Vermont Legislature SmartTranscripts:

[Speaker 0]: Hi, welcome back. We now have Katie, Counsel with us to walk us through the Senate proposal of amendment eight sixteen. This is up for action today, correct? Okay. All right. Fast and furious. Good morning.

[Katie McLennan, Office of Legislative Counsel]: Katie McLennan, Office of Legislative Counsel.

[Speaker 0]: There we go.

[Katie McLennan, Office of Legislative Counsel]: So what I have is this eight sixteen three point one. This is the report of the Committee on Senate Health and Welfare. Their changes are highlighted in this draft, so I thought that would be helpful for you to sort of see the differences. I guess this is an imperfect tool because it doesn't show what has been struck through. So it shows the language that they have added, but not the language that they have removed. But it gives you a sense of where some of the changes were. So for the purpose, it is the purpose of this act to safeguard individuals seeking mental health services in Vermont from psychological harm, including death by suicide, by ensuring that these services are delivered by mental health professionals and not independently by artificial intelligence systems. New language. That's new language. Section two, unprofessional conduct, has for any mental health professional engaging in the prohibited use of artificial intelligence pursuant to the next section. So this language is meant to pick up this language, the title of this section. And so this applies to OPR professions, mental health professions. And you'll see a new section that is very similar language that applies to board of medical practice, mental health professionals, or who is listed as a mental health professional. And this definition, who is governed by board of medical practice. In terms of artificial intelligence, there's no longer language about generative artificial intelligence. Same definition of mental health professional. Mental health services has changed. Means counseling therapy or psychotherapy services used to diagnose or treat an individual's mental or behavioral health or provide ongoing recovery support, including providing therapeutic decisions, issuing direct therapeutic communications, generating treatment plans or recommendations, or detecting or interpreting emotion or mental states. Therapeutic communication means a written verbal or nonverbal interaction intended to diagnose or treat any type of mental or behavioral health concern, provide ongoing recovery support or provide any advice related to diagnosis, treatment or recovery, such as engaging in direct interactions with clients or patients for the purpose of understanding or reflecting the clients or patients' thoughts providing guidance, therapeutic strategies or interventions designed to achieve mental health outcomes Offering emotional support, reassurance or empathy in response to emotional or psychological distress. Collaborating with a patient or client to develop or modify treatment plans or therapeutic goals. And the top of page four, delivering feedback intended to promote growth or address mental health outcomes. Subdivision five, therapeutic decision is the same. And then this subsection B and subsection D sort of compress a lot of the work that your bill did, but it removes some of the nuances around exceptions for supplementary administrative tools and administrative tools. What is the I forget the term that you used. You had administrative and supplementary resources, and those were exempt. And this does the same work without having quite as much prescription around it. So this language in subsection B, an individual corporation or other entity shall not offer or provide mental health services through artificial intelligence without the review and approval of a mental health professional. And then there's language that a violation of this section by a corporation, an entity or an individual who is not licensed, certified or rostered as a mental health professional shall be subject to the Consumer Protection Act, and that each violation shall carry a civil penalty of $10,000.

[Speaker 0]: I just grab it? Individual is still in. I think is yep.

[Katie McLennan, Office of Legislative Counsel]: This is the report of the Senate Health and Welfare Committee, and this does not reflect what happened on the floor. So that was the next thing I was gonna say is that there was a floor amendment to remove individual in subsection B and C. So you do not have a document. I don't have a marked up document of has passed the Senate. I only have a marked up document of what happened in Senate health and welfare. So that's what you're looking at. So it's not capturing strike throughs of that committee, and it's not capturing what happened on the floor. Or there was an amendment for B and C. B is slightly rewritten and C, in both places, it removes individual. So they would only apply to corporations and entities. So that's the change I think you're referring to. And then in subsection D, this is new. Nothing in this section shall preclude a mental health professional who is operating within the professional scope of practice from utilizing AI tools that are compliant with HIPAA provided that the mental health professional reviews and approves any mental health services. Section four, this is the section I referenced before about having parallel language with regard to the Board of Medical Practice. And section five is the creation of a new report from OPR to come back next January, OPR and Board of Medical Practice, to submit recommendations to various policy committees for the regulation of the use of AI by regulated professionals, including recommendations for legislative action. The genesis of this was that there is some conversation from OPR that I don't wanna say why limit it to mental health professionals, but that there could be a wider look at the use of AI in many of the professions that OPR administers. So Senate Health and Welfare took that idea and asked for this report. And then you have an effective date on passage.

[Speaker 0]: So I have no idea What sort of, what did this language do to this bill?

[Katie McLennan, Office of Legislative Counsel]: It's more streamlined. There are fewer sort of nuances in the language in section three, but ultimately it has the same goals and effect of requiring a mental health professional who uses an AI tool to review and know what they're using, review and accept what the AI output is before using that with a client. And it also has language that says corporation or entity cannot issue mental health services using AI unless it's with the review and approval of a mental health professional.

[Speaker 0]: Would that inhibit my ability to go to chat GPT and say, how am I going to get through this next week in the legislature? What is your suggestion? And not be able to actually respond to that? That's you as an individual as opposed to the provider. That's different, right? It's all not understanding. Just one second. Trying to find

[Katie McLennan, Office of Legislative Counsel]: the language in the amendment. I

[Speaker 0]: don't have the problem with this.

[Katie McLennan, Office of Legislative Counsel]: Let's see. Here. Let me stop sharing. Let me pull up a new language. I think that might be helpful. Okay. So this is what ended up passing for that subsection b. So subsection b was withdrawn or struck in its entirety, inserting Luther Avenue subsection B. You'll see it doesn't apply to individuals. A corporation or entity shall not provide, advertise or otherwise offer mental health services, including through the use of AI, to the public unless the mental health services are provided by a mental health professional. So this is prohibiting a corporation, a chat box, from providing, advertising, or offering mental health services to the public if it's not a mental health professional that's offering them. So this would allow HIPAA, as we see in subsection B, there's a HIPAA compliant tool that a mental health professional is using, a HIPAA compliant AI tool that a mental health professional is using. That mental health professional uses the tool. They review the output before using it. That doesn't prohibit the mental health professional from using that tool. But what this subsection b is saying is that to the extent there is a chat box or a corporation that owns a chat box, they can't provide mental health services as defined in the bill using AI to a member of the public if that service isn't being provided by a mental health professional, which a chat box would not be.

[Rep. Lori Houghton (Member)]: Can you go to the definition of mental health services, Katie? Yeah, I have to switch down. Because I just want to flag for everybody that this definition is what came back from the Senate, right? Did they change it, Katie? Of mental health professionals? No, mental health services. Yes. I think they did. But Maine has just passed a similar law that uses a different, more narrow or more broad. It's a shorter definition. And it's been recommended that we consider that in order to stay regionally aligned with what people are doing in this space. This is not the main definition. So this

[Katie McLennan, Office of Legislative Counsel]: is what came back from the Senate. So what came back from the Senate, again, counseling therapy, psychotherapy services used to diagnose or treat an individual's mental or behavioral health or provide ongoing recovery support, including providing therapeutic decisions, issuing direct therapeutic communications, generating treatment plans or recommendations, or detecting or interpreting emotion or mental states. And then what passed in

[Speaker 0]: Maine? Wait a second. Not

[Katie McLennan, Office of Legislative Counsel]: sharing my inbox.

[Speaker 0]: Is

[Katie McLennan, Office of Legislative Counsel]: that mental health services means services provided to diagnose, treat, or address an individual's mental health or behavioral health through therapeutic communication. Right off the top, that excludes therapeutic decisions. Mean, So, that's a policy decision for you, but it would seem that you have a specific definition of what therapeutic decision is. And you would probably want to say that also. Right now, therapeutic decisions and therapeutic communications are listed as including and mental health services. And this change is that the diagnosis treatment of an individual's mental health or behavioral health is through therapeutic communication or through a therapeutic decision.

[Rep. Brian Cina (Member)]: I just have a question, Gerardo. Can you go back to the part that defined mental health services?

[Speaker 0]: Yes, as passed

[Katie McLennan, Office of Legislative Counsel]: Senate.

[Rep. Brian Cina (Member)]: Yeah, the most recent version. I'm wondering, this the only place in state law that's going to have a definition for mental health services or is it defined in other places already?

[Katie McLennan, Office of Legislative Counsel]: I don't know if there's a specific definition of mental health services. This would

[Rep. Brian Cina (Member)]: be the first time we actually define it in the- I'm not saying that. Okay.

[Katie McLennan, Office of Legislative Counsel]: I don't know, I have

[Speaker 0]: to look.

[Katie McLennan, Office of Legislative Counsel]: Oh, okay. Yeah. There's probably variations, but I don't know if the exact term mental health services is defined.

[Rep. Brian Cina (Member)]: I'm curious about that, because if we're talking about being consistent with Maine, we should also look at being consistent within our own law. And then the second thing would be, I'm just concerned about detecting or interpreting emotion or mental states. Every human does that. That's part of our basic functioning as humans. We're detecting and interpreting people's emotions and mental states. So, to now define that as a mental health service, if an AI is trying to do that, to communicate with a person better and to respond to them better, I don't see that as mental health services. I think if doing that to then go further, then it's a mental health service. But I think the simple act of detecting and interpreting emotional state, I would be hesitant to start defining that as a service.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: No, but

[Rep. Lori Houghton (Member)]: it was with intent, right, Katie? It's prohibiting it. No, it's with use to diagnose or treat. We were trying to isolate it. But see, there's some complications around, I think, the definition of mental health services with regard to our original intent of wanting to be able to allow the use of digital therapeutics by our professionals, make sure that they feel empowered and safe to do that, but also minimizing harm to patients. So, Brian, I think we're on the same page, that there are some nuances that we want to be sure we address. I think we can discuss this more, but I'm just going to be frank with everybody. I think we need to discuss it a lot more than we have time to do today before it comes up on the floor.

[Rep. Leslie Goldman (Member)]: Maine's definition is much more broad. It just defines mental health services, means outpatient counseling, other psychological, psychiatric diagnostic, therapeutic services, and other allied services.

[Katie McLennan, Office of Legislative Counsel]: That's not the definition that I was sent. So I guess I'm curious. Where are you reading that from?

[Rep. Leslie Goldman (Member)]: From the Maine statute.

[Speaker 0]: 2082.

[Rep. Leslie Goldman (Member)]: Later on. Thirty two zero two.

[Rep. Lori Houghton (Member)]: That's not the right. It's LD23.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: Or 3,601.

[Rep. Brian Cina (Member)]: So Maine has different definitions of mental health services in their law, it seems.

[Rep. Leslie Goldman (Member)]: Yes, probably do.

[Rep. Brian Cina (Member)]: There was one other question or comment I had. Just that the way that I agree with what you just said, I wanted to say that, but I think we need to explore this more. What I see ChatGP doing when I ask him, would say wellness questions, is finding wellness information for me. And it has done interesting things, like on its own said, Would you like me to take these five interventions you're researching and combine them into a recommended regimen? And I'm like, okay, but I don't trust you. So I feel like that might be where it's crossing the line a little bit, but I don't think that this would inhibit people from using AI to gain access to resources. It would just put a limit on how far that AI goes with making recommendations. I have found that it's behaved in questionable ways when I'm experimenting with it. So, do think we need to be thinking about that, because there's a fine line between what's self help and what's formal treatment from a licensed provider. I'll just leave it at that.

[Rep. Lori Houghton (Member)]: Yeah, and I think Katie did an incredible job around the therapeutic communication definition. And I worked with an ASW to pull in a

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: little

[Rep. Lori Houghton (Member)]: bit more language from what the Senate did, just to specify that what we're really talking about is clinical advice, diagnosis, clinical treatment, and make sure that we're really focusing on the clinical setting here, because I don't want to prevent people from having access to those low barrier supports.

[Speaker 0]: Am I reading this right? I mean, I'm just seeing this language for the first time. Am I I mean, essentially the bill has passed by the house. It felt like we were trying to ensure that licensed professionals that we have in Vermont providing services to Vermonters, that AI as a tool can be used, however everything has to have clinical decision making ultimately by the licensed provider. And am I reading this in that it's sort of expanded it now to everything?

[Katie McLennan, Office of Legislative Counsel]: I don't know what everything means. That

[Speaker 0]: any mental health services, regardless of if they're provided by a licensed professional, which seems like it could be anything.

[Katie McLennan, Office of Legislative Counsel]: It says that a corporation or entity shall not provide those services using AI.

[Rep. Lori Houghton (Member)]: And then they expanded the mental health services definition to include things like empathy is in there somewhere or interpreting empathy,

[Speaker 0]: Detection or interpreting emotion and Yeah, mental so

[Rep. Lori Houghton (Member)]: for example, when I'm on a job board and I'm saying, I've been unemployed for this long and it's really depressing. If the job board says, we understand. That's why we're here to give you this list of jobs. So we understand. We don't want to penalize anybody for saying something like that. That's not who we're targeting. And we want to allow people to continue to develop other tools. And we want to focus this on tools that enable clinicians to do their work and clarify for them what they can and can't do. And since that is in OPR's lane, I had a chat with OPR. They also testified in the Senate. They want to be added to the AI Advisory Council that we talked about when we worked on 08/14. And so I think there's an opportunity to have them build upon any recommendations that might come up in terms of clarification to help clinicians or to help let some of these technology companies know exactly what we do and don't need. So there's that space in that advisory council. And we added, I'm recommending adding that section five.

[Speaker 0]: Go ahead, Brian, but let me put something out there first. As it came over from the Senate, I am not prepared to support the amended Senate version. Where that goes, so I would like to ask for at least a delay on this, because it is up for action today. And I think we need to either take more testimony on this, and then we can discuss whether or not we want a further proposal of amendment or possibly ask for a committee of conference. Those are my feelings right now. Just thinking about calendar math. I know we can't deal with it today, but I think we have to think about if we're done next Friday. Be thinking about it. Yeah, and I'm just thinking, just on this first read, for myself personally, I am not comfortable recommending that we concur. I'm recommending that we at least try to get some testimony tomorrow on this and then decide what to do with it. Is everybody okay with that? Thank you so much. Let's do that. Did you still want to ask your questions? I

[Katie McLennan, Office of Legislative Counsel]: would answer to your other question.

[Rep. Brian Cina (Member)]: One? Don't understand.

[Katie McLennan, Office of Legislative Counsel]: Definition of mental health services. So there is at least one other definition of mental health services, specifically in the health insurance title. I don't know that it is useful for our purposes, and we define the same term different ways in different contexts. That is an overlay. It means acts of diagnosis, treatment, evaluation, or advice for any other acts permissible under the healthcare laws of Vermont, whether performed in an outpatient or institutional setting, and include treatment of substance use disorder. Thank you.

[Rep. Brian Cina (Member)]: We are going to come back to this, so I don't want to belabor the point, but I wanted to just make this point, because I heard other members bring up the detecting language. One concern I have about leaving that in is that, and I don't know if this is a question that you can answer, but I want, would it then prohibit artificial intelligence technology from catching a problem and calling for help or sending someone for help? Like if someone is trying to use ChatGPT to plan their death, which has happened, that's part of what's driving this effort, and ChatGPT can't detect that that person's depressed or asking or suicidal, then how would ChatGPP know to say to them, call this hotline, which is what it does now. I ask questions about Ibogaine and it's like, call this number if you have drug addiction, call this number, this is not medical advice, that stuff pops up. And I'm just asking it, what's the range of a booster dose of Ibogaine? And then it starts saying that. So it's already detecting questions about drugs and mental health and responding in a way to say to you, I can't give you medical advice, call your doctor, or if you have a problem, call 900188 or whatever. If we prohibit it from being able to identify if someone's suicidal or depressed or anxious, then we might actually contribute to deaths because it won't catch them. So I think that there's, in order to prevent harm, it has to have I don't think we should prohibit its ability to detect emotions and mental state. I think that's different than because it's not invasive, you're giving it to it. You're telling it how you feel. So it's not like it's going in your head like the neural data. So I don't know. I made my point. I don't need to belabor. I think

[Speaker 0]: I said what I need

[Rep. Brian Cina (Member)]: to say. We can talk about it later, but I just wanted to get that out now so that it's out there.

[Rep. Lori Houghton (Member)]: Yeah, I agree with you, The

[Katie McLennan, Office of Legislative Counsel]: same issue came up in Senate Health and Welfare. We talked a little bit about how you're right. It's viewpoint neutral. So it's not allowing some statements by AI, but not other types of statements. And some of the conversation there was how do you control whether you think AI is providing a response that's aligned with clinical practice versus whether it's providing a response that isn't aligned with clinical practice? So that was the conversation downstairs.

[Speaker 0]: Okay. Well, I think we should table it for today. Puts off the double d acting largely. Okay, great. Thank you. Thanks, Katie. Thank you so much, Katie. Yep. Alright, so, to 197. Is Jen back? So, I had it on schedule, I wanted to talk about section five and sort of get the thoughts from the four entities named in section five. And I think I'm going to flip the schedule a little bit, and I'm going start with the health care advocate. So Chief Fisher, if you would like to jump in.

[Mike Fisher, Office of the Health Care Advocate]: I don't know what

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: to call me.

[Mike Fisher, Office of the Health Care Advocate]: Hi, I'm Mike Fisher, the health care advocate. Yeah. I thought that maybe I can just attempt to set the stage a little bit. I think I recognize that all year long, this committee has heard from the different entities about what they say they're doing well and what they think is be is missing and what, and and maybe in cases what they, concerns about what's not being done. And I know that the members at this table also have similar discussions and concerns about the landscape. And so as I read this language, I think it is intended to tee up a conversation for next year. Sort of, you know, how how do you sort of bring to the table a start of the conversation from the various entities? And so I think that's not a bad idea. And but I think that I've been around this long enough that I my caution is that I wouldn't want to ask for consensus or consensus building at this stage. I think I would want to

[Speaker 0]: Sorry. Didn't hear you.

[Mike Fisher, Office of the Health Care Advocate]: I think I would wanna ask the entities to consider the, you know, the gaps and areas for improvement and maybe on a little bit of a higher level, not name every detail, but and and ask them to come to you to come with a recommendation in early in January, and that maybe that in and of itself would facilitate and and if there's opportunities for the entities to come together and work together to figure out stuff, they can do that. But I wouldn't wanna ask them to spend a lot of time being in the same room. I think I think they can do that on their own. I just I'm I'm not sure I see as much for the premise in that. So and and as far as the HCA, you know, if indeed you go the direction I just said, then I'm not sure that the HCA needs to be, you know, at the table if there isn't a table. Though we would be to the same end, we'd be happy to give our thoughts as well.

[Speaker 0]: I realized in here, it's just asking for a report back. And do you think that if they do engage discussions, but rather than a single consensus report back, and I used to work report really loosely. Could be a letter.

[Mike Fisher, Office of the Health Care Advocate]: You think that the

[Speaker 0]: individual entities should report back their own

[Mike Fisher, Office of the Health Care Advocate]: I do.

[Speaker 0]: Actually Most one cumulative.

[Mike Fisher, Office of the Health Care Advocate]: With the caveat that I recognize that the administration, the DFR and AHS are part of the same administration. So there's a sort of structural difference there between that. So they can talk about how they would facilitate that, but they are part of of, you know, one structure. So, yes, I think asking the entities to to, to report their recommendations, to the legislature, you know, maybe when you call them in January.

[Speaker 0]: Thank you. Maybe maybe I could.

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: Oh, sorry.

[Speaker 0]: Are you seeing three entities? You're seeing the administration with those two, and then the Green Mountain Care Board and then you? Is that what you're thinking?

[Mike Fisher, Office of the Health Care Advocate]: I think that makes sense.

[Speaker 0]: Okay.

[Mike Fisher, Office of the Health Care Advocate]: Let me just say again, I would ask AHS and DFR to consider how they what makes sense for them. I don't want to speak for how they should be recognized.

[Speaker 0]: Right, right,

[Mike Fisher, Office of the Health Care Advocate]: That's their job.

[Speaker 0]: That would be one. And then two is Greenland Care Board.

[Rep. Leslie Goldman (Member)]: Yeah.

[Speaker 0]: And then you So there is no consensus that that's what you were talking about. Everyone just gets their own opinion about. And the question that's being asked, is that clear? Do we understand what we're asking them to respond to in this section?

[Mike Fisher, Office of the Health Care Advocate]: I think it is making sure that everyone's there's clarity in roles. And I do think it is it is, yeah, you know, gaps, areas where there are are gaps and where there needs to be improvements. Think it

[Speaker 0]: Specific to transfer transformation or specific to more than that or what?

[Mike Fisher, Office of the Health Care Advocate]: I think you've heard significantly more than that.

[Speaker 0]: Yeah. So beyond transformation, right now, the entire focused on since this bill is about universal primary care, is it about that? Is it about implementation Not of necessarily. So I'm just trying to get the

[Mike Fisher, Office of the Health Care Advocate]: I think it is about our health care regulatory planning. All of the activities that take up.

[Speaker 0]: All within the health care space. Yeah. Okay. That's pretty big.

[Mike Fisher, Office of the Health Care Advocate]: Yeah. I if if you're asking I don't I'm trying to be responsive to what I've heard from various other people. I'm I'm not necessarily saying that I think there needs to be a rethinking of all that stuff. You won't hear from the HCA that there needs to be a broad change in all that stuff. Right. But I think you've heard perspective, and so, you know, give the entities an opportunity to make their needs.

[Rep. Lori Houghton (Member)]: But we were hoping, if

[Speaker 0]: I understand sort of the origin of this, was that we wanted things to be moving a little quicker, asking them to respond in a timeframe kind of way or not necessarily. Think my concern is, and why I proposed it in this, is that if our intention is to, as a state, move forward with universal primary care and developing universal primary care, there will be key decisions along the way of how and who will implement. And it will involve various entities. And I think that as we make decisions over who is best tasked with achieving those goals, it's important for us to ensure that we've got all the information on who is best positioned to do that and where maybe alignment could be had to allow us to further implement things. Social. No, I mean, we in this room have made decisions. We sort of make decisions like that, who's best to do this? Should it be the board? Should it be AHS? And we make the best decisions with the information we have, but sometimes those decisions have led to unintended consequences for another entity.

[Emily Brown, Executive Director, Green Mountain Care Board]: I mean,

[Speaker 0]: perfect example is the Green Mountain Care Board is responsible for rate setting or QHP market. And yet we also have DFR who is regulating the entities and are they aligned? And I mean, I think that you would find it not bad or good. I'm not making a judgment call that sometimes if people have a different charge, you know, if DFR's charge is insurance solvency and protecting the insurance market and the Green Mountain Care Board's charge is Vermonters and the costs, are those working in alignment with each other? I'm just sort of thinking here. So let's say we want to implement universal primary care by 2030. What structures need to be in place in each of these entities in order to accomplish that? That kind of question? Yeah, or which entities are best positioned to be able to implement that and which decisions we make in the various entities that it goes to, are there possibilities that we could have competing interests, which doesn't allow for smooth implementation or planning or I mean, I'll give the example of hospital transformation. We have the Green Mountain Care Board tasked and they're working right now on reference based pricing. How are they going to set the reference if they aren't party to hospital transformation, what are they referencing to if they don't know where we're going? And that's what I'm sort of talking about is everybody able to actually function at their highest level? Or are people working in silos where they're not given information or not a party to the information that needs to have, they need to have in order to make other decisions. I think that's all. And then I'm going to walk, honey. Well, I think you're ready to go. My question's more for you. Well, let's have a mic, and then you should read. Here we go.

[Mike Fisher, Office of the Health Care Advocate]: Sorry. Read this language to be significantly broader. This is about our health care regulatory structure. I know it's in the context of 01/1997, a primary care focused bill, but the language to me is not about how do we set our regulatory structure up to achieve universal primary care, if that's what you want it to be.

[Speaker 0]: No. Well, it's in this bill. Yeah. I think that's part of the conclusion. No. I want a level set so when we do start making decisions that we, as a legislature, will have better information on who should be implementing what, where, when, how, that sort of thing. And so this is looking at the current structure that we have now to see where there's areas of agreement, where there might be areas of conflict, so that we have better information going forward than where to house things. That's for them. Section five is not who should implement universal primary care. Right, and I think that's confusing. Well, I thought it was focused a bit on that. So that's helpful, thank you. And I'm hearing you say areas of agreement, areas of conflict, and I'm trying to think about charge in order to have people focus on the questions that we want. So in a way, you're saying what the questions are. In order to optimize the functioning of our healthcare system, in order to

[Rep. Brian Cina (Member)]: I have a list here. Where are you? On page 10, line seven, It says, in order to optimize collaboration, information sharing, and efficient operations and furtherance of attaining the principles for health care reform set forth in, I'll just say, Act 48, and is codified at 18 VSA nine thousand three seventy one, establishing universal primary care, improving access to high quality affordable health care services, accomplishing health care transformation, and safeguarding hospital sustainability and insurance.

[Speaker 0]: That works.

[Rep. Brian Cina (Member)]: Sure, solvency. It's quite exhaustive list.

[Speaker 0]: So that's their charge. Well, then maybe we should make it higher in the section, that's all. Just be clear on that's what you want. Because it felt very to me. And it took me a while, until now. I mean, read it, broad, and I think that's very helpful, but I think we should put it over top. But that's okay.

[Rep. Leslie Goldman (Member)]: So if we're looking to get positions from the various entities on how to move forward, shouldn't we have the chief prevention officer involved in this? Because the role of that position is identify and coordinate initiatives across state government and among community stakeholders groups that improve well-being. So that's the chief prevention officer's role, to get these various entities, Regional Healthcare Board, AHS, DFR, to work together to see how they can operate.

[Speaker 0]: I have to be honest with you, I don't know what the chief prevention Where is that?

[Rep. Leslie Goldman (Member)]: It's out of the administration and

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: It's it's

[Rep. Brian Cina (Member)]: in the agency administration.

[Speaker 0]: Oh, that's mine. Yeah. Yeah.

[Rep. Leslie Goldman (Member)]: And it just seems like that would be the perfect role to get these three entities together to, to form the, things we're looking for. Let's I think it's a

[Speaker 0]: great question. Let's ask AHS and the board and DFR when they come up, what they think about that.

[Rep. Leslie Goldman (Member)]: Alright.

[Speaker 0]: I didn't know that was the title. Thank you. Let's see. Chittenden.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: You. Good morning, everyone. Where am I? I'm Jill Olson. I am the Medicaid and Health Systems Director for the Agency of Human Services. I will talk about Section five, but Madam Chair, do have those other concerns that we've talked about around some other changes yesterday. Is that Okay if

[Speaker 0]: I address those Yeah, let's I'll start with Section five.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Okay, I'm just gonna try to

[Speaker 0]: get the bill open as my computer does nothing.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Copy.

[Speaker 0]: Just frozen. I'm going to

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: just start talking and see if it'll Do wake

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: you want to just look at

[Speaker 0]: our hard shots and hear me talking? No, do you mind?

[Mike Fisher, Office of the Health Care Advocate]: Not at all.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: This sounds generous. I can't get my printer

[Speaker 0]: to work at home, and this

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: was late night thing.

[Emily Brown, Executive Director, Green Mountain Care Board]: Let's go

[Speaker 0]: back to it within ten minutes.

[Emily Brown, Executive Director, Green Mountain Care Board]: We can do

[Speaker 0]: it because Ledge Council actually needs to go. Fair enough. Okay.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: So I would say that on balance, we are supportive of this concept. It's something we've talked about behind the scenes a little bit. I think that you have observed some of the questions about role clarity that come up. Emily and I, we've all talked about it. And so I do think that you're identifying something that is a real thing where there's some room for discussion. So I think we can generally support moving forward with some version of this. I definitely don't want to write a report. So I think we're talking about something more informal than that. So I just want to say that out loud. And I would actually be less specific than you've been, not more, only because I don't want us to all have to spend a lot of time on things where we actually might not think. And it might be possible that none of us think a change needs to be made. And so now we have to sort of wrestle with particular item that you've listed. So I would probably recommend leaving it more high level so that we could talk about recommendations for change so that everything else none of us think should be changed is the default. So that would just

[Speaker 0]: be a suggestion to simplify it a little bit. Could you tell me a very

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Well, I would take out So the words that you listed that you liked, I'm saying I would cross

[Emily Brown, Executive Director, Green Mountain Care Board]: them out. So

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I'm on yeah. I would

[Emily Brown, Executive Director, Green Mountain Care Board]: say no. Let's see. 10. Line.

[Speaker 0]: Wherever it said the blueprint. I'm trying to find it.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: This is why I had my

[Speaker 0]: highlight two, three, four. Yeah.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Those Transformation. Yeah. All that. Yep. Line two, three, four in there. I would actually leave it more high level where we would evaluate our roles respective in healthcare regulation, healthcare reform, and not actual list items.

[Speaker 0]: That would be my suggestion. I don't want to interrupt, but I think that I did not clarify correctly. So I know you made changes in other parts of the bill. So let's start with those with alledged counsel, not section five. We'll come back to section five.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Oh, I'm sorry. I I heard you. I know.

[Speaker 0]: I think I was not clear. Or I didn't listen well.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Both those are possible. Okay. So thank you for the opportunity to talk about some of the other sections of the bill. So what and this is why

[Speaker 0]: I want my talk because it's really a little confusing. So you made

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: a change yesterday that I think you thought was more just moving stuff around. What you actually did was change who's doing it and also by when.

[Rep. Brian Cina (Member)]: Is this the blueprint targets?

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Uh-huh. What page? Six. Thank you. Six. But the move you made moves it under Blueprint. It's really a diva task and changes the date from 2028 back to 2027, just because of where it's moved into a section where there was a different date. So those are both things that matter to us. The Agency of Human Services, I think, is who was assigned, but it would typically be Diva, not the Blueprint. So I would prefer to leave it Agency of Human Services. I guess I liked it the way it was. And I would prefer that in terms of just the capacity of that group. Then that is, in fact, the group that is also now managing this new request that we have from CMS on provider revalidation. It's part of this fraud, waste, and abuse focus. So I really want to make sure we're not adding new tasks outside of the time frame that that team identified as the one that made sense. Change the date to what? Back to 2028.

[Jennifer Carbee, Legislative Counsel]: Jen Carmen, Senate Council. Can I just clarify because I think part of what they did is conveyed that AAS rule out of statute? Are you okay with it being just the standalone, what was formerly Section five primary care spending targets report and some version of that? That's a 2028 report, but not tied to codifying the targets and directing something there.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Jen, say it again. So am I okay with restoring Section five as it was? The

[Jennifer Carbee, Legislative Counsel]: statute? Section seven ten of it being added on the top of page six. So adding back the language that was 55 on page nine, but not adding back the language that struck on the top of page six, as long as the concepts may require more explanation.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: So I'm not sure. I feel like I need to But that's a yesno question. I just need a little more can get offline. Yeah, that would be great. Okay.

[Katie McLennan, Office of Legislative Counsel]: But I agree with you.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Those things typically were built to go together and so that is a great question.

[Speaker 0]: Okay. Yep. Nice catch for whoever caught it. Jo Ellison got it.

[Emily Brown, Executive Director, Green Mountain Care Board]: She got it all by herself. Yep, 05:00 and then

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I had a little panic attack because I hadn't caught it before. Okay. And then I did talk to the Blueprint team about some of the language on page seven, establishing a target for PMPM, transitional schedule. Oh, that's what was there. No, it's the You added some of the Blueprint language on page eight, line six. Description of the ways in which Blueprint can optimize delivery of services within the current initiatives. So if what you mean is to describe the new payment model for CHT that we're working on, that's fine. We can do that. So I think that's what those words mean, and the team felt that they could do that. And then I would finally ask that you added a new task for us, section eight, to do this sort of survey of different states on universal primary care. I would prefer that that not be assigned to AQS.

[Speaker 0]: Brian, go ahead. Do

[Rep. Brian Cina (Member)]: you have any recommendations about what the best approach might be to doing that work? Might it be best done by a working group or like some other branch of government or existing body?

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I don't. If you really want to dig into primary care at times, body has actually hired their own consultants to do work. You have done that. Obviously, that changes the fiscal note implications of

[Rep. Brian Cina (Member)]: the bill. But that is

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: something that this body has done at other times in health care reform.

[Rep. Brian Cina (Member)]: Can you give an example?

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Oh, back in the single payer days, were healthcare studies.

[Rep. Brian Cina (Member)]: You should have come out of 2011 study or whatever it was. The

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: The Yes, exactly that. But I'm just saying it's a thing that sometimes legislature is done. I don't have a recommendation for which entity of government would do a full service study of universal primary care.

[Rep. Brian Cina (Member)]: But you're saying not us.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I'm saying that.

[Speaker 0]: Okay, thank you. So do

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: we offer a better fail

[Speaker 0]: state of universal primary care implementation needs to be done? I mean, that what this bill? It's been done. It's been done. That was in 2018. 'sixteen.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: 'sixteen, whatever. There's been many a study.

[Speaker 0]: Love And who wants another study and I get those studies are not really mentioned in this bill.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: It's kind of a survey of lots of other states' work. I have no idea what other states have done. I don't know how extensive this would be, but it's a fair amount. It's a lift to go and look. I doubt there's a list. Maybe there's a list, but if there is, then you could just pull that. But I don't think this is a task that I'm

[Speaker 0]: going ask if it's take on. I just pulled up NASHP.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Yeah, just like to ask them. Yeah, Your legislative association, I mean, might

[Speaker 0]: just be other bodies who might be able to

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: pull this information for you. So that's about more? Think I said essentially my piece. We're comfortable conceptually. I hope that we would be able to identify consensus to the extent possible, but otherwise we might not be able to. Just again, to say my primary point, I would make it less specific so that we can focus on the areas where we think there should be change, instead of having to focus on areas where we don't think there should be change. That would just narrow the scope of the work for each tribe, each the groups. And if we wanted to collaborate, if one felt like there needed to be a change and another didn't, that will come up in that process. And I think that'll be useful information for you. I would also add that as part of the development of the strategic plan that's due in 2028, we have been inventorying from every department within AHS and also who's now done the Green Mountain Care Board, and we haven't yet done DFR, but we will, that just everybody's role in the healthcare regulation and reform space. It's just something we've been working on as a thing that we felt like we needed in that, partly because, and I think this is what you grappled with this year, it's a little hard to understand who does which parts. And so we felt like actually part of the strategic plan, that would be a helpful thing for us to consider so that it might be more clear. So this has been on Romance.

[Speaker 0]: I see, Leslie, you have a question, but do you want to weigh in on Dave's

[Rep. Leslie Goldman (Member)]: Yes, the chief of her time.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I sort of feel like I'd like to ask the chief prevention officer how she feels about it before I weigh in on her behalf. But I would also say, just thinking structurally, that's a person who works for the administration. And so I would expect that our position, DFR and the Agency of Human Services, we would come together. So it's not really a neutral party with the Green Mountain Care Board. So

[Speaker 0]: I just acknowledge that.

[Rep. Leslie Goldman (Member)]: Isn't the role, though, to get the three entities to provide their physicians and then to get them all together?

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I'm just saying the Green Mountain Care Board is not part of the administration. And so if I were them, I would feel like that was not an entirely neutral facilitator. And

[Speaker 0]: if the administration would get somebody, then maybe the legislature should have somebody as well. Now we've got

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: a whole Yeah, starts to be a lot of people.

[Speaker 0]: I don't think enough. Yeah,

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I agree. This could be hard. I don't disagree. We some challenges this year as we tried to work through 01/1989 in terms of who was going to do what. So no question there's conflict potentially to be had. That's what we do. And I actually think the Green Medicare board staff and the HS staff have actually been working together incredibly productively over the last several months. And I feel really good about that work. So I'm hopeful we can make it.

[Speaker 0]: Any oh, Leslie, I just need clarification to to understand what you're saying. So are you saying that you agree that these different entities do their own separate analysis and write a letter because you're saying no report. I'm just trying to

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Yeah, yeah. So I definitely don't want to do a report. I hadn't thought about the healthcare advocates' idea of having everybody do their own and then collaborate as they want to or think they could. I think that's an interesting idea. Could see the simplicity, but I also sort of like the idea of having to work together. A little bit of it being the forcing function, even if it's hard.

[Speaker 0]: So, would you imagine being sort of in charge of setting the meetings and the agenda and facilitating? How does that work? I think we'd have to

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: sort that out. Mean, isn't a neutral, there isn't an obvious that I have not been able to think of an obvious or fully neutral party that could do that. Right. And we do it now. Have meetings between the Medicare board and the Medicare reform staff. Do it every Yeah. Day to

[Speaker 0]: Who shows the agenda then? How does that

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: work?

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Actually, the way it works is a member of the pre Medicare board team very graciously volunteered to be the, Hey, what do you guys think? Here's what I have on my list. And the rest of us say, Yep, that sounds great. How about this group? We just kind of work together. It's pretty informal.

[Speaker 0]: And who runs the meeting?

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Emily and I, if I can stop it.

[Speaker 0]: You guys. Okay. So as far as section five, you're okay with that sort of less defined, and I know you're going to come up and sort of sounds like this sort of less defined model is something that you see as workable. Do you see yourself coming out with a joint letter by January, whatever it is, morning? 2027.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: I don't know that we can come to consensus. I'm not sure how much disagreement there is. So that is something we'll have to explore. But it's certainly possible to write a letter saying this is what we don't agree with. Or even just to do a recommendation, just to do

[Speaker 0]: a test of each party having their own recommendation, that you don't spend 10 meetings trying to come to consensus on what's going to go in

[Emily Brown, Executive Director, Green Mountain Care Board]: the letter. Yeah. Yeah. Yeah.

[Speaker 0]: Everybody write their own report, which is not a report.

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: Please stop saying that word. Recommendation. How do we say a recommendation or a report back? A

[Speaker 0]: letter. A report back. Okay. Any other questions for director Oates?

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: You. Thank you so much. Thank you so much. Sorry about that. Thank you.

[Speaker 0]: Sometimes the paperwork is better than

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: the machines. The problem is I can't get

[Speaker 0]: my printer to talk to this machine. Yes. Go right ahead.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: For the record, all my own joints in the school office, legislature has done a study in the past, had Doctor. Chao do the study, there was a high level study. In the end, the administration did all the work, did their own studies, wound up actually doing something much different than Chao had proposed. So before you start deciding if the legislature should do it, or JFO or Legis Council, we to compare what was done and what we can and to not do. Before this committee makes a decision about what JFO or legislators should do, let's have a further conversation.

[Speaker 0]: Go ahead, Brian.

[Rep. Brian Cina (Member)]: I know that we're allegedly ending next Friday, but I'm wondering if there was time, because there may not be, if it might be useful before we make a decision on that section about looking at the part AHS doesn't feel like they should do, that before we decide maybe having Nolan or another witness or combination of witnesses quickly, it doesn't have to be super detailed, but quickly review for the committee all the things that we've done. What you just shared was an example of the nuance and details of what we did at that time. It would be good to be like, let's rewind into 2011. What happened in what order? Why did things get derailed? What have we studied since? Because it might be good to not make the same mistakes, or there might be something that worked that we're like, that actually worked. Why don't we do that part again? So I don't know. Might only take an hour to thoroughly do that, even though time is short. I just was wondering if that might be something we could consider before we decide.

[Speaker 0]: I think we'll have time for, like, testimony. I know that that would mean that you would have to do a whole history of

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: Dig deep into

[Speaker 0]: catacombs. So that would be work for I know that would be

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: a lot to get I can probably do a higher level, but to get you someplace. And I also want remind you, well, was actually another study before the Doctor. Chao study, the Ken Thorpe study. Yeah. We are old. That's a deep cut right there.

[Rep. Brian Cina (Member)]: Go back to 1791.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: I think that the rap machine is too much. Think it is useful for me to go back and say we did these things and that the administration at a high level, I think I can do this.

[Speaker 0]: And links are

[Rep. Brian Cina (Member)]: Like who did what? Because it might be like, did this, who did that? Because then we're like, who did what? Do we want to do

[Speaker 0]: that again? I just want to say that I see section five, the new section five as being detached from this conversation. This is more, okay, so when we do get to that place next year and we're having to make those decisions that we have sort of a and then we can go into the nitty gritty about let's see what's happened in the past and we'll be able to make better decisions on where to go forward. Let's have Emily Brown, up. Sorry, I'm trying to use people's titles now. Director? Yeah, sure. Director Brown.

[Emily Brown, Executive Director, Green Mountain Care Board]: Thank you.

[Speaker 0]: Just a creative type.

[Emily Brown, Executive Director, Green Mountain Care Board]: Yeah, I like that idea too. Good morning, I think. It's Emily Brown. I'm the executive director of the Green Mountain Care Board. So I think the Green Mountain Care Board, or I know the Green Mountain Care Board supports section five as a concept. I agree with the healthcare advocates' suggestion of making sure that each entity who's included in the study has an opportunity to kind of come forward with its best ideas and thoughts. I kind of view this exercise as all of our agencies and entities have really smart, dedicated public servants. And so while we may not always agree on what the solutions are to issues or how regulatory functions should be carried out. I think I'm viewing this as an opportunity to kind of bring those all to the table next year so that we can have an informed discussion, or you all can have an informed discussion around all the points that we're kind of bringing to you and all the ideas. So I support this concept. I think that, to Jill's point, there might be areas where we have consensus and there might be areas where we don't. And I think, as she said, we work together on a weekly or biweekly basis, so we have existing touch points. And I expect if we were to engage in this work, we would be openly communicating with AHS and DFR as we move through this. And again, I don't think you should require consensus. I don't think that that would happen on all points. But I think making sure that there is an expectation of communication between the agencies makes sense to me. So I will also say I like the idea of pointing out areas which you'd like us to focus on. Clarity is kindness. So if you want us to address something, I think it's important to lay those out. And you've done so here. And then to the question about the chief prevention officer, I would agree with Jill Olson's point. I think that is a position that's embedded in the administration. So wouldn't necessarily be someone who I think the Green Mountain Care Board might again, might have alignment, might not at some point. So I don't really have a comment on that being part of the DFRHS process. I think that might make sense for them, but I wouldn't wanna speak for her either. So yeah. So that's all on section five. And then I did want to bring up I think Elena Berbeco, our director of policy, was in here, I think it was April 1, to talk about a prior report that we had done, the Green Mountain Care Board had done, and I want to draw your attention to section six, which is requiring us to update the twenty seventeen's clinician landscape study. I believe when we did that report prior in 2017, we had a full time position as well as it took us about eighteen months. So I just want to highlight some resource concerns the board has for that requirement in section six.

[Speaker 0]: We haven't really touched section six from the Senate. Was this

[Emily Brown, Executive Director, Green Mountain Care Board]: I believe we brought up

[Speaker 0]: in senate?

[Emily Brown, Executive Director, Green Mountain Care Board]: I believe we brought up resource concerns when we testified on this in the senate. And, it might have been Elena Berbeco, our Director of Policy, but we did resource concerns.

[Speaker 0]: We need to shrink that test. Yep, just wanted

[Emily Brown, Executive Director, Green Mountain Care Board]: to read it since I had the opportunity.

[Speaker 0]: Anything else? No, that's it. Thank you for having me in. Did you want to I know that you're not named in it, but Section eight, which is, I mean, fair efforts in other states

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: and AHS,

[Speaker 0]: is advising that they, well, they don't want to do good, is this something that Dream Mountain Care Board would like to?

[Emily Brown, Executive Director, Green Mountain Care Board]: I don't have any answer. I wasn't prepared. I was like, no, it's okay. I would like to go back and talk to my staff and the chair. Brian?

[Rep. Brian Cina (Member)]: Yeah, I have a related question. I was going to ask you if you had any recommendations about who might be the best part of your parties to do that work. That could include the Green Mountain Care Board, but it's sort of a broader question than the chair asked. So my question isn't like, do you think you all should do this, but who do you think might be the best people to do this work? If that includes you, great. And if you have other ideas, it would also be useful to hear. Not right now, but after you consult Yes. None of you thought of this. There's the Office of Universal Healthcare that exists that we don't utilize.

[Speaker 0]: I can

[Emily Brown, Executive Director, Green Mountain Care Board]: tell you, I'll either try to get back in writing as

[Speaker 0]: soon as possible. It could be, it was formed in 1873. Exactly.

[Rep. Brian Cina (Member)]: We just never funded it.

[Speaker 0]: Yes, you're right. Sorry. Was just wondering about section three. You're talking about blueprint payments for practices and primary care and whether you think that the group benefit were to be involved in that conversation, might it affect hospital rates or hospital budgets or that you think a voice there would be important.

[Emily Brown, Executive Director, Green Mountain Care Board]: So this, again, is one that I'd like to take back. So I do know I can say that we have provider rate setting authority, generally. So this does relate to that, but I wouldn't want to comment on this. I haven't had a chance

[Speaker 0]: to That's why I'm just bringing it up

[Emily Brown, Executive Director, Green Mountain Care Board]: to So I can also take this one back Thank as you.

[Speaker 0]: Any other questions? Alright, thank you so much.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: Thanks.

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: Good morning still? Morning. Mary Good Block, Deputy Commissioner of Insurance for DFR. So we also support the idea of collaboration in Section five, agree that we are likely to have consensus about some things and not consensus about other things. And so it probably makes sense to hear from all of us as to where those differences exist and where that consensus exists as well. We, I think, probably lean more towards AHS's thoughts around being a little bit flexible, because I think there are things that we already have consensus around, and there are things that we already know that we've had conversations about should this change in. And so we're already starting down that path in some ways. We have no issue. I don't think we need the chief prevention officer. I agree from Emily's perspective that the care board from from the care board's perspective, it's probably not a sort of neutral party. I know that we work daily with the chief prevention officer, so it's definitely something that is a part of our world as opposed to the Green Mountain Care Boards world. So it would definitely slant things, I think, in a less neutral and collaborative way. But we would be having those conversations anyway because we have those conversations generally from an administrative perspective with the Chief Prevention Officer. So yeah, I think we're perfectly comfortable. We were already having conversations about whether things needed to be rearranged, rejiggered, where there's conflict, how we can work better together. And as care board's talking to AHS, they're also talking about regularly, and we're regularly talking with AHS. So I think by default, we sort of have to be talking to each other because we have no choice. As you can see, we don't always agree. We are more than happy to have conversations about that how might change to make that easier. I don't think you're with split responsibilities, which I think are almost necessary. I don't think you could put everything that all three of these agencies do in one place. It would be this behemoth that would be impossible. So there's always going to have to be some collaboration. But we've tried things in different ways over the years since 1872 when we started doing this or whenever it was. So maybe it's time to rethink how we do it again.

[Speaker 0]: Any questions? Go ahead, Brian.

[Rep. Brian Cina (Member)]: Do you have any suggestions about who might be the best entity or organization or individual or group or community or other being to conduct universal primary care efforts in other states report?

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: I think I need the same time to go back and have a conversation and figure that out.

[Speaker 0]: Thanks. Not something we have considered at this point. I might strike that because in all honesty, I'm on Nasty's website right now and I'm on their state tracker and they pretty much have it all. This date, yeah. Done.

[Katie McLennan, Office of Legislative Counsel]: There you go, done.

[Rep. Brian Cina (Member)]: We just use the time then to pick stuff off their website and do it. No,

[Speaker 0]: I'm gonna get AI to summarize it all for me. I bet I could write

[Rep. Brian Cina (Member)]: a bill and a plan in a minute.

[Speaker 0]: Yes. Just on that subject of consensus, now, like there are areas we already have consensus in. Isn't it a simple matter even within the structure of some specificity thing? Any downside? Is

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: Other than time, no. And since we're all always strapped for time, having the conversation to make sure we're all in consensus and not make assumptions, it's just memorializing

[Speaker 0]: things.

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: You.

[Speaker 0]: Do you think we're going to have a conversation about it now? I'm thinking of I'm sorry? It's still morning. I know we didn't say that. Oh, it's still on the floor. Section five. To me it stands out from the rest of the bill as another initiative, let's say, something worth doing, it sounds like, from what I'm hearing from people. And I'm wondering, and I know Jen's not here, but just think about an intent section for that to set it up about why we're doing it and what we hope to gain from it and what our expectation and maybe start out with that language that Brian pointed out in the middle, is great. And how we want to accomplish. So if we could just make it a little more just for clarity about why we're doing that. The intention, yeah. That's what I'm thinking about, an intent section for that and how we imagine it being operationalized by the entities what the expectations are to them. Before we have Ledged Council utilize resources and time and effort on intent language for this, can I just get a general consensus from the committee on whether or not there is general support for Section five or not general support? Because if we're going to strike it, I'm not going to have Jen work on language. Anyone have strong feelings against including? Okay, so general consensus is we're neutral. We're neutral. Okay. So I'm taking neutrality as and it would feel better if there was intent language if I were Jewish. When I would when I would see that Okay. I would feel better about it. Okay.

[Rep. Brian Cina (Member)]: Is the language at the beginning of the bill not enough intent language?

[Speaker 0]: Oh, it's not to that section.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: Mean, I

[Speaker 0]: I did it's it's a different topic to me.

[Rep. Brian Cina (Member)]: Than than section five?

[Speaker 0]: Yeah.

[Rep. Brian Cina (Member)]: Which is the one where the different entities talk about how they coordinate better?

[Speaker 0]: Yeah, but they're coordinating in a universal way. My interpretation was it was about universal primary care. Misunderstood, I think, for a while, the intent of that.

[Rep. Brian Cina (Member)]: Well, you read I'm sorry.

[Speaker 0]: Oh, was going to say the intent language that says to gather information.

[Rep. Brian Cina (Member)]: Yeah, so we have this intent and purpose. It says that it's to invest in primary care and to establish a program. It also says it's to obtain the information, to develop a framework, including optimizing the blueprint for health. And so I feel like we say our intent there, and then when we ask them to look at these, it says in order to, when you read it, I mean, it cites Act 48, which was the universal healthcare law, and the foundation of all our principles currently, and then it adds on universal primary care, but then it continues on to mention other efforts that we've been working on over the last few years. So, feel like the intent in the beginning explains it there, but I wouldn't be opposed to having another sentence in that section to clarify it. But I do feel like the existing intent, it it kinda links to it already.

[Rep. Leslie Goldman (Member)]: So get rid of fives and add the extent?

[Rep. Brian Cina (Member)]: Mhmm. I wouldn't get rid of section five because we're hearing from the stakeholders that they think it'd be useful to clarify who's doing what in the middle of this. We're asking them to do, like, a 100 things right now. So at once. So I think it's good that they get together and, like, who's doing what? You know? Who's

[Speaker 0]: that person?

[Rep. Brian Cina (Member)]: Yeah. Who's doing what? And, like, also making sure, like, people aren't being redundant is important because that's a waste of government resources.

[Rep. Leslie Goldman (Member)]: Well, it may be redundant, some of

[Speaker 0]: the things that they're It's

[Rep. Leslie Goldman (Member)]: not true working together. Yeah. No one really

[Speaker 0]: seems to work. So Leslie, is the for you, is section five is if you look on, page one, number 19, line 19, Is that not a strong enough correlation for you between those two sections, between that intent language and section five? Since the purpose of this bill is to obtain the information necessary to develop a framework for implementation of universal primary care, do you not see five as I see universal primary in five, but it goes way beyond it. Improving access to high quality, affordable healthcare, accomplishing healthcare transformation, safe care hospitals, sustainability, insurance solvency, that's way beyond universal primary care being. So that's where I just saw it went beyond that. And I'm not saying this isn't good and shouldn't be done. I just see that section as sort of an outlier, I guess, from the rest of it. Well, let's work with Jen. Is it something you do to put in plant language in a section within a field, instead of all at the beginning? Because it does seem to broaden the scope in the middle of it, than in the beginning saying, we're doing primary and then maybe as part of that effort by It could be, just in order to accomplish our goals of reaching universal primary care, we need blah, blah, blah, blah, blah. And that to me would give it context.

[Rep. Brian Cina (Member)]: Is this committee discussion right Yes. Okay, then I would like to share a thought. Okay. I just wanted to make sure that I wasn't misunderstanding that it's feeling like it, and that there wasn't another witness waiting or something. The section eight situation.

[Speaker 0]: Section eight situation? Yeah. The situation shift. The one that I just did. Yeah.

[Rep. Brian Cina (Member)]: Then you said

[Speaker 0]: you wanna cut it out.

[Rep. Brian Cina (Member)]: I feel like we don't need, like, well, the intent of that is, I think, good, but I don't think we need it. But I also feel like if we don't do anything in that regard, we're gonna get a bunch of information. It may not be all the information we need, and I'm just concerned we're not going to move fast enough in the face of collapse or whatever you want to call it that's happening. I'm trying to think of a better word that's less catastrophic, but

[Speaker 0]: Can I tell you my thoughts of adding this when I added it? It's sort of like instead of us trying to reinvent the wheel, we should look at what maybe other states are doing so that we might be able to get ideas from them. I mean, for instance, when Doctor. Song came in here and he started talking about Massachusetts is working, you know, they've had legislation around the common good fund. And it's kind of the same question that you have for Nolan, which is what have we done in the past and what's been tried. This was really just an attempt to make sure that we're not just because we haven't thought about it, maybe other states have, and we want to be exposed to that so that we can be thinking of that. That was the only reason I had this in here.

[Rep. Brian Cina (Member)]: Yes, think there's there was good re there is good reason for that. And so what I'm instead of just taking it out and saying, oh, we have a list now. I'm wondering if it might be unrealistic, but I'm wondering if like, what I think would be useful would be to come back, whoever comes back, and have a little bit more information on the financing and the projections of cost and all that as soon as possible about different approaches. So for example, let's say one approach is expanding the blueprint, and another approach is I'm making these things up, so let's not get into like, oh, it can't be this or that. I'm just doing this for the sake of just getting it out there, expanding the blueprint, establishing a common fund, or using the taxation system. I'm throwing it out there, and then we get a report. If we go this way, here's the projected impact on healthcare spending and utilization. If we go this way, here's the because it would be nice to see, and so those things could be things other states have done or Vermont has tried in the past but didn't move forward on. But it would be good to see numbers and have a sense of the financial impact of different pathways towards universal primary care. And if we can't afford it right now, I would disagree with that statement, because I think if we tax people fairly, we could afford a lot more right now, but we won't go there. But if in the existing boundaries on spending, it hasn't been prioritized, I just wonder if appropriations could look at all the studies and all the reports and all the things every committee is asking them to do and find a way to carve out the money needed for the actuarially on that actuarial analysis or whatever would cost to get some numbers on that. Now I will I'm just to finish the thought, we could just do that next year, and then in the second year of a biennium, make the decision, but that is now delaying implementation of any kind of universal system at least three years. And I just don't think that's quick enough, because there's going to be people in the next year or two losing healthcare insurance in massive amounts. And we're not going to have a safety net in place besides things like the, okay, so here's another way, example, fully funding and expanding the free clinics. That was an idea that was brought to us. We could study what that would cost as a starting point. So that's another example, but I brought it up just because I think we're going to see massive amounts of people with nothing soon. So I don't know. My thought is, is there anything we can do now to get ahead of the curve and not because the intent of this, I think, was good, but if have that info, then it's like, okay, now what? What would we have done with it? Maybe we should pick a few things and study those specific things.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: Thank you. So to both recognize to represent Gia's point, one of the things that the SHOW study did was saying that they would use CAPS should come up with three ideas and then come up with how you can fund them. So you have to come up with what do you want a plan to look like? What do you want to do? It was like, do this, do this, and then come up with your third idea. So if you wanna do something like that, you need to put some time and thought into what it is you want to study. And then what, you know, so it's like, I think, and your clock is running out unfortunately, but like to come up with, okay, let's look at something, you need to step back and say, what is it you want to study? Like it was very specific in the shop and so they took a lot of time to test the ball again. So I think you'd have to really be thoughtful and you can look at the shop studying and some ideas on the approach and framework, but it's not that easy to just say, go do a study, like what is it he wants to study? So that's the only caution I have. That became the framework for then what McCulloughton said, okay, I'm gonna take parts of this plan. Yeah. That was the kind of

[Speaker 0]: And unfortunately, also wanna remind everybody, we have no funds for a Senate. Yeah,

[Rep. Brian Cina (Member)]: just to that point, the question would be like, how hard would it be if we had a few things that were not, they might be bigger than I realized when I said it, so I'll just be humble and say that to start. But studying how to use the blueprint and the free clinics as a starting point to providing access to care to everyone or the FQHCs. I don't know, I'm just wondering if there might be a way to look at the the things that already exist in Vermont and how to use the expand access to those existing measures. I'm just wondering if you

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: have To your point, that's exactly the kind of guidance you would want to provide in LIDS. It's rather than just go study something like, to your point, look at this, this, and this, how does that work? So I think you're on the right track.

[Rep. Brian Cina (Member)]: Yeah. I'm just thinking that you might be able to hear, like if we structured a day in the next week where we first hear Nolan present on the past, and then we maybe Nashpie or someone comes in and in half hour reviews what you just found on the web. And then we look over what we know we're doing, and maybe we're like, you know what, out of all this information, we can pick something small. It could be one thing that we have them study that we decide this makes the most sense. Or it might be looking at these three things combined, might we don't know, it's just a thought because the intent of Section eight, I don't want to lose that by cutting it out. Think there's something there. I don't think this was the best way to I think this was noble, like the attempt, but I don't think it went far enough. And so if we're gonna cut it out, I'd rather think about how to address the attempt of it versus just letting it go, if possible. And if we have to let

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: it go, we have to let it go.

[Speaker 0]: I I feel like I'm hearing from multiple people, just a reworking of b, little b on page one. Exactly where I was going, I was going

[Jill Olson, Medicaid & Health Systems Director, Agency of Human Services]: to say if I

[Speaker 0]: may obtain information necessary including what's going on in other states. Well, yeah, except the problem is we can't put that in the intent language if there's nowhere in the field that says look at other states. And I think we just heard that nobody wants to look at other states except for families. No, I don't know that anymore. No, think we do. I think you said we do, right? I think what we just heard from the various entities that we were asking to look at other states indicated that they do not have the resources or the time to do that. But I think Brian makes a point about having NASHV testify for half an hour or whatever, and then that gets on the record. For this bill? Well, if it's in, we sweep it in.

[Rep. Brian Cina (Member)]: I was suggesting it as a like In other words, Section eight had a certain intent, and what we're hearing is the resources aren't out there to do it, plus what I was also hearing is you can do this to yourself. So what we're essentially doing is doing it ourselves. We're having NASHV come in and do section eight for us in a half hour, and then we're like, now what? Is there something we want to put there instead? And we might be like, we can't, we have to just wait. If

[Speaker 0]: we want any movement on this bill, this bill needs to be out of this committee tomorrow at the latest. At the latest. So we can't take more testimony. We can work on beefing up this intent. That is something that we can do, and we can keep working on making some small edits, but I'm sorry, we're out of time, we're just out of time. Go ahead. Well, along with the same lines, I appreciate what you're saying, Brian, about Section eight as an intent. Like another one in testimony for the public hearing that Doctor. Governor Dean, said, we have documentaries, and why does it look like? We already have, know, fever, or psoriasis, I don't know, for certain categories. I mean, have some in house things we're finally doing, and then Doctor. Song isn't and running yet, but his theories doesn't necessarily mean The United States are already doing it, but there are approaches that are really being deeply thought about, and how do we get ahead of that thought process so that we have some discrete models to figure out finding

[Emily Brown, Executive Director, Green Mountain Care Board]: the shape of a drug.

[Speaker 0]: I mean, I'm just agreeing, and I don't know how to get at it in a twenty four hour period. But I think that's a really important part of what we're trying to do. Can I get just general thoughts on whether or not people are supportive of other changes in the bill except for section eight? We also have the option of simply just concurring with what the Senate we have that option. So, I mean, I wanna put all the options on the table that we can concur with the Senate and what came over, make no changes to it. We can work on going through the changes that are in this yellow, marked up version that I have put forward for the committee, and Or we can frankly not do anything. So I guess, what is the consensus of the committee? I'm asking for Jeeples thoughts, Lori. I think we should move this vote.

[Rep. Brian Cina (Member)]: Which one? The amended version?

[Speaker 0]: Rec 1.3. I think there's some really good work that this committee has done on this that would be lost if we just concurred with this.

[Emily Brown, Executive Director, Green Mountain Care Board]: And that does

[Speaker 0]: but it also leaves open the possibility that then nothing happens depending on what happens in the Senate. But that shouldn't concern us. Need to do what we think is best. And I think we should take out Section eight. I hate taking out Section eight. However, you can't get any more seats like it. You want to work on a summer project? I put this out there, this is my project, and I want to work with everybody on this. I really do. And I think it's important, I do. I was just doing some-

[Rep. Brian Cina (Member)]: So then why don't we create a legislative working group in this that works on it over the summer, so that it could be on the record instead of people privately meeting? If

[Speaker 0]: we put it in this bill, it will require an appropriation. There is nothing that says that a bunch of us can't do research throughout the summer. So we cannot create a working group. Cannot create a committee. Cannot create anything that has money attached to it. So I know it's sad. I would love it. I would love to be able to create a study of, you know, a million dollar appropriation or We talk. To come back and create the three options that we have, but unfortunately we don't have that. We do have ourselves. Do have ourselves. Oftentimes are oftentimes. And so this bill, some of big recommendations today from folks in the room about the separate entities, with that change, I mean, think we should do something with this. Okay, let's work with Jen. We will work with Jen to beef up bottom of page one. And we're hearing, we're gonna hear back from Emily on two things, right? Section three and what was the other thing?

[Emily Brown, Executive Director, Green Mountain Care Board]: The other one was Section

[Speaker 0]: eight, but it's up since we're out.

[Emily Brown, Executive Director, Green Mountain Care Board]: Section three and then, are they concerned we don't have

[Speaker 0]: any resources for Section six.

[Rep. Lori Houghton (Member)]: Let's I think take out section eight

[Speaker 0]: and someone put a short bill up on the wall there. That's too late. Short forms. There will be a resource of all sitting up there next time. I want to know if that resource is in section six, should we take that out to you? Or what do you think?

[Emily Brown, Executive Director, Green Mountain Care Board]: What should we do for that?

[Speaker 0]: Is there any work that the board is currently embarking on or working on that perhaps doesn't necessarily go into as detailed of a report that you did in 2017, which was a great report, by the way. Is there anything that would be able to help us coming back in January that could be accomplished without additional resources?

[Emily Brown, Executive Director, Green Mountain Care Board]: Looking at section six, Emily Brown, Greenland Care Board, looking at section six, not currently, we don't have any current reporting underway on clinician landscape or site neutral. Know there was some site neutral reporting at five eighty five, but I don't believe they were part of that. But I can go back and check with Zach and see if there's anything we're doing that correlates with this.

[Speaker 0]: Actually, may I ask you a question, Ledonia Council? In section six two, the site neutral, It does seem that that somehow became a little bit disjointed from the rest of the build. Do you know where that

[Mary Good Block, Deputy Commissioner of Insurance, Department of Financial Regulation]: came from? It the bill as introduced. Was

[Speaker 0]: Okay.

[Emily Brown, Executive Director, Green Mountain Care Board]: Yes. Sorry. Thank you. I'm

[Speaker 0]: I'm sorry. I'm I'm sorry. Guessing if

[Emily Brown, Executive Director, Green Mountain Care Board]: you add the revamp your board, we're likely to object. I need to go over it more closely, but I would suggest you're already asking them to

[Speaker 0]: do some more clarity. Or should we repeat that question for that rather than making a change in the right now without getting real time to get in. So the board is asking to go into section three? No, I'm just saying maybe just set that aside since it's not a request. I think that's why we need section five. Right, which we support. I hear you, but I'm curious to know your opinion on it. I know you were going to take it back. And you may say, yes, we really want to see the table, and then we could once again see how you guys work it out. But you may say, yeah, I agree. And I'm curious. Thank you. Okay, so let's work on those changes, and then of course working on the changes that you've included about flipping into here and there. What were you to stop? Sorry. Do you remember Doctor. Olson indicated that because we removed last section, put it into the blueprint report, we basically took what AHS was doing and we gave it to the blueprint. And it'll go in its own sort of back into its own area, included in the other report. So back to section six, fixing plates. I am recommending that you remove it. What I think. Six and eight. Right? Six and eight. There, Leslie, you were concerned about all the fourths. Oh, yeah.

[Rep. Leslie Goldman (Member)]: And we're 80 sixing six and eight.

[Speaker 0]: Yes. We need to Six, seven. This may also be not possible. Are any of can be combined? Very distinct, right? They just have no overlap I'm or sort of combining what was one into kind of another. I'm not sure what you're referring to. What I just explained. You changed that. So you're taking section three. Take that report, combining it with what? It's section two. Okay. So in section two, page go to the top, page six. See all that stuck out language in 07/10, primary care spending target? We had struck that out. We had taken the pieces of it, and they had put in those pieces into a blueprint report. Section three. Section three. But to Director Olson's point, what we did was we took something that HHS was doing and we gave it to the blueprint. So now we're going to take the seven ten secondtion. We're not restoring it, but we're taking the language out of the blueprint and we're putting it into section Which section?

[Emily Brown, Executive Director, Green Mountain Care Board]: Think you're exploring the old section five.

[Speaker 0]: Yes, there may be issue as well, if you There have some chance to is a section five in the original bill, not the section five, page nine. So on page nine, we're restoring that and incorporating that seven ten start language feature. And in our current pill, where is it? You're storing it to where? It's not in the current. It's the idea, so the idea of it is where. So we're going section five that says primary care spending targets report. Oh, yeah. So I'm looking at 1.3, and I'm just trying to orient myself. And you're looking at what? I'm looking at 1.3 is loud. Okay.

[Rep. Brian Cina (Member)]: It's on page nine, and It struck

[Speaker 0]: stuck out.

[Rep. Brian Cina (Member)]: It's right before the existing section five.

[Speaker 0]: How many reports are in this? Old section five is struck. How many does it take for us to ruin a lifeboat? Remove lights. I'm gonna work with lights and control with other people if they wish, and we will get this all straightened

[Rep. Brian Cina (Member)]: You see it now, though, struck out.

[Speaker 0]: Well, I see what struck out. I'm just trying to see much more sense when Jen has it. Thank you. Thank Thank you, everybody. Oh, any other discussion? No. Good.

[Nolan Langweil, Joint Fiscal Office (Health Care Analyst)]: I think we hit our threshold.

[Speaker 0]: Are done.