining, there were many public school workers that didn't pay 20%. They were paying numbers less than that. So in addition to the cost of the premiums going up for all the reasons you know, the actual percentage that school employees, teachers, paraeducators, bus drivers are paying in have gone up. I did some analysis and the dollars coming out of paycheck for a teacher paying 20% in 2019 compared to a teacher paying 20% in fiscal 'twenty six is a 200% increase of dollars out of their paycheck. We know their salary increases haven't kept up with that. So I think there's a lot of assumptions when we have this conversation that public school workers aren't paying. And I just wanna make it clear that since the move to statewide healthcare bargaining, for example, a first year paraeducator in Essex Westford went from paying 11% of her income on a family plan to now paying 24.8% of her income. A first year teacher in Winooski in 2019 for a family plan went from paying 9.5% of her income towards her healthcare premium to 16.5.

[Alyssa Black, Chair, House Health Care Committee]: I have to stop you here. Okay. So going back to, you said between now and 2019, the cost that they are paying out of their paycheck is 200%. Can I have actual real dollars? Because, I mean Yeah. You know, if I said $20 was coming out of my paycheck, and now it's 40, that's 200%.

[Colin Robinson, Vermont-NEA]: Give me one minute on my spreadsheet.

[Alyssa Black, Chair, House Health Care Committee]: And percentages don't really and then you're and then let's and then go back to what you were saying about percent of income. Is that how much the plan is or is that how much is coming out of their paycheck?

[Colin Robinson, Vermont-NEA]: Simple question first, that's what's coming out of their paycheck. So as practical matter, as a percentage of their paycheck, it went up from X to Y. So, for example, I'll actually give an example. Burlington teachers, for instance, were already at eightytwenty when we went to say, what, healthcare 20. So, a first year teacher in Burlington in fiscal 'nineteen was already paying 20%, that would have come out to $3,829.97 out of her paycheck over the course of the year. In fiscal 'twenty six, starting salary is now about 55,000, that same teacher is now paying $8,179.4 out of her paycheck.

[Alyssa Black, Chair, House Health Care Committee]: Is that a family plan? That's a family plan.

[Colin Robinson, Vermont-NEA]: Yeah. And again, my intention here is not to drown you in numbers, but I appreciate the question.

[Alyssa Black, Chair, House Health Care Committee]: No, you're not drowning me in numbers at all. Is what we do in this community all day long. And that is a huge increase. The chair of House Education is leaving the legislature because this year his insurance went up by $20,000 I am the chair of House Healthcare. Last year I paid $400 a month for my health insurance. This year, I pay $1,200 a month. I realize for that person that that 8,000 is a huge amount. I do. I totally understand that. The cost of care is out of control. But I have businesses, I have individuals, I have Medicare patients going to critical access hospitals who look at that $8,000 and they wish. They wish. And you talk about the increase that that person is paying, but you're talking about the 20%. That $8,000 multiply that, that other 80%, that is property taxpayers that is paying that 80%. So on top of the fact that the chair of a house education has $20,000 more he has to pay, he's also got to pay 80%. So I have a great deal of sympathy. I really do. But everybody's in this boat. And Okay, I'm sorry. Don't disagree. You're throwing out numbers and we deal in numbers all day. And your numbers are making me emotional. Yeah, that's what I see. Your hand was made. Daisy? Yeah, no,

[Daisy Berbeco, Ranking Member, House Health Care Committee]: I was going exactly where you were going because we heard at a public hearing last week, several people from Windham, thank you for lifting up the salary of our teachers, a constituent of mine spoke that her family is paying 42% of their annual income toward their family plan. And I'm just realizing that it's because the other 80% of the teacher salaries, their families like that are absorbing that cost too. And this is just illuminating. It doesn't make anything right or wrong, but it's just, I think I wonder if the general public realizes this, that that's part of our premiums that we're paying. And I think in order I'm still piecing this puzzle together. But it's like in order to reduce the cost for families like that in my community that's paying 42% of their annual salary, Is this in 4C going to allow us to reduce the costs for her?

[Colin Robinson, Vermont-NEA]: So the only thing in this bill that is guaranteed to reduce costs is the reference based pricing section. I I I believe that deeply and firmly. The sections in four and four c do not guarantee any outcome because a bargaining process is intended to be a bargaining process where the two sides come together and figure out the cost. At the end of the day, what they're negotiating over is all the things that your committee has spent a lot of time on. I wanna be very clear and I hope you have been clear about this previously, is that those same families that you're talking about and you hear from, our members work with those students every single day and see that suffering themselves. And that is one of the reasons why our members have been deeply committed to broad systemic healthcare reform for a long time and advocating for things like reference based pricing, because when everybody wins, everybody wins. I will also say just to the cost, I was talking with we were interacting with one of our support staff members recently up in Lemuel County, and her take home paycheck was $2. And it was because she doesn't get paid over school break and her 20% of her health care premium was fully absorbed by her paycheck. Now you can say, yes, she has access to health care. That is a true statement. Her take home pay was still $2 that that pay period. And and so I only mentioned this. It's just like four and four c at the end of the day don't get to the root cause like the reference based pricing conversation that you have been having and that is is presented here.

[Leslie Goldman, Member, House Health Care Committee]: Can I ask you okay? So

[Alyssa Black, Chair, House Health Care Committee]: Commissioner Sampson mentioned, and we we use this phrase a lot in here, which when you think about healthcare and dermatology, it's probably not the best analogy, but skin in the game. Would you agree with just sort of the microeconomic principle that when a consumer is making a decision about purchasing something, that they take the cost of that item into account. In general, most I mean, if I'm going to buy a bag, am I going to buy a $20,000 Chata bag, or am I going to buy a

[Colin Robinson, Vermont-NEA]: $1,000 Coach bag? Sure. In that example, I would agree.

[Alyssa Black, Chair, House Health Care Committee]: In that example. So if someone in the healthcare sphere, because this is consumption, these are commodities, These are goods and services. They're commodities. If someone can get that Prada bag or someone can get that Coach bag for free, which do you think they're going to choose? If something is being prevented to them and there is no cost to them, no skin in the game, are they going to be making their decisions about whether or not to consume that goods or service with money in mind? So,

[Colin Robinson, Vermont-NEA]: I would say respectfully, I don't think when we talk about healthcare, folks are saying, oh, I woke up with a major rash. Think people, as a general matter, are going to the doctor not for frivolous reasons. They're going because they need need care. And do people avoid care because they can't afford it? Absolutely. But I would say, I don't think our members or other public sector workers or other workers who happen to have access to healthcare say, well, I have pretty good healthcare benefits, so I'm just going go to the doctor today. And I'm not sure that that's where you're getting at, but I don't think that that is a situation that is necessarily born out in experience. And looking at

[Alyssa Black, Chair, House Health Care Committee]: I'm sorry, we just had Commissioner Sampson and we just had Chair Foster. That is the decision that Vermonters are making every single day. UVM Health Network was in here a week ago and is losing a half $1,000,000 a day because people are not utilizing their services. So yes, people are making that decision every day. You wake up with a rash and you say,

[Colin Robinson, Vermont-NEA]: I ain't got it. I hope it goes away. Sure. And I would say

[Owen Foster, Chair, Green Mountain Care Board]: I

[Colin Robinson, Vermont-NEA]: will clarify my comment. I don't think our members experience and utilization of care is different than other Vermonters.

[Alyssa Black, Chair, House Health Care Committee]: I'm looking at the BHI's report, their annual report, and the average claim cost per member per month for VI is significantly higher than Blue Cross Blue Shield's other banks' books of business. So I would say that utilization is being driven by having no skin in the game, which when demand increases and supply remains the same, or in some cases decreases, that drives up cost of care. It's still a commodity.

[Colin Robinson, Vermont-NEA]: I would encourage you to have VHI in. I know you've had them. They can obviously speak to those numbers better than I can.

[Alyssa Black, Chair, House Health Care Committee]: I'm sorry. I've got Dave and then I've got Daisy.

[Kai Sampson, Commissioner of the Vermont Department of Financial Regulation (DFR)]: What's the deductible for your members?

[Colin Robinson, Vermont-NEA]: So the terms of the statewide health care bargaining agreement, the majority of school workers are in a gold CDHP plan. However, that is paired with a health reimbursement arrangement, not an HSA, but an HRA, so it stays employer money. And the current terms have that first dollar covered by the HRA, but it does not cover the totality of the out of pocket exposure for those plans.

[Owen Foster, Chair, Green Mountain Care Board]: Thank you.

[Alyssa Black, Chair, House Health Care Committee]: Easy. And then I think we're going to take a break.

[Daisy Berbeco, Ranking Member, House Health Care Committee]: I received more than 100 emails yesterday from school employees. It was amazing. But I'm not sure that they all read this bill. So I just want to round, give an opportunity to let you succinctly, and also myself, to be honest, in what 4C says. And I'm reading the highlighted portion, and to me, it says that there must be equity in the actuarial value of the plans that school employees have and the QHP plans that people like me would buy. And that teachers' plans or school employees' plans cannot be a higher value. So I should not, in this situation, be paying for a teacher or school employee's plan that is a higher value than one that I could potentially be eligible for or access. So this is saying teachers should not have access to a better plan and charge taxpayers for it, essentially.

[Colin Robinson, Vermont-NEA]: Our members don't charge anybody.

[Daisy Berbeco, Ranking Member, House Health Care Committee]: Is that correct, that this is just saying there could be equity in the the highest valued QHP plan and that which teachers and school employees get, that there should be equity? So I I appreciate that there

[Colin Robinson, Vermont-NEA]: might be a kind of talking across each other a little bit. The the statute that is being changed in for in foresee is a collective bargaining statute. So plain reading of the language you just articulated, that that is what it says. If it is the policy of the legislature to cap benefits for all workers in Vermont to a certain level, I guess you can make that decision. I think that would not be a good decision. But essentially, what this is doing is you're, intruding into a collective bargaining process. Collective bargaining processes aren't supposed to determine outcomes and benefits. It's supposed to be a process to determine the contours of that. And so that is the fundamental objection here. If in the context of the negotiations process, the school board's association comes forward and makes a successful argument through the process that results in that outcome, so be it. That is the conclusion of the collective bargaining process. The language that, it misplaced language in a collective bargaining statute is our position.

[Daisy Berbeco, Ranking Member, House Health Care Committee]: If this creation of equity and health plans for every Vermonter were elsewhere in statute, would you support it?

[Colin Robinson, Vermont-NEA]: What I would say is fundamentally no. And because as we've talked about and I said last week, we as an organization have broadly and significantly supported efforts to move towards single payer, universal primary care, Doctor. Dinosaur. If that is the direction you're going, sign us up all day, every which way, yes. But when you start saying that certain segments of workers or some workers or picking winners and losers in this context, specifically in a collective bargaining context, that's something that we're not going be

[Daisy Berbeco, Ranking Member, House Health Care Committee]: able do. So, because I'm suggesting taking it out of collective bargaining, just to say in the healthcare context that everyone should have equal access to care,

[Alyssa Black, Chair, House Health Care Committee]: which is one of our

[Colin Robinson, Vermont-NEA]: I don't know. I mean, this is way outside my lane, but I would imagine there are a lot of large employers in Vermont, the private sector, in the public sector that provide benefits to their workers that would be impacted by that. I don't know their thoughts on that, the workers that would be impacted by that. That is a major would be a major change.

[Alyssa Black, Chair, House Health Care Committee]: I have Leslie, but you did just say you shouldn't be picking winners and losers. Sections one and two is the legislature picking you as the winner. And if you're pleased with us picking you as the winner, we're just simply asking for a little more equity

[Colin Robinson, Vermont-NEA]: in future plan designs. That's what this section is. But we've already picked the winners or losers, and you came out the winner. You get reference based pricing before anybody else does. Well, I think I was clear on this. We support reference based pricing for everybody. If you want to go rad and lab, if you want to go a different direction, what was presented in the bill, of course, is specific to the high pool, which, of course, we would support, but our advocacy this session has been broader than that. And I would also say that the majority of that savings would actually be realized by taxpayers.

[Alyssa Black, Chair, House Health Care Committee]: That's why we have it. That is the point. Leslie, then Val, and then we're gonna take a break.

[Leslie Goldman, Member, House Health Care Committee]: I appreciate the framing about equity and the rest of the population. That really helped me understand a lot more about what was going on. So thank you for that clarification, both the clarity. I'm just curious to know what would be your actions should four and 4A stay in? What would be

[Colin Robinson, Vermont-NEA]: I'm not sure of your question. I heard your words, I apologize. Yeah, don't

[Leslie Goldman, Member, House Health Care Committee]: a bargaining issue. 4A stays in, what actions do you take as your union as a result of that?

[Colin Robinson, Vermont-NEA]: In a bargaining context?

[Leslie Goldman, Member, House Health Care Committee]: In whatever context is appropriate. I under I mean, that's way out of my lane too. But I'm really interested in the actuarial value of things. And of course, your plans have very high 98. And bringing it down to the QHP sort of 90 twos or something along those lines. So let's say this stays in. Mhmm. And you're against it. I'm hearing that. You want us to take that language out. Am I understanding that? Okay. Let's say it stays in. What happens next?

[Colin Robinson, Vermont-NEA]: I mean and you mean it becomes law? Yeah. Well, I mean, a you know, again, this is a collective bargaining statute. So as you will hear later from legislative counsel, I imagine Joe McNeil and others, the collective bargaining process would play out. It would be conditioned collective bargaining, which doesn't exist anywhere else in any other collective bargaining statute in Vermont. It would be unique. It would predetermine outcomes like first dollar, last dollar, and it would place a cap on benefits. These are unique provisions that have never existed in a collective bargain collectively bargaining statute.

[Leslie Goldman, Member, House Health Care Committee]: But then you would weave it in to with that work? That would be your obligation?

[Colin Robinson, Vermont-NEA]: It would be the law at that point.

[Leslie Goldman, Member, House Health Care Committee]: So that means you would do it. It has to be done. Yeah, thank you.

[Jennifer Carbee, Legislative Counsel]: I'm sorry if this doesn't play into exactly what you're talking about. Thank you. So you said teachers have, given up wage increases.

[Alyssa Black, Chair, House Health Care Committee]: Would that backfire on us?

[Jennifer Carbee, Legislative Counsel]: I mean, wouldn't they just be looking for I I don't

[Wendy Critchlow, Member, House Health Care Committee]: know anything about the Barclays

[Jennifer Carbee, Legislative Counsel]: Would they be asking for wage increases?

[Colin Robinson, Vermont-NEA]: I think that's a really astute question. And obviously, the way collective bargaining works for public school employees outside of healthcare is they meet and negotiate with their employer, which is the school district or school boards. And our local members work with their colleagues to come up with goals. And as a general matter, if one is paying more for one thing, one will work to get more in another place. That's historically why prior to 2019, teachers in Newport North Country were paying 12% of their premium. They jumped on day one from 12% to 20% because of this statute, But historically, they were paid less. So as a recognition of that, they paid less of a premium, and that was something that played out globally.

[Alyssa Black, Chair, House Health Care Committee]: Want to make two points. First of all, I've been around for a long time and I've seen every incarnation of educators, health insurance. Yes, their cost share went up. They went up to 20%, but what you don't mention is that they used to have cost sharing. They had co pays, they had deductibles. Those went away as their 20%. And I want to reiterate what this bill does is we are lowering their cost of care and we are lowering their premiums so their 20% will be less. We are saving educators money in their 20%. That is what this bill will have an effect on. Thank you. Thank you very much. Let's take a break. Be back here at 10:30