Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, welcome everyone. It is Wednesday, May 13, House Healthcare. We are going to walk through some proposed changes to S197 based upon committee discussion and working with Ledged Council. Jen, whenever you're ready,

[Francis McFaun (Vice Chair)]: if you want to come up,

[Alyssa Black (Chair)]: this is a good time for me to level set 197. I guess I want to set expectations about what we were given in the Senate and wanting to support the work that the Senate did before crossover on this, because I know they took a lot of time with this. Well, at the same time, the testimony we've taken, kind of getting us onto a path. So I think the language that we're going look at, which is posted, is it posted, Tasha? Okay. The language that's posted sort of lays out what our intent is, but also realistically sets what we can achieve this year because we're running out of time.

[Jen Kirby, Office of Legislative Counsel]: Jen Kirby, office of legislative counsel. Also just to say that the senate is on the floor and people monitor for me, but I may have to

[Alyssa Black (Chair)]: You gotta go. We'll we'll just break. Move up and run. We have nothing until noon. So Those are our bills on the floor, so we're wanting you

[Jen Kirby, Office of Legislative Counsel]: to support those. Six eleven just happened. Sources.

[Alyssa Black (Chair)]: Alright.

[Jen Kirby, Office of Legislative Counsel]: So this is a new draft of s one ninety seven. It's 1.3, but you haven't seen it yet because I've been working on stuff and having it edited and all of that. So it has been for editing. So all of the changes from the bill as it came over from the senate should be highlighted in yellow. The first section should look fairly familiar because we had talked about it on Friday. So this is me trying to operationalize largely what you had talked about. It starts off saying it is the intent of the general assembly to invest in primary care and to establish a program of universal primary care that is accessible to and affordable for all Vermonters and will promote the public good by and then this is thanks to Representative Goldman sending me the quadruple aim by improving the patient experience of care, improving population health, reducing costs, and improving the well-being of clinicians and staff. And then it says the purpose of this bill is to obtain the information necessary to develop a framework for implementation of universal primary care, including optimizing the blueprint for health to determine whether it is an appropriate mechanism for which to provide universal primary care.

[Alyssa Black (Chair)]: Just keep going. Anyone has and I am open to feedback. Certainly open. Absolutely.

[Karen Lueders (Member)]: So, line 10 on page one To establish a program of universal primary care that Re establishing a program or a system?

[Jen Kirby, Office of Legislative Counsel]: Think it says, I mean, system is your healthcare system. It may not be a program, but it's something I needed them now.

[Nolan Langweil (Joint Fiscal Office)]: So

[Francis McFaun (Vice Chair)]: maybe we can go through

[Jen Kirby, Office of Legislative Counsel]: the whole bill and then we can think about it. Section two is the blueprint chapter that we had looked at before. Much of the language is unchanged until we get to the spending targets. And I struck out that codifying that language,

[Alyssa Black (Chair)]: but I have put the first two sentences in as part of the study in section three.

[Jen Kirby, Office of Legislative Counsel]: So, as far as establishing a target for per person per month spending, that should be for primary care transitional schedule with targets that may be adjusted. But the last piece, the part about the increased spending shall be directed to the per person per month payments, is not included.

[Alyssa Black (Chair)]: Yeah. And if you recall, that's something that Nolan that you flagged a little bit for us.

[Jen Kirby, Office of Legislative Counsel]: I think he had wanted to discuss the per person per month spending. I think it's the last piece that the increased spending shall be directed to the per person per month payments. That was the part that was actually operationalizing the blueprint as the source of funding for the expanded primary and singled primary care payment for all services. So this is not taking that step forward at this time. Section three, and you'll see throughout there were some reports. We usually do reports January 15. There were some reports that had a January 1 due date, so we've moved those to January 15. So this would still have by, let's just say January, the Director of the Blueprint in consultation with the Blueprint Executive Committee and the Vermont Steering Committee for Comprehensive Primary Health Care reporting to this committee and Senate Health and Welfare regarding changes to the payment amount amounts or payment reform methodologies or both that are necessary to transition Blueprints per person per month payments to primary care practices include payment for primary care routine primary care needs of attributed patients who are covered by participating health plans. Maybe it should say that would be necessary as opposed to that are necessary. This is largely informational at this point. So that's gonna say and then the report shall and it keeps a lot of the same things with a few new or expanded ones. So this refers to not defining what services should be considered routine primary care, but establishing definitions of primary care services and primary care provider and defining which services should be considered routine primary care. Then it continues to talk about differences in methodology for different practice types, recommendations on risk adjustment and attribution methodologies, describing ways in which the methodology will balance capacity, volume, quality, and outcomes. Include mechanisms for ensuring plans make accurate and appropriate payments to practices in a timely manner. Make recommendations on participation or quality measurement requirements or both. Provide an analysis of including cost sharing amounts for individuals covered by participating health plans and the methodology, including the extent to which the inclusion would be permissible for high deductible health plan. And then we have what I moved over from the struck language in the previous section. So establish a target for the amount of per person per month spending on Vermont residents that should be for primary care services and develop a transitional schedule that increases that target over time, adjusting targets as needed to reflect payer specific differences such as age and health status. And then adding a new well, amending what becomes number 10 on the operational plan to add not just an operational plan and description of additional legislation needed. The language in the bill as it came over to you talked about language needed to implement the methodology not later than 01/01/2028. This would instead have a proposed timeline for implementation. And then number 11 is new, and this would say provide a description of the ways in which Blueprint can maximize can optimize the delivery of the services within each of its current initiatives, the costs associated with enhancing each initiative to its highest level, and the amount of additional per member per month spending that would be needed to support the enhanced delivery of these services across all BLUEPRINT initiatives. Is this what you had in mind? Yes. Okay. Thank

[Alyssa Black (Chair)]: you for making my word salad as I was trying to what I was trying to essentially get to is, you know, the BLUEPRINT has all these different delivery of services. Are there gaps in that? Could they be further optimized? And basically, what it would take and what would they need to really fully meet all the needs that are needed. Thanks Jen for the really great language around my incoherent thoughts. So

[Leslie Goldman (Member)]: just so I understand this, and you may go further, To me, this seems like this language is just looking at what the blueprint is currently doing and not necessarily what we think the blueprint could be doing. Because in the original bill, it was expanding the blueprint beyond, you know, routine primary care. And this doesn't seem to say that.

[Jen Kirby, Office of Legislative Counsel]: And You mean number 11 And maybe it's also I think it's looking at at what if the blueprint if the blueprint were to achieve its sort of full potential with the way it is currently configured, what would that look like? What would it cost?

[Francis McFaun (Vice Chair)]: Then And

[Leslie Goldman (Member)]: it would still be within those limiting For number 11. Four things or something. I mean, if I remember right, they have the pregnancy thing and they have STD- Right. But I think a lot of the rest

[Jen Kirby, Office of Legislative Counsel]: of this is looking at

[Nolan Langweil (Joint Fiscal Office)]: So

[Leslie Goldman (Member)]: that's 11. But as you go further, you look at

[Jen Kirby, Office of Legislative Counsel]: a broader- I would say what comes earlier was the broader.

[Leslie Goldman (Member)]: Can you point me to that?

[Jen Kirby, Office of Legislative Counsel]: Well, it starts off with the blueprint for keeping the fund changes, the payment amounts or payment methodologies that we This is on page six. It would be this is in the language that came over from the senate that are necessary to transition the blueprints for person per month payments to primary care practices to improve payment for routine primary care needs. And then it's having them do all of these

[Eva (Agency of Human Services)]: That's additional services.

[Alyssa Black (Chair)]: Yeah.

[Jen Kirby, Office of Legislative Counsel]: Right. And then number 11 is just Just their current Okay.

[Alyssa Black (Chair)]: Thank you. I think the thinking behind what I was trying to get to, Leslie, is, we heard and we heard in testimony from the blueprint that they're actually engaged in, I think Doctor. Saroyan used the word modernizing the blueprint. So if the blueprint moving forward as we move towards universal primary care, if the blueprint is going to be the mechanism in which we do that, then they should be modernized to the best of their ability for us to be able to make a decision on whether or not that is the right methodology moving forward. So they need to be doing this anyways. And in order for us to make actual, real, coherent decisions around how this is going to be implemented, we want to make sure that they're functioning at the highest capacity that they have possible. So could there be language and I'm back on page one, I guess. I'm not sure if this is Wendy, you want to talk about it.

[Leslie Goldman (Member)]: In the B section, which says including optimizing. For me, when I read that, it sounded like the blueprint was sort of default being chosen.

[Francis McFaun (Vice Chair)]: And I'm not

[Leslie Goldman (Member)]: sure that's what the language necessarily says, because it does say including optimizing. But could there be language and I have no idea what the right language might be but with the idea that there may be a whole other mechanism that we haven't thought

[Alyssa Black (Chair)]: of yet. Well, that's sort of what So remember, we're still in the intent language of what this bill is doing. And the bill, as it came to us, is really about optimizing and modernizing the blueprint. So that's still the intent of Bill, which is why we have including So the intent is to optimize the blueprint in order to determine whether it's going to be the appropriate mechanisms. No, can read that. But what I'm saying is,

[Leslie Goldman (Member)]: could there be language or another or something else yet to be determined or something like that? Mean,

[Jen Kirby, Office of Legislative Counsel]: Well, it it's says whether it is an appropriate mechanism. Among others

[Francis McFaun (Vice Chair)]: considered. But maybe that's not the right fit

[Alyssa Black (Chair)]: for it. I don't think we're asking the blueprint to report back on whether or not they're not the appropriate mechanism and what else would be the appropriate mechanism. We're more asking them to modernize themselves so that we can make the determination on whether or not they're the appropriate mechanism.

[Leslie Goldman (Member)]: So my preference would be take out the sentence starting on line 21 and not even mention the period, purpose of obtaining information, and then you were going to go on and talk about the blueprint. So

[Nolan Langweil (Joint Fiscal Office)]: Yeah. But

[Alyssa Black (Chair)]: In the intent where the intent section has to relate to what's in the bill, and that's what's in the bill.

[Leslie Goldman (Member)]: What's in the bill is to optimize the blueprint, but it doesn't necessarily have to be related to universal primary care. I mean, it just seems that's my reading of it.

[Francis McFaun (Vice Chair)]: Maybe

[Lori Houghton (Member)]: we just remove the word optimizing, including the blueprint for health as an option blueprint for health to determine whether it is an appropriate mechanism for which to provide universal primary care.

[Leslie Goldman (Member)]: And any others that might be created But through this

[Lori Houghton (Member)]: I think the first part gets to that. That's why

[Leslie Goldman (Member)]: I don't know why we read that part.

[Francis McFaun (Vice Chair)]: It does seem to narrow it back, it does seem to indicate on a quick reading that Blueprintless being the one that this does, but maybe we could read the whole bill and then come

[Leslie Goldman (Member)]: back Yeah, to definitely finish reading the whole bill.

[Jen Kirby, Office of Legislative Counsel]: Page seven. Page seven. Yes, page eight. So this was the list of what's supposed to be in this report from the Blueprint. And then in B, it says the director of the Blueprint or designee shall be available upon request from July through December 2026 to provide updates to the Health Reform Oversight Committee on the development of the report required by subsection. And then Section four, think it did not change. Section four is the primary care spending, again changing to January 15 and having the agency of human services in consultation with the Green Mountain Care Board, reporting to this committee in Center Health and Welfare the baseline per person per month spending on primary care services for Vermont residents overall and by each pair. And instead of having the agency use the definitions from the AHEAD model or NESC, so it would have them use the definitions of primary care providers and services established pursuant to Section 3A. What we had said.

[Alyssa Black (Chair)]: What I said? What's the definition of primary care?

[Jen Kirby, Office of Legislative Counsel]: Right, Section five as it was in the bill is no longer really relevant because we've moved the per person per month spending targets to the report section and pulled out the codification of applying those. Put in a different section five. This is on distribution of duties for health care regulation and health care reform. This would direct the agency of human services, Green Mountain Care Board, and Department of Financial Regulation in collaboration with the Office of the Healthcare Advocate to evaluate the roles their respective organizations play in health care regulation and health care reform in the state, including with respect to hospital transformation efforts, health insurance rate review, management of the Office of Health Care Reform, operations of business and health, and administration of other programs and initiatives. I would have the agency, board and department collectively determine where each health care regulation and health care reform function should be most appropriately located in order to optimize collaboration, information sharing and efficient operations, and further into attaining the principles for health care reform from Act 48 and as codified in the Vermont Care Board statute, establishing universal primary care, improving access to high quality, affordable health care services, accomplishing healthcare transformation, and safeguarding hospital sustainability and insurer solvency. They would, the agency board and department will provide their joint recommendations by January 1527, including areas of agreement and disagreement, gaps and overlaps identified, and any legislative changes needed to this committee, then a health and welfare and senate finance. And it would also require them to be available upon request from July through December 2026 to provide updates to the Health Diploma Oversight Committee on their efforts and the development of work.

[Alyssa Black (Chair)]: Oh, thought you said, Oh, okay.

[Francis McFaun (Vice Chair)]: She made a noise.

[Leslie Goldman (Member)]: Leslie, I'll make sure when you want to talk about this, on section five, what problem is this section addressing? What is not happening now that I'm not sure I understand what the confusion is with these three different agencies and what this look for. Help me understand it.

[Alyssa Black (Chair)]: What problem are we trying to solve? First of all, we're just asking them to talk amongst themselves about where I And we have heard in testimony over and over on many different bills, many different topics. You know, we have, like, the Department of Financial Regulation is tasked with insurance regulation and insurance solvency. Well, we have Green Mountain Care Board who's setting rates for insurances based upon affordability for Vermonters. And we often hear and this is not a criticism of anyone in any way because everybody's working really hard in the things that they're doing, but sometimes they compete with each other. We've established that the Green Mountain Care Board or we've tasked the Green Mountain Care Board with establishing reference based pricing for hospitals, but then at the same time when you have the agency of human services on hospital transformation, so it's not saying that either of these parties are not working diligently on what they're trying to do. It's sort of like, okay, Green Mountain Care Board, how do you establish reference based pricing if you don't know the services or needs of a hospital that AHS is working on to ensure that hospital transformation is happening. So it's just them sitting around discussing things like, I mean, if we're going to move forward with universal primary care, should that be in the health reform, Office of Healthcare Reform? And if so, should that Office of Healthcare Reform be within the Agency of Human Services? Is that their task to implement universal primary care? Or is that the board's task to implement universal primary care? It's just sort of a question of, is everybody working with all the information they need to be able to make the best decisions around what we've tasked them with doing? That's the problem we're trying to solve. And this is actually not a solution. This is them talking about where things should be. I don't know, perhaps Lori might, know, hospital in Act 167, we tasked the Green Mountain Care Board with hospital transformation and then they did the Windham report, and then we moved hospital transformation to AHS. And so was that the right thing? Has it achieved what we wanted to achieve with 167? Or has it created like a whole new layer that was unintended? And so this is what this is really trying to get to do, is look at what everybody's doing and figure out where things should best be housed so that everybody can achieve to the best of their ability what we've given to them.

[Karen Lueders (Member)]: Yeah, and I'll just say.

[Alyssa Black (Chair)]: I ask you because you were the history

[Lori Houghton (Member)]: of Yeah, and I think this is great because I do think when we have a big problem, and we have different divisions doing different things, nothing in my mind, and I'm sure everyone else is here, is moving fast enough. And we have tripwars that happen sometimes, no fault of anyone's. And so I personally think this is really important to try and make sure we are finally moving things forward and the right people are doing what they're supposed to be doing.

[Leslie Goldman (Member)]: Can I? Yeah. My curiosity- What

[Alyssa Black (Chair)]: kind problem are we trying to solve?

[Leslie Goldman (Member)]: Yeah. My curiosity is that, so we have the big three, let's say, in a room, and then they are tasked with whatever, duking it out. I'm unclear on how this process happens. I remember there was a bill that came out of the Senate asking for AHS to look at themselves and evaluate their structure. And that turned out to be pretty much of a debt. So I don't see how this process,

[Alyssa Black (Chair)]: I'm not sure. I mean, and I'm seeing

[Leslie Goldman (Member)]: it for the first time, five seconds, and we haven't had time as a committee to think about it or with witnesses. If this is the right structure to think about looking at the problem. It doesn't appear to have any input from anyone outside of them. So where's the public? Where's anybody?

[Alyssa Black (Chair)]: Are health care advocates in the room? Lori?

[Leslie Goldman (Member)]: I don't see where the health care Okay, there it is. Great. Thank you. Which is great, of course.

[Alyssa Black (Chair)]: Go ahead. I was just gonna say, I

[Lori Houghton (Member)]: mean, I have a lot to say on

[Karen Lueders (Member)]: this as well, but I don't think we're done.

[Francis McFaun (Vice Chair)]: Are we

[Jen Kirby, Office of Legislative Counsel]: done? We are not

[Alyssa Black (Chair)]: quite done yet. You want to wait till we're done?

[Leslie Goldman (Member)]: Yeah. Let's finish. Let's let's go through the changes.

[Jen Kirby, Office of Legislative Counsel]: Alright. Section six, just updating that date to be January 15 for the Green Mountain Care Board updating its reports on clinician landscape and site neutral reimbursement. Section seven no changes from transitioning care to community settings, already had a January 15 date. Section eight is a report on universal primary care efforts in other states. This directs the Office of Healthcare Reform the Agency of Human Services to examine efforts that have been undertaken or are currently underway in other states to establish universal primary care, including the methodologies, funding mechanisms, implementation plans, and timelines considered or pursued or both, and any legal or regulatory obstacles identified and potential solutions explored. On or before 01/15/2027, the office would report to this committee and Senate Health and Welfare with the most promising opportunities identified and lessons learned and how those compare with the approaches to universal primary care contemplated in this. And then no changes to section what is now section nine, regional universal primary care sections ten and eleven are just renumbered as section as is section 12, and I flag that the build title may need to change.

[Francis McFaun (Vice Chair)]: There's the health reform or like looking up oversight committee, and then there's the Office of Health Care Reform, two different entities.

[Jen Kirby, Office of Legislative Counsel]: Health Reform Oversight Committee is a legislative committee that meets when the General Assembly is not in session. The Office of Health Care Reform is in the agency of human services, and they're the ones who are leading hospital transformation and other. Yes.

[Francis McFaun (Vice Chair)]: Actually, can I reach out to someone on the bench? Maybe Eva,

[Alyssa Black (Chair)]: agency of human services. Can you give us the organizational structure? I think I have it right in that AHS central office within that is Medicaid, essentially Medicaid policy. Underneath that, that would be the director, like Jill Olsen. And then underneath that is the Office of Healthcare Reform. And then within the Office of Healthcare Reform, underneath that is the blueprints or where is

[Jen Kirby, Office of Legislative Counsel]: Yeah,

[Francis McFaun (Vice Chair)]: I'm

[Alyssa Black (Chair)]: trying to figure out what the org chart is.

[Eva (Agency of Human Services)]: Yes, glad that you came in services. That's correct. Within the agency of human services central office, there is the Department of Medicaid Policy, which works closely with but is separate from the Department of Vermont Health Access. And within Medicaid policy, that is our director of Medicaid policy. Blueprint is separate from Medicaid policy, but it is within that central office structure. And so within that structure, there is Medicaid policy, there's ViewPrint, there's the Office of Healthcare Reform, which is also separate from Medicaid policy, but also supervised by director Jella Olson. And then we also work closely with Vermont Chronic Care Initiative, which is within central office. And oftentimes that collaboration also informs some of the group recognitions as well.

[Nolan Langweil (Joint Fiscal Office)]: Great, thank you, fair.

[Francis McFaun (Vice Chair)]: When you

[Karen Lueders (Member)]: say central office, you're not talking about the secretary central office, you're talking about DIVA now? Yeah,

[Eva (Agency of Human Services)]: so within central office, it is the secretary central office and DIVA is within the umbrella of the agency of human services, but it is a separate sister department. Got it.

[Alyssa Black (Chair)]: I think what I just understood from your answer is that if we looked at an org chart, that we would have the secretary, underneath the secretary would be the director of Medicaid equivalent and opposite of that. We have the blueprint equivalent and opposite that or also reporting to the secretary. We have the office of healthcare reform and then the other one that you talked about Chronic Care Initiative. I thought I understood that they sort of went down from the Medicaid policy.

[Eva (Agency of Human Services)]: All of these are supervised by Director Jill Olson, but Medicaid policy is a separate offshoot from Blueprint, both supervised by director Jill Olson.

[Alyssa Black (Chair)]: Okay.

[Leslie Goldman (Member)]: Thank you.

[Francis McFaun (Vice Chair)]: You

[Leslie Goldman (Member)]: have it? Have it? Can you email it to us?

[Alyssa Black (Chair)]: Yes, if we could. Thank

[Francis McFaun (Vice Chair)]: you.

[Alyssa Black (Chair)]: Alright, so those are the changes that

[Francis McFaun (Vice Chair)]: working with Ledged Council

[Alyssa Black (Chair)]: was sort of thought it was incorporating some of the ideas we had. Again, as the bill that came to us, it was really about moving forward in a path to, I felt, set the blueprint up and steps that the blueprint would need to take for us to then move the blueprint forward in some sort of more universal primary care. And I do think that this work needs to be done. The blueprint has already said that they're engaging in this work and that there are lots of things that need to be done. I think that it's really important that they be allowed to continue that. And also through that work, can gather more information as we make decisions going forward whether or not the blueprint is the right mechanism for doing this. And so I'm interested in people's thoughts or concerns or additional language or language taken away, or maybe Yeah, food.

[Dave (Committee Member)]: So looking at page nine, section five, with the Agency of Human Services Green Mountain Care Board and Department of Financial Regulations in collaboration with the Office the Healthcare Advocates. What do you envision that being? Do they have any input on how this is, or do they just

[Alyssa Black (Chair)]: I will tell you that I've actually had conversations with all these organizations. And they're already talking amongst themselves. This is really just saying, continue these conversations you're having amongst yourselves. And we really want to know what the outcome of those conversations are. And the healthcare advocate, because the healthcare advocate represents Vermonters and they are outside of legislature, the administration, the quasi governmental regulator, the Green Mountain Care Board. It's the Office of the Healthcare Advocate is hopefully somebody that will provide kind of an unbiased it's not that in collaboration means that the healthcare advocate is the one that does this. It means that they just have a seat at the table as part of the conversation that these various agencies are having with themselves. Can I follow-up on?

[Leslie Goldman (Member)]: Yeah, because I had a similar question. I'm not sure I understand what in collaboration means because they could be excluded easily because they're not officially at the table because it's in collaboration. My preference would be that we just say they are included and not say in collaboration.

[Alyssa Black (Chair)]: I absolutely understand what you're saying. I don't know how to make them informed. Because we're not asking

[Leslie Goldman (Member)]: Well, because you're talking about It

[Alyssa Black (Chair)]: needs to be housed in the office of the healthcare advocate. I'm trying to, I guess, I mean, there a way, a word that we can come up with supervised?

[Dave (Committee Member)]: Collaboration is

[Leslie Goldman (Member)]: sort of like the words that they came up with. I see your point totally. But I also could see how it excluded, you know, that I just don't you were going raise your hand.

[Francis McFaun (Vice Chair)]: What would consultation be more than maybe? Any consultation?

[Jen Kirby, Office of Legislative Counsel]: I mean, use those words a lot. See consultation potentially being less involvement than collaboration.

[Alyssa Black (Chair)]: Like, hey, we had a meeting and here's what we talked about.

[Francis McFaun (Vice Chair)]: Yeah. Because

[Leslie Goldman (Member)]: when you go on to the next page, The office of the health care advocate is not really mentioned in the first paragraph. And that's why I missed it because it's at the bottom. The agency board department to collectively determine where each health care regulation, care reform should be most appropriately located. Wow, that seems like just such an opportunity for conflict. I am struggling with that. And who's the leader? I don't know who in here is leading this process. And I think there always needs to be reliable leadership in who sets the meetings, who sets the agenda, who all that work is really fundamental to any process moving forward. And that's why I'm a little stuck on that.

[Alyssa Black (Chair)]: I hear that. I think the goal is to make it informal. And I think I'm anticipating conflict. And that's why they have to support them, not just on what their recommendations are, but where the conflict was and the reasoning for the conflict. Because I think that if they have to report back to us where the conflict is, it allows us to make better decisions about where we wanna put things.

[Leslie Goldman (Member)]: Well, that's asking us to be the referee again. And if that's the intent

[Alyssa Black (Chair)]: Go ahead. No.

[Francis McFaun (Vice Chair)]: Go ahead. I'm putting my well,

[Nolan Langweil (Joint Fiscal Office)]: I'm just

[Alyssa Black (Chair)]: letting you know, I was sort of babbling. Once again, I mean, I'm not comfortable with that as a process, but I guess I can just say. What process would you do you have suggestions on

[Leslie Goldman (Member)]: what you're I'm seeing this for the first time. I don't know your object. Mean you did say something about your inner intent, but I'm not sure I get it. So I mean that's just that particular section.

[Francis McFaun (Vice Chair)]: I

[Lori Houghton (Member)]: don't think this is a

[Karen Lueders (Member)]: standard process.

[Lori Houghton (Member)]: I see this how I am taking this if I agree to keep this in and vote on this bill, that hospital transformation has taken far too long. We have a health system in crisis, and we're getting piecemeal ideas from various parties. And no one is driving the whole thing. And so we need to say our intention to all of these parties to get in a room and figure it out. I'm going to be clear on record that this year, I wanted to pull money away from hospital transformation and give it to something else. Because it's not happening how it's set up right now. And we could sit here and try and find a way to dictate to do it, but that doesn't mean our intention will be followed. So in my

[Karen Lueders (Member)]: eyes, this isn't a normal process.

[Lori Houghton (Member)]: This is just get in a room and battle it out. And you better come back with some ideas because the legislature is tired of this. I will say I'm tired of it. I won't speak for all

[Alyssa Black (Chair)]: of it. And I will say on record that the thought was removing hospital transformation from the agency of human services because it is not happening fast enough. It is not happening with urgency. And that was not agreed upon by all parties. And this is getting people in a room and figuring it out and come back to us and come back with clear justification of why things need to be where they are. Because we're just working on turf wars at this point. And as Lori said, I mean, you indicated that this seems like a turf war and that there will be great conflict in this. There's already great conflict and there's already turf wars. And the legislature needs to make the best decisions that they can in how to get to the aims of where we're trying to get to. And unless we know about that conflict, then we can't do anything. But all these organizations

[Leslie Goldman (Member)]: pretty much have their roles, I didn't raise my hand, I'm sorry,

[Francis McFaun (Vice Chair)]: established. Okay, we'll keep talking. In

[Leslie Goldman (Member)]: statute, mean, I it's pretty clear. Some of it, maybe not all of it, but I'd imagine that's where it would start. No Green Medicare award has a statute. We know that

[Alyssa Black (Chair)]: healthcare advocate has a statute. No DFR.

[Leslie Goldman (Member)]: Some of these things already exist. And I agree, it is certainly not moving fast enough. But I've seen West Side Story enough to see what happens. People die when you let people in a room killing each other. I just am very unchangeable.

[Alyssa Black (Chair)]: Really, really helpful. Yes, Daisy. I'm not

[Leslie Goldman (Member)]: saying you're going to kill each other, obviously. I'm just saying, well, we talk about turf war.

[Karen Lueders (Member)]: And someone brought up that idea, not me. Can we just kind of zoom out? I think that overall, the changes that were brought in, including the quadruple aim, which I think is incredibly important framing, are wonderful changes. Wonderful. And I wish Jim was here, because I think her wording through this is fantastic. I think that you all preserved what the Senate sent us and worked so hard on, but also incorporated what all of us have been hearing for years around exploring the possibility of universal care in Vermont and universal primary care. And I think this is wonderfully done. I think that listening to Leslie's concerns, I think they're really valid. But I also think that this language in Section 11 is going to bring us a report that brings us into the conversation. So I fully support this as it's drafted right now, and thank you for working on it. It's wonderful.

[Francis McFaun (Vice Chair)]: Did I see Karen, did I see your hand go up? Oh, I'm just murmuring. I'm happy to think about my history. In the collectively determined section, I think it would be really difficult to name a leader or someone that sets an agenda within that context. They might not determine. They might not come collectively up with that, but they might be able to identify why they didn't. And so that's valid information. Is the health care advocate at all included in being a thought partner in the collectively determined thought? Or are they just left? They sloughed off? No, no, no.

[Alyssa Black (Chair)]: They're not just there to observe. They're there to be an active part of the conversation. The reason why it's in collaboration with them is because we're asking these three agencies to think about themselves. And because we're not thinking of the office of the healthcare advocate of being also involved in where things should be, it's really just that he's an unbiased collaborator.

[Francis McFaun (Vice Chair)]: So on page nine, line 20, there's the intercollaboration language, on page 10, line five, six, it's agency, board and department, but there's no healthcare advocate mentioned at that point. Is that intentional?

[Nolan Langweil (Joint Fiscal Office)]: Yes.

[Alyssa Black (Chair)]: Because he's there to help facilitate. And I am sorry, I keep saying I think the Office of the Healthcare Advocate is really in a facilitating role. And I will tell you that one of the reasons that there is not a lead on this is because they each have an equal responsibility. And any time we have said, and I can think of so many bills where we have said, the agency of human services in consultation with Green Mountain Board or the Green Mountain Care Board in consultation with the Department of Financial Regulation. The moment that you put that person or that entity in charge, it's just, which is sort of what I'm trying to get at here, is we, the legislature, agonize over every bill that comes before us about who's going to do it. And you said, aren't these things already in statute? And one of the problems that we have now is that we have put so many things in statute and given them to the loudest voice in the room at the time that things are not jointed correctly. Well, I will just Or also that a lot of these tasks and these things that are in statute, they're iterative and they have changed over time. Like the Office of Healthcare Reform. The Office of Healthcare Reform was established and it was originally in the administration. It was in the governor's office. And it was established around to try to get us to universal health care when Vermont was doing that. Well, that's not what they do anymore. And over the years we have said, oh, why don't they do this? Why don't they do that? And they moved. I mean, they were in diva for a while. Then they went back to the central office. And then I think they went back to Diva. No, they've gone back and forth one time. So they've actually moved and their tasks and their charge has changed over the years. And I just think that this is a level set of these various agencies to talk about where things are and what the tasks that they're trying to achieve now are and where they should be housed so that they can actually move forward with the things that they're all trying to do. Dave?

[Dave (Committee Member)]: Yep. So originally, I was looking at it going, how are the three entities gonna come up with a plan? But then in reading that through July, probably know where I'm going, that the Health Reform Oversight Committee will check on the progress. Where do we stand? I think the What

[Alyssa Black (Chair)]: have you guys been talking about? Yeah. You know, where are the pitfalls? Where are the hiccups? Where is the agreement? Where is

[Dave (Committee Member)]: Yep, and through this process, the healthcare advocate will be able to collaborate and say, as they move along, Have you thought of this? And that kind of stuff.

[Francis McFaun (Vice Chair)]: Leslie, go ahead.

[Nolan Langweil (Joint Fiscal Office)]: I think

[Leslie Goldman (Member)]: I heard you say, but correct me if I'm wrong, that you saw the healthcare advocate as the facilitator. Did you just say that?

[Alyssa Black (Chair)]: I'm trying to think of words. Supervisor, facilitator, a voice

[Leslie Goldman (Member)]: in the room. Facilitator is a word that's a leader, an organizer, you know, who makes the process happen. Or keeps things on track. That's right. So if we made the healthcare advocate the facilitator, that would relieve me. He would probably say, No, thank you. You said you saw the healthcare advocate as a facilitator of something.

[Alyssa Black (Chair)]: I see him as a non biased seat at the table.

[Leslie Goldman (Member)]: But everybody's biased. And that's, of course, where I struggle with this language on the first page of implying that the blueprint, is a contender, let's say, and that is a huge bias setting up this bill for me. So, yeah,

[Francis McFaun (Vice Chair)]: obviously.

[Leslie Goldman (Member)]: And it's really seven reports, right? It spills down to seven reports.

[Alyssa Black (Chair)]: No, I think we even got it down further. No, I think it's now three.

[Leslie Goldman (Member)]: Oh, well, let's look at that because there's a report. Section three is a report, Blue Paid Payments to Practices and Primary Care. Section four is a report, Primary Care Spending, Agency of Human Services. Section five is a report, Distribution of Duties for Health Care Regulation and Health Care Reform. Section six of the report: Vermont Clinician Landscape Site Mutual Re endorsements. Section seven is a report: Transitioning Care to Community Settings. Section eight is a report: Universal Carberry Care on one sec. On.

[Jen Kirby, Office of Legislative Counsel]: That is a report. Hold on.

[Alyssa Black (Chair)]: So, Section five is not a report. Section five is, Provide us with your recommendations.

[Leslie Goldman (Member)]: Section five at the end says Report Distribution Futies for Health Care Regulation and Health Care Reform Report. That's what it says. Now, the language is long and whatever, but it's a report, right?

[Alyssa Black (Chair)]: I see it more as a report back.

[Leslie Goldman (Member)]: Can I ask why you're concerned about so many reports? Like what's happening? Well, happens with all that? There's a whole lot of work being done. The treasurer wanted $350,000 It's gone, obviously. Who's going to pay? How does this all get

[Alyssa Black (Chair)]: implemented? Of these reports have been an appropriation requested by any of the agencies. And we've all lived through all the reports that sit on the shelves. And in order for us to move forward with universal primary care and to make the best of Can I ask something about Section five? So when we move forward in universal primary care, we, the people around this table and people in the Senate, will be tasked with figuring out who's going to implement it. We will have the same various agencies in front of us either asking not to be responsible for it or asking to be responsible for it. The reason that we're asking them now to be thinking through what they're doing and how they can best work in concert with each other so that we can make an informed decision about who we're going to tasked with implementing Universal Primary. So, I mean, that's one of the reasons that I think it's so important. And these report backs are really just for us to have the information we need to take the steps forward that we want to take. That's what I'm seeing this as.

[Francis McFaun (Vice Chair)]: Did you have No comment.

[Allen "Penny" Demar (Member)]: Weird question, I guess. Number one, all of a sudden we've got universal primary care. What exactly are we talking about? I know what definition universal means, but can you explain this in this pill?

[Alyssa Black (Chair)]: What is universal? Secretary Chair, we had a very robust discussion yesterday around the word universal, didn't we?

[Francis McFaun (Vice Chair)]: Yesterday? We weren't included

[Leslie Goldman (Member)]: in this.

[Alyssa Black (Chair)]: Okay. That's fine. We're working with legislative council and universal, available to everyone, accessible,

[Jen Kirby, Office of Legislative Counsel]: affordable.

[Allen "Penny" Demar (Member)]: And when we say everyone, that's the whole spectrum. For monitors. So then my next question to follow-up on that, we've a report on section three to establish a definition of primary care services. Yes. Did you discuss that too?

[Alyssa Black (Chair)]: No, I will tell you, we actually, so this was the bill that came over. And this is something that the blueprint already does and AHS does. When it says primary care services, if you're going to be able to decide that you're going, that if we were ever to do like a sort of a capitated payment model, what you have to do is you have to decide what services are actually primary care services that would be included in that sort of capitated one payment model. So for instance, so when it says primary care services, know, think about going to your primary care. You have an office visit with them. Well, that would be included, an office visit. But what your primary care, what if you came in with a huge laceration and your primary care squeezed you into the schedule and spent forty five minutes stitching up your laceration? Is that considered a primary care service or is that separate from primary care services? That's kind of what this is, is what services are considered essential in primary care that have to be delivered.

[Allen "Penny" Demar (Member)]: My last question, same thing, primary care provider. We don't have a definition of that yet?

[Alyssa Black (Chair)]: No. Okay, so you might recall because you've been here. We've done a

[Francis McFaun (Vice Chair)]: couple

[Alyssa Black (Chair)]: bills and we've done bills that reference primary care providers. And legislative counsel is always trying to reference something to define what primary care provider is, and there is no definition in statute. And so this was me actually saying to legislative council, Hey, Jen, why don't we finally have a definition so that when we talk about primary care providers, we're all working throughout statute on what an actual primary care provider is because we never defined it.

[Allen "Penny" Demar (Member)]: And again, this is studies. This is all going to be studied. These questions are going to be hopefully different answers, but then we go over all this stuff again.

[Alyssa Black (Chair)]: Well, we haven't made any decisions.

[Allen "Penny" Demar (Member)]: No, but if this continues, the study is going to happen.

[Alyssa Black (Chair)]: They'll send us a report on what they found. And then it will be up to the next legislature to decide what to do with it. That's what I'm saying. Yeah.

[Leslie Goldman (Member)]: Yeah, so I

[Francis McFaun (Vice Chair)]: had asked yesterday, and I think last week I had mentioned how the bills that we're passing work parallel with

[Jen Kirby, Office of Legislative Counsel]: overall transformation. I just

[Francis McFaun (Vice Chair)]: think this is necessary to I mean, we want primary care to work for all homeowners, I think this just brings everybody together, makes everybody move down the road together, even if it is messy. Every agency is there and they're talking and I think I just feel good. Do you want me to get you open? This strap? I have one question. Yeah, of course. Maybe it's not understanding Senate health interaction, but emphasizing the blueprint, it does feel like a little bit of an emphasis even in the purpose section. Is that to, I don't know, to align to the work that's been there to sort of recognize that, because I think we're thinking more broadly the Blueprint, and so I'm just wondering, like if you put a period at the end of a framework for implementation of the University of Primary Care, is that a bad thing to do in the context of?

[Alyssa Black (Chair)]: Well, because we have several sections in this bill around the blueprint and sort of optimizing the blueprint and having the blueprint look at itself. Remember, this is just the intent section, so we have to put in the intent section what is in the fill. So we don't want to be citing the blueprint.

[Francis McFaun (Vice Chair)]: Because it makes a clear appearance later, but you're saying lay the groundwork in the intent section.

[Alyssa Black (Chair)]: Yeah, which is why it's B instead. I mean, we have House health care A, and then we have Senate Health and Welfare B and the bill that came over from us.

[Leslie Goldman (Member)]: And for better or for worse,

[Alyssa Black (Chair)]: we do have a twenty year history with the blueprint for health. Right And now, blueprint for health, I think it was the Vermont Medical Society who testified, know, the blueprint for health has actually already sort of built the relationships and the operational administrative capacity around distributing to primary care. So, whether or not it'll be the blueprint isn't really, I think, relative. It's what we have right now. It doesn't mean that's what we go forward with, but we currently have the blueprint. And we want the blueprint to function as optimally as possible, given that they actually are what we have now. This doesn't tie us to using that, but they're named because it's actually the It's the only plan in place right now. I think the goal of what I was trying to put in here is, this is what we have now. Let's make sure that we're looking at it and using it to the best of its ability as it's currently configured, because frankly, I don't think we are. And I think that they will acknowledge the fact that they are trying to optimize themselves. They're going through this process. But I don't think it ties it. It's just that they're frankly named because it's the owner of If the you go back to that bill from 2018, it says, let's go forward and decide whether it's going be the all payer model, the ACO, or the blueprint. Because at the time that that bill was written, those three entities were possible. I think that this envisions that maybe if the blueprint is maximizing and working at their highest function and it's working and the model is working, maybe they would be best positioned. But also it allows us to say, maybe that's not the best mechanism that we want to move forward with. And we won't know that until we have the information that's in there.

[Francis McFaun (Vice Chair)]: Along that thinking, is it wrong to say after optimizing this blueprint for health, line 21, first page, to say, among other possibilities, broad so A is broad, B seems to maybe narrow it, does it open it up again or align it with A to not only name infant, but among others. Actually, that's great. Why don't we ask Jen, because there is, later on,

[Alyssa Black (Chair)]: in

[Jen Kirby, Office of Legislative Counsel]: the report

[Francis McFaun (Vice Chair)]: I don't to find it.

[Alyssa Black (Chair)]: Sort of section eight, we're asking them to come back to us and look at ways, other methodologies, other funding mechanisms, other possibilities. Tell us what other states are doing. And there's a lot of innovative work being done in a lot of other states currently this year. And so they are coming back to us with, here's what others are doing. And if it I think it might be a good addition to Section B on page one. The purpose of this bill is to obtain the information necessary to develop a framework for implementation of universal primary care, including optimizing the blueprint for health to determine whether it is an appropriate mechanism for which to provide universal primary care. And then we could say something like, or alternative, or if an alternative mechanism shall be developed.

[Francis McFaun (Vice Chair)]: Among others. Among others. That sets you up at that latter second.

[Alyssa Black (Chair)]: We can't name anything because it doesn't exist yet, so what do we need? But we could absolutely, I think it would make it stronger. I think the intent would be stronger to say we're not going down, we're not pigeonholing ourselves with the blueprint, and we want to look at other We want to make sure we're going in the right direction.

[Francis McFaun (Vice Chair)]: I mean, one of the things we could do is just have administrative importance. And hopefully that's something they're looking at by the time.

[Alyssa Black (Chair)]: Oh, it's always happened. Now I said, oh, well, maybe you need to work with Jen to do this, and I, like, gave another word salad that I always do, and then you walked in the door.

[Jen Kirby, Office of Legislative Counsel]: You have to repeat the words.

[Alyssa Black (Chair)]: Leslie.

[Leslie Goldman (Member)]: I'm thinking back, if we're ready to think about section five, which is the one I'm struggling with. We haven't taken any testimony from any of these three groups, or four groups for that matter, on this idea. Are you thinking about that?

[Alyssa Black (Chair)]: We could, and ask them about this section. I almost feel like all the testimony that we take on every single bill from these three areas sort of highlight the need, but if you'd like, I can ask each of all four parties to come in and speak to Section five and whether or not

[Leslie Goldman (Member)]: how that would impact them, what they think of the process, because, as I've said, I have concerns about it, and if I could be reassured, I'd feel better.

[Alyssa Black (Chair)]: Okay, you can do that. So I see the Green Mountain Care Board writing down. I see the Agency of Human Services.

[Leslie Goldman (Member)]: Can put

[Alyssa Black (Chair)]: out the invitation? And I don't see anyone from the Department of Financial Regulation, but we'll actually speak to them and have them. I can admit. Yep. And healthcare advocate.

[Leslie Goldman (Member)]: Could literally know the board manager in this

[Alyssa Black (Chair)]: board meeting, so I've texted them in my opinion, but that's just how they

[Nolan Langweil (Joint Fiscal Office)]: find it.

[Francis McFaun (Vice Chair)]: Six months is pretty short, January 2027 is when you expect this report to be completed? Yeah.

[Alyssa Black (Chair)]: Well, like that. Everything else

[Francis McFaun (Vice Chair)]: is January 15. Yeah. So by January 15, I should expect them all to have convened and come back with a plan, including what they found out from other states.

[Alyssa Black (Chair)]: Well, I think that what we're really getting at here is tell us about your discussions. Tell us what things were contemplated. Tell us what things were agreement.

[Leslie Goldman (Member)]: If there was a definition of a

[Alyssa Black (Chair)]: primary physician. Oh, no, well that's a different report. No, But

[Francis McFaun (Vice Chair)]: by that time, you expect there to be some sort of idea of a plan, concept of a plan. I think that

[Alyssa Black (Chair)]: they will have had time to discuss amongst themselves the best.

[Leslie Goldman (Member)]: Concept of a plan for what?

[Alyssa Black (Chair)]: The report is to begin a discussion on universal No, no. Are we talking about Section five? What section do we have?

[Francis McFaun (Vice Chair)]: They all seem to have a 01/15/2027 deadline on them.

[Alyssa Black (Chair)]: So, I would say that essentially section don't want Section three, Doctor. Saroyan testified that this is what they're already working on this. I think they had

[Francis McFaun (Vice Chair)]: a meeting yesterday, didn't they?

[Alyssa Black (Chair)]: I think there was a meeting yesterday. He talked about how they're sort of in the process right now of modernizing. He was talking about, we're reassessing the quality measures, the administrative for the So they're really already in this process. Okay. And just help me.

[Francis McFaun (Vice Chair)]: Do you expect? And what would be next steps? I guess where I was struggling.

[Alyssa Black (Chair)]: What do I expect? Or what am I expecting? I'm expecting that if we put our legislative intent out there and that people know that this is where we want to go. That a lot of really, really smart, hardworking, skilled people will start working together and come up with a path forward that will at least culminate itself in next biennium, someone putting forward a well thought out, carefully planned, step by step bill that will get us to where we say we want to go. If you read back, Jen, can you remind me what that bill number was from? 3. S-fifty3. Go and you read that bill. That was section by section. First you do this, then we establish this, then we do this, then we do this. And I feel like for

[Leslie Goldman (Member)]: the

[Alyssa Black (Chair)]: legislature in the waning days of this biennium to throw words on a page with all of those steps is not a prudent thing to do. No, I wouldn't. No. I think the intent of this bill is to set our intentions where we want to go and that a lot of people who do this work every single day to start thinking about how we get there so that next year we can come back with a fully formed path and on what needs to be achieved and how we implement it at each step. Thank you.

[Francis McFaun (Vice Chair)]: It's just hard to get from a report to what we envision. I'm just trying to

[Alyssa Black (Chair)]: Well, I hope every member is back in this room next year, and we're the ones that make those decisions. So if it's our intention today, we're the ones that are going to be sitting here figuring out our intentions. So it's up

[Francis McFaun (Vice Chair)]: to us. Which brings me to the last page. An act relating to.

[Jen Kirby, Office of Legislative Counsel]: I I didn't wanna try to recital the name before you had talked about changes that were in the bill. So I you know, that will be something to decide once the bill contents are produced. How

[Alyssa Black (Chair)]: about an act relating to reform for primary care? Because right now it says an act relating to payment reform for primary care. Just how about getting rid of the word payment?

[Francis McFaun (Vice Chair)]: Awesome. So I'm thinking about things which works.

[Alyssa Black (Chair)]: And it seems like a lot

[Leslie Goldman (Member)]: of the content overlaps. I mean, it almost feels like it should be one report in some ways because it's part A and part It all fits together in this giant attempt to start something really huge and would be great, could we be able to get there. But the reports, like one involves one set of people and then another is another set of people, And I don't know what you're thinking, so that's why I'm asking, is how these reports intersect and overlap. Like, how does the work of that get done? And is that what the work of this committee is in January? Is that what you're thinking? Taking all these reports and then seeing how they fit together?

[Alyssa Black (Chair)]: Yeah, and also, really starting to your point of who do you pick to do these things, which we're constantly in the role in this realm of picking who to give something to. Maybe it should be overlapping a little bit so that we're getting that we're getting better options, more diverse options rather than like pigeonholing one person. So like, what do you, you said that a lot of them seem to have redundancies?

[Leslie Goldman (Member)]: Not necessarily, I mean, I haven't read every word, I haven't had time, we just got up this morning, you know, so I don't know the We're

[Alyssa Black (Chair)]: not voting on this today. We got plenty of time. We don't know

[Leslie Goldman (Member)]: the details, you know, and that needs a deep dive. But if we're talking about definition of primary care services per member per month payments, I mean, those intersect. I mean, have to like you said, is the suturing for that terrible laceration included in routine care or is it fee for service? We heard testimony from Doctor. Song and others that something should be fee for service, like immunizations.

[Alyssa Black (Chair)]: It's a

[Leslie Goldman (Member)]: lot of thinking, I think, that needs to happen. And I'm just wondering, I'm just seeing this giant diagram of all these reports and what overlaps and what does not overlap and who's doing what over there and who's doing that over there. And I'm just a little confused, guess.

[Alyssa Black (Chair)]: Remember, nothing's happening with any of the reports. No, we want them to happen. I mean, it

[Leslie Goldman (Member)]: would be stupid for them. I mean, yes, I mean, the point of the report is to create action, right? Yeah. So we

[Alyssa Black (Chair)]: need that allows action. So that's, I hope. I mean, otherwise, why do it? Yeah, except we actually removed from the Senate version a lot of the actions because we weren't comfortable with who was performing that action. I mean, you have concerns about the blueprint doing this, and so we actually removed the things that said that they then shall No, do I don't

[Leslie Goldman (Member)]: understand that. Because we wanted to open it up to a broader Open it. Yeah, just to broaden our thinking. Which is good. I mean, I think that's good, but I just want to understand a little more about how these reports intersect, I guess.

[Francis McFaun (Vice Chair)]: Well, do you want to take time with it?

[Leslie Goldman (Member)]: I will. Okay. I don't know that it's my understanding that's necessarily accurate because I didn't write this.

[Alyssa Black (Chair)]: Jen, right before you got here, we talked about page one, line 21, line up, page two. Can you help us Can you help us actually sort of expand? So we have including optimizing the blueprint for health to determine whether it is an appropriate mechanism through which provide universal primary care or other methods, other alternatives.

[Jen Kirby, Office of Legislative Counsel]: Jenny Harvey, legislative counsel, Susan Beck. I'm not sure that that fits because I don't think you are obtaining information necessary to determine whether somebody else is the right fit.

[Alyssa Black (Chair)]: Well, we have ours our look at other states, what other states are doing. K. So, you know I mean, we don't have a named group, but we have asked them to look at, you know, what other ways could something like this be structured. So other methodologies or So

[Jen Kirby, Office of Legislative Counsel]: whether whether blueprint's not in the methodology.

[Francis McFaun (Vice Chair)]: Great idea. Yeah,

[Jen Kirby, Office of Legislative Counsel]: I mean, you could say whether, I don't know, whether other structures or other approaches.

[Leslie Goldman (Member)]: Approaches.

[Alyssa Black (Chair)]: Probably can't write out outside the box and use that too.

[Jen Kirby, Office of Legislative Counsel]: Whether other approaches would be, I don't know, maybe I think we wanna say a better fit, but sort of what and I don't wanna say appropriate because that suggests something is inappropriate. But yes, whether other explored. Other approaches to be explored. Well, says optimizing putting optimizing blueprint to determine whether it is an appropriate mechanism through which to provide universal primary care or whether Other approaches might be explored. Other approaches should be explored. Or other approaches

[Leslie Goldman (Member)]: arise from all these reports. Other approaches become obvious, other approaches that we learn about, other approaches, whatever. Say, because we've

[Alyssa Black (Chair)]: used them or

[Francis McFaun (Vice Chair)]: including blueprint, you can actually say and including, and also including other. Well, it's

[Jen Kirby, Office of Legislative Counsel]: saying including optimizing a blueprint to determine whether it's an appropriate mechanism. I don't think we need

[Leslie Goldman (Member)]: to see Or are there others? Might there be others among other approaches might be more suitable, might meet our needs.

[Jen Kirby, Office of Legislative Counsel]: Yes. No. I think maybe more suitable remind us needs, something

[Alyssa Black (Chair)]: like that.

[Francis McFaun (Vice Chair)]: Getting that work universal, private.

[Alyssa Black (Chair)]: Is that Darren, is that Yeah. I

[Francis McFaun (Vice Chair)]: don't know. Well, I like Okay. Okay.

[Alyssa Black (Chair)]: Anything else or suggest we end or early?

[Brian Cina (Member)]: I have a comment.

[Alyssa Black (Chair)]: Oh, yeah. Cute and stuff. My brain. Hey.

[Brian Cina (Member)]: Hi. Yeah. Was listening. I was waiting just to, I was waiting for the right moment and you just kind of said this is it or we're going to end for now. So I want to say it. My remaining concern is that we're gathering a lot of information that's important, but I still feel like we're lacking the focus needed to achieve the job. And and we're not asking or delegating anyone with the responsibility of coming up with, like, a road map. Like, you know, we have we we can get all this information, but it still would be good to have someone kind of do, like, a cert like, it's almost like a survey of of the terrain ahead. And I I so I just and you know we're getting some information. Like I'm trying to think of like the analogy. It would be like asking someone to report on the climate and asking someone to report on the animal life and asking someone to report on some of the basic geographic features but no one's telling us how to get from here to the top of the mountain. And so I'm a little nervous about or a little skeptical. Maybe it's unnervous. Like skeptical that it's just going to yield a bunch of information and then in the first year, we're gonna be swamped with all this other stuff next year. And then the second year, there won't be time to do anything. And then we'll be kind of in the similar position. So I'm a little a little concerned about that piece still. And I don't have a an exact suggestion to make that hasn't been made already. I think the best thing would be is if there was a group tasked with coming to us with a plan or with a few plans. So that's just my thoughts. Thanks.

[Alyssa Black (Chair)]: Fantastic thoughts, Brian. And let me be completely and totally transparent. That is the best thing. And I have discussed with anyone who would or has the capacity of doing this just what you said, and they all required an appropriation. And there is no appropriation to be had. I also looked at forming a study, summer study committee, Sort of like what we did with education last year. It would require an appropriation. I thought about tasking the Health Reform Oversight Committee with coming back in January with recommendations and a fully formed thought. Health Reform Oversight Committee, I think is appropriated. They can meet up to six times. I honestly had conversations with other people who were on that committee. And I don't think that people who are on that committee would be able to commit to the time that that takes. To be honest with you, I'm sort of hoping that committee members will I'm hoping that all committee members will come back next year, who are coming back, and that will work with me over the summer and we'll come up with something and we'll come up with a roadmap. Because that's the only thing I could think of that didn't need an appropriation. Are you volunteering?

[Allen "Penny" Demar (Member)]: Was looking at the pay here. If the studies come back and everybody's on the same pace, there's going to have to be some appropriation of money to continue. This is just not going to happen without funds.

[Alyssa Black (Chair)]: You mean universal primary care?

[Allen "Penny" Demar (Member)]: Yeah.

[Leslie Goldman (Member)]: Well, the plan even.

[Allen "Penny" Demar (Member)]: Creating the plan, the whole thing.

[Jen Kirby, Office of Legislative Counsel]: It's going to require work.

[Allen "Penny" Demar (Member)]: Yeah. But we've got to find out what the study is, the results are.

[Francis McFaun (Vice Chair)]: Yeah, we've to find out. I love that you've done all that attempting.

[Leslie Goldman (Member)]: I'm exhausted at the thought

[Francis McFaun (Vice Chair)]: of my summer ahead, to be honest with you. But the oversight committee, I mean, everyone agrees how significant this issue is and how urgent it is and how it's taking too long already. And I'm just a little surprised there isn't a little more interest or capacity, since it's already up and standing, it's already got its meetings. If they couldn't be

[Alyssa Black (Chair)]: a sound, it's real. I want to mention, because it's in statute, the Health Reform Oversight Committee are the chairs of the four money committees, the chair of health and welfare, the chair of community services, the chair of health care, health health care, and Yeah. And those same people serve on multiple other, like they're JFC. They sit on a number of during the summer. So, if they're doing six here, six here, six here, I mean, that's a big commitment. I mean, I personally can commit to six, but that's just because I don't sit on any other committees. I

[Brian Cina (Member)]: have another comment or question. Penny, when you mentioned, you, you said a few, a few minutes ago, you mentioned that it's going to cost something eventually. Like, I agree like that at some point we need to invest in, in, in the, in the proper studying of things if it's going to be financially viable. And I don't think, I don't think like legislators are qualified honestly, like we don't, we're not actual actuarial analysis, you know, and analysts or whatever. We, we, we would need them to, if, if it was like the Health Oversight Committee, for example, or whatever committee we delegated this to that goes on year round, they would like, they would need, JFO would need to at least spend money on it, if not additional consultants I would think. So I'm just curious like do we did we ever see a fiscal note or has there ever been an assessment of how much it would actually cost to invest in paying a group or paying analysts to do the work over the summer? Because I think that the cost of a working group, we have an idea of what that is because we've passed bills out of the committee with working groups. And and sometimes that cost is considered de minimis if it's part of an if it's able to be pulled out of someone's existing budget which so it's not a lot of money to pay people a little bit to just be on a group. I think the issue comes in when you're hiring actuarial analysts because I remember, like, past studies being, a $100,000 or something. And so I don't know if anyone, you know, or Alyssa, I don't know, or or chair, I don't know if you had a chance to talk with JFO, if we had any idea, like, of how much it might cost if even if we're not gonna do it now because we don't think appropriations will appropriate money to it. I'm curious if we have any idea how much it would cost.

[Alyssa Black (Chair)]: I did not ask Jeff if I should come up with it unless you have a set number that you think

[Nolan Langweil (Joint Fiscal Office)]: For the record, Langlov Joint Fiscal, I've, Rob Tina asks a good question. The answer, just like the other study, depends on what it is we're studying. Depends on how broad or how specific it is. So it would depend because if you were actually doing a study like we did for a universal unified system, you would say we're gonna look at this, this, this, this, and this, and each one of those would have costs. So it would depend on what it is you want us to look at. Do you want us to look at reimbursement rates? Do want us to look at the impacts on macroeconomic, microeconomics? So the answer is it all depends on what it is you want us to study, and that would depend on who we have to hire and how many consultants. So the answer is it depends on what it is you want.

[Brian Cina (Member)]: Can I can I put a few things out there and if you don't know, it's okay, but like what, like I'm wondering one, and I could probably look this up online, but I think it's important for the record to put it out there? Like I'm wondering how much the study cost. I think it was in 2014 when I can't remember his name. Is it Shao report?

[Francis McFaun (Vice Chair)]: Yeah.

[Brian Cina (Member)]: Yeah. He came back he forward with three different pathways. Like, much would something like that cost? And like like if we wanted someone to actually crunch the numbers and and say here's here's projections on how much it would cost per year. Here's how you build the public, you know, financing aspect of it and here's sort of the projected impact on premiums over time. Like how much would something with that level of detail cost?

[Nolan Langweil (Joint Fiscal Office)]: Sure. So if I can jog my memory, I believe that contract somewhere between 507 and $50,000 However, Doctor. Chao donated his own time pro bono and used a lot of graduate students because he was doing it through Harvard. So that cost was on the cheap because he was willing to do a lot of the work out of his own pocket.

[Francis McFaun (Vice Chair)]: A million dollars.

[Nolan Langweil (Joint Fiscal Office)]: Well, that's for that. Mean, again, and now you get a copy of term inflation and again, it all depends on what it is you want. The bigger question would be, what did the administration spend when they were trying to figure out what it would cost? I mean, they hired tons of consultants, tons of people. That to me would be a bigger question.

[Alyssa Black (Chair)]: Okay, we should end for the day. So, we'll come back to this, we'll try here on 06:11 tomorrow, and then we'll come back to this tomorrow. Thank you everybody.