Vermont Legislature Senate Health and Welfare - 2026-01-08

Meetings

Appointment of Committee Clerk (00:00:22)
Senator John Morley was nominated and approved by voice vote to serve as clerk for Senate Health and Welfare.
Chair’s Overview of Meeting Plan and Upcoming Testimony (00:02:28)
The Chair outlined a two-part background series: Legislative Counsel on recent health reform laws and the Health Care Advocate on federal funding changes today, with AHS fiscal details tomorrow and next week.
Introductions (Staff and Members) (00:04:48)
Legislative Counsel Jennifer Carbee introduced herself and committee members John Morley and John Benson stated their districts.
Overview of Act 167 (2022/2023): All-Payer Model and Hospital Transformation (00:06:13)
Legislative Counsel reviewed Act 167’s directives on developing a successor all-payer model proposal, value-based payments, hospital transformation engagement, funding, and required reports.
Overview of Act 68 (2024): Reference-Based Pricing and System Reforms (00:21:17)
Legislative Counsel explained Act 68’s reference-based hospital pricing (beginning by FY2027), potential global budgets, hospital network oversight, contract transparency, statewide delivery strategic plan, data integration parameters, short-term cost targets, and related appropriations.
Public Testimony: Health Care Advocate on Affordability and Federal Changes (00:57:36)
Mike Fisher discussed impacts of lost federal premium tax credit enhancements, limited coverage for certain immigrants, small-group market instability, Medicare affordability gaps, and hospital financial assistance, urging careful monitoring and balanced reforms.

Transcript: Select text below to play or share a clip

[Sen. Virginia “Ginny” Lyons, Chair]: Access to the work that we do. We cannot sit in this room. Alright. We are now live. Good morning, everyone. It is Thursday, January 8, and it is Senate Health and Welfare. We've got a good meeting planned today and I'll talk about that in just a minute. But before we get started, think it's really important that we have a clerk in the committee to bring bills down to us and then to record votes and keep us online with getting our bills upstairs, helping folks get those upstairs. So I would entertain motion to or for guest senator Cummings. I would like to nominate our most experienced newbie, senator John Morley. Validizing the

[Jennifer Carbee, Office of Legislative Counsel]: Is there any

[Sen. Virginia “Ginny” Lyons, Chair]: so senator Morley, you've been nominated. Are you okay with that nomination? Absolutely. And are there any other nominations?

[Sen. Martine Larocque Gulick, Vice Chair]: Okay. Any discussion? We have any discussion? Any discussion? I just wanna my name is hard to pronounce, so I just wanted to tell you because you will have to do role. Martine Larocque Gulick. Gulick. Gulick. Yeah. I know. I know.

[Sen. Virginia “Ginny” Lyons, Chair]: I'm finally getting it. It

[Mike Fisher, Office of the Health Care Advocate]: would it's been yeah. It's been

[Sen. Martine Larocque Gulick, Vice Chair]: fun with with with mister Boomer upstairs. But thanks, I'll second the nomination. We're good then.

[Sen. Virginia “Ginny” Lyons, Chair]: And hearing no other nominations, then why don't we just do this by raising your hand and saying aye if you approve of the nomination and appointment of Senator Morley as clerk for Senate Health and Welfare? Aye.

[Jennifer Carbee, Office of Legislative Counsel]: Wonderful. You wanna vote for yourself? Sure. Okay.

[Sen. Virginia “Ginny” Lyons, Chair]: Those opposed, and we are fine. Thank you. Thank you for doing that. It is important to us, and it does require some attention when you get to doing our bills and your experience. And you can help our other new member, because he's filling his role, I think, in institutions. It's great.

[Mike Fisher, Office of the Health Care Advocate]: Thank you.

[Sen. Virginia “Ginny” Lyons, Chair]: Okay, so this morning, just to help us through, you were interested in looking at historically where we are with the laws that we've passed on healthcare reform. So we've asked Jen Carvey to come in, give us a quick overview of some of those laws. And then the other issue that we've been concerned about was the effect of federal changes, the big bill from July 1. And so we've had to split up the testimony on those two things. So today we're getting a start on each one, starting with Jen Carvey on the laws we passed and what's happening there. And then on federal funding, our healthcare advocate will be in today. Next week we'll pick this up again and tomorrow we're actually gonna pick up federal funding from the Agency of Human Services. They'll give us the nitty gritty of the dollars and the people, and then next week we'll have AHS in on the laws that we passed and the work that they're doing. So it was difficult to schedule this and Calista's had quite a fun time doing it, but we will have the full testimony first from Legis Council, then from HHS on the laws, and then today from Mike Fisher, our healthcare advocate on federal funding, and tomorrow, HHS on federal funding. So we'll try and get that background. I think it'll help all of us to do it. Helps us back on our feet. So, Jen. Alright. Is Mike in this meeting?

[Mike Fisher, Office of the Health Care Advocate]: Mike Marcon?

[Sen. Virginia “Ginny” Lyons, Chair]: Well, Mike. Yes.

[Mike Fisher, Office of the Health Care Advocate]: You can.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. My my came in and sat behind. I'm forgetting to remind everyone to make sure your cell phone is muted.

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

[Jennifer Carbee, Office of Legislative Counsel]: Good morning, Jen Harvey from the Office of Legislative Counsel, and I have not been in your committee yet this year, so welcome to the Oh my gosh, wait, before we

[Sen. Virginia “Ginny” Lyons, Chair]: start, I've met with you so much I forget. So, Jen, introduce yourself and then we're gonna have folks introduce themselves. Okay.

[Jennifer Carbee, Office of Legislative Counsel]: I'm Jen or Jennifer Carvey from the Office of Left Side of Council. I was here when you were representative Morley. So I've been here for a while, and I handle healthcare and human services issues. So you'll see Katie and I, I don't if they've met Katie yet. I haven't met. Katie and I will both be here later this morning talking You'll about some new see a lot of Katie and me because we cover most of the topics that are

[Sen. Virginia “Ginny” Lyons, Chair]: in this committee. So, and if you have a question about any of the bills, the specific language, Jen is the person to go to. You can start with me and others.

[Jennifer Carbee, Office of Legislative Counsel]: Right. Probably do most of the healthcare bills. Katie does most of the human services bills. So you'll see both of our names up there. But yes, we're happy to talk about any of the topics we work on or help you answer questions or understand things a lot.

[Mike Fisher, Office of the Health Care Advocate]: Thank

[Sen. Virginia “Ginny” Lyons, Chair]: you. And so, why don't you two introduce yourself?

[Sen. John Morley III, Member]: John Morley of Orleans District. Yeah, I'm John Benson. I have Orange District.

[Sen. Virginia “Ginny” Lyons, Chair]: Great. Well welcome to you both. Yeah, it's great. We're glad you're here. And you know the rest of us. It's really cool to hear. Okay, so Jen, Laura, Great, go right

[Jennifer Carbee, Office of Legislative Counsel]: okay. So my understanding of what we're starting with this morning is looking at a couple of bills from recent years that are working on healthcare reforms, specifically around what being called the transformation efforts. So looking at a couple of provisions from, or summary, a couple of provisions from Act one hundred hundred sixty seven of 2023, and then Act 60, or

[Sen. Virginia “Ginny” Lyons, Chair]: 2024. 2022, when was that?

[Jennifer Carbee, Office of Legislative Counsel]: Think it's 2022. Yeah, it wasn't here. Okay, 2022, and then Act 68 from last year. Let's see what else we have time for. Okay. Can you make me a cohost so I can share? I'm putting up, this is a document that I had put together for Health Reform Oversight Committee meeting. We've looked at it a couple of times there. And so this is just looking at a couple of specific provisions from Act 167 of 2022, and then there was a piece added to it in 2023 as though it were in the original act. So section one from Act 167 was looking at the development of a proposal for a subsequent all payer model agreement. This was to come after an agreement we had with the federal government trying to get participation from all or most payers in a particular way of aligning payment processes. So this language required the Director of Healthcare Reform and the Agency of Human Services to work with the Green Mountain Care Board and develop a proposal for whatever was going to be next after that all payer model agreement with the federal government and that's how we can get Medicare's participation in our multi payer alternative payment models. Yes.

[Sen. Virginia “Ginny” Lyons, Chair]: Can you give a short definition of all payer models, what all payer means? Or alignment, what it means to what we line payment?

[Jennifer Carbee, Office of Legislative Counsel]: Yes. I mean, all of the we have many different payers in healthcare space. We have, and some of them we have, some people over and some we don't. So Medicaid is a state federal kind of partnership. We have some authority there, but we need to get permission from the federal government to do a lot of stuff. Medicare is all federal. So unless the federal government specifically gives us permission to have Medicare do something a certain way, we have no authority as a state to require Medicare to pay for services, pay in a certain way, pay certain amounts. Then we have the private insurers. So for commercially insured plans, yes, and if you have Nolan's pie chart we have today, whenever he talks to you, that's great. So when the private insurers or commercially, commercial fully insured plans, the state has significant amount of authority to tell them how to go about doing things, what to cover, how to pay, what to pay. There's also self funded or self insured plans, and if they are not government plans, then we are preempted under federal law. So we're not allowed to tell them what to do unless, again, the federal government were to tell them do something in a certain way, which is somehow under the Affordable Care Act, we got a little bit more alignment with what's covered because the federal government pulled the self funded plans, some things that had to do. But otherwise, can only ask them that they don't have to agree to participate. So when we're talking about all payer model and all payer payment reforms, we're really talking about Medicaid, private insurance, and Medicare to the extent that our government gets willing to approve and won't send anybody. Beyond that, it's largely voluntary. There are certain ways we've structured things going forward that may allow for some greater uniformity because we're controlling the provider side, not

[Sen. Virginia “Ginny” Lyons, Chair]: the payer side. Is that helpful? Questions?

[Sen. John Morley III, Member]: We got a lot of this yesterday.

[Sen. Virginia “Ginny” Lyons, Chair]: Okay, good. Okay, this is great. Great,

[Jennifer Carbee, Office of Legislative Counsel]: yes. Great, one back.

[Sen. Virginia “Ginny” Lyons, Chair]: Great 101. Reinforcement is great.

[Jennifer Carbee, Office of Legislative Counsel]: Great, and when it all makes sense based on what you've already heard, that's helpful. Helpful.

[Sen. John Morley III, Member]: That's

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

[Jennifer Carbee, Office of Legislative Counsel]: Yes. And more like if you've got the basis and you've got the base level and then the next pieces make sense, that's a signed progress. Alright. So this act required that the state develop a proposal for a new way. The all payer model was a particular agreement with the federal government that was time limited. So kind of what's next in our multi payer alternative payment models. And particularly around how to get Medicare participation. And there were certain things that the development of the proposal had to include, at least in good consideration of, and that was looking at alternative payment and delivery system approaches. So not just how do we pay, but how is the care delivered and where, for hospital services and community based providers. So that was the part of that act that directed the agency of human services to do things. Then it also directed the Green Mountain Care Board in collaboration with the agency of human services, and now Green Mountain Care Board is leading, to develop value based payments, including global payments from all payers, again, payers to the extent we can, to Vermont hospitals or accountable care organizations or both. Determine how best to incorporate value based payments, so payments based on the value of the care the care setting into the board's regulatory processes. Yes. So when

[Sen. Virginia “Ginny” Lyons, Chair]: we say value based care, we're talking about looking at the outcomes for the care. Often, yes. Yes. Okay. Sometimes it has to do, I think,

[Jennifer Carbee, Office of Legislative Counsel]: with the right care at the right place at the I right

[Sen. John Morley III, Member]: know what ACO is, the acronym, but what is an accountable care organization, genetics?

[Jennifer Carbee, Office of Legislative Counsel]: So Accountable Care Organization, One Care was one, if you've heard of them, they had One Care Vermont where they wrapped up operations at the end of last year. It's an organization that contracts with providers to provide them a set amount of money to care for the population that they are caring for. And there are arrangements between the two of them about attribution, which patients are attributed to the academic care organization, which providers are participating in the academic care organization. But it's coordinating the care at a larger level than individual clients. Remote Care Board regulates them. We are down to many fewer in the state than we had and largely only in the Medicare space, but there have been, there's arrangements with, at least with one care, with Medicaid and commercial insurance to participate. A lot of it is around trying to get our arms around or get some control over what costs are and what care is appropriate. All right, so the Green Mountain Care Board was supposed to develop value based payments, determine how to incorporate those into the board's regulatory processes, recommend a methodology for determining the allowable rate of growth in hospital budgets, Vermont Care Board regulates hospital budgets, and consider the appropriate role of global budgets for Vermont hospitals. We will get a little more into global budgets in Act 68. Talked about this in healthcare the other day, part of the issue with global budgets or global budgets is the very initial step is defining what people mean by global hospital budgets because people mean different things when they use that. Alright, section two was hospital system transformation. This is a lot of what we are continuing to talk about today. Section two of Act 167 directed the board in collaboration with the Agency of Human Services to develop and conduct a data informed, patient focused, community inclusive engagement process for Vermont hospitals. So kind of convene everybody and talk event and engage them in talking about Vermont hospitals and how we can reduce inefficiencies, lower costs, improve outcomes, population health outcomes, reduce health inequities, and increase access to essential services. And some of the outcome of this, if you remember hearing about the Oliver Wyman report, there was a lot of attention on that a year or two years ago. And some of the recommendations from there, I think, are starting to trickle through into some legislation.

[Sen. John Benson, Member]: Just a clarification, is there regular meetings that occur between the different hospitals that meet on a regular basis to continue this effort, or how is that working?

[Jennifer Carbee, Office of Legislative Counsel]: A lot of this is being, and you'll see some of this in some of the other legislation we'll look at, a lot of this has kind of transitioned to the agency of human services leading the transformation work with hospitals. So yes, they are facilitating meetings, not necessarily all of the hospitals together all of the time, but in part because some of their needs, the hospital's needs are different and their community's needs are different. But yes, there's ongoing work and engagement with the hospitals and also some work with the hospitals meeting together to discuss issues.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah, and that's what we were talking about yesterday where the hospitals have really taken some lead, strong leadership in evaluating what their needs are regionally and working with AHS to make change in

[Mike Fisher, Office of the Health Care Advocate]: doing a lot of good work.

[Jennifer Carbee, Office of Legislative Counsel]: Okay, section 2A, which was actually, if you look up here, added by a 2023 act. A little unusual, in this case, we opened up an old act and put in a section. And this section directed the agency of human services to start doing the transformation planning, engage in transformation planning with up to four hospitals to be informed by that data analysis and community engagement effort that the board was doing in collaboration with the agencies, and provide a progress update to legislative committees in February 2024. In this act and this 2022 act, there was $5,000,000 appropriated for this work. Dollars 900,000 to the Agency of Human Services in fiscal year 2023 for that work on the subsequent all payer model and hospital transformation efforts, hiring consultants and

[Mike Fisher, Office of the Health Care Advocate]: a

[Jennifer Carbee, Office of Legislative Counsel]: little over $4,000,000 to the Green Mountain Care Board for its role in those two processes as well. There were a number of deliverables that were required and that were provided. The act required the agency of human services to report on its all payer model subsequent proposal activities, and the Green Mountain Care Board on its efforts, including around hospital community engagement by 01/15/2023. And so I've linked to the agency's 2023 presentation and a 2024 update. A couple of reports from the Greenback Care Board in 2023, 2024, and a couple of presentations from them. There was also a requirement for the Agency of Human Services to provide an update on its stakeholder engagement in March 2023, which it did, and the Green Mountain Care Board announced that Oliver Wyman report produced a community engagement report, I'll link to that. So that's the Act 167 that you hear people talk about a fair amount. There's a lot more in Act 167 on other topics, but these are the specific pieces in this area. And then

[Sen. Virginia “Ginny” Lyons, Chair]: I was gonna jump over to Act 68. Just wanna take a breath and see if there are questions or clarification. And we have that summary sheet on our webpage. I believe so. Yeah. So She's checking. Go You back and look and there are Thanks. The links are live, I think. So I hope so. Yeah. Calista, they're out. Yes. They're out. She's got them. Yes. So if you have questions about it now or later, we can come back and if you wanna come back to this and drag Jen in again and talk about it.

[Jennifer Carbee, Office of Legislative Counsel]: You'll see me a lot anyway. I know. And speak about John's. It's good. Or you can meet her separately. That's true. Alright. So you do, do you wanna do Act 68? And I've just, I brought my whole presentation that I've put upstairs. That would be great. Would be great. But I don't know, so I was just gonna use the ACT 68 slides from there, but I can do whatever you want on ACTs from last year. Do you wanna stick with ACT 68 for the moment since we're kind

[Sen. Virginia “Ginny” Lyons, Chair]: of on this- Let's start with that and then we can move into the solvency or the other thesis that you I don't

[Jennifer Carbee, Office of Legislative Counsel]: know which ones you have. We have which acts do you have? There's so many. Okay. Not the you know, many of the ones there.

[Sen. Virginia “Ginny” Lyons, Chair]: Okay. Well, let's start with that one. Alright,

[Jennifer Carbee, Office of Legislative Counsel]: so we have Unit 68, which was healthcare payment and delivery system reform. It was S-one hundred twenty six, which is when we were here in the building. I think people are still learning the new ACT number, but that's what ACT 68 is. Oops, I'm not gonna get started. So the first big thing that it did, I think you'll be hearing a lot more about this topic this year, was to require the Green Mountain Care Board to establish reference based prices that represent the maximum amounts that Vermont hospitals can accept as payment in full for items or services delivered in Vermont. So let's break this down a little bit. A reference based price is a price that is literally linked to a particular reference. In this case, the reference would be Medicare, the Medicare rate for that item or service, or another benchmark as appropriate. Some are not included in Medicare, some may not be a rate that makes sense for Vermont. But the idea here would be to be a percentage of Medicare rate, so it might be 125% of the Medicare rate, it might be 300% of the Medicare rate, it might be less than 100%, although probably not in many circumstances. But the idea here is just to have some kind of agreed upon reference that we can use for the Green Dot Care Board to set rates, to set prices that will be what the hospitals will get paid for items and services. So they might not be the same for all Vermont hospitals, depending on their financial needs, their payer mix, etcetera. But that is the concept to start getting cost containment by setting prices. When

[Sen. John Morley III, Member]: I get a bill from a device, let's say, both at the hospital, And then, the bill comes through. It's usually, like, we'll just type it out. It'd say $3,000, but the bill is actually a thousand dollars. Right. I don't understand for the life of me. I don't wanna because Blue Cross Blue Shield says, we'll pay this. Right. That's payment in full, although the bill was $3,000.

[Jennifer Carbee, Office of Legislative Counsel]: Right. So the way and and there were probably other people who were better at explaining this than I am, but the way in general hospital prices work now is the hospitals have, I believe, this call it a charge master, which is like a comprehensive list of all of their prices, but their prices aren't necessarily the price that any individual person or insurer pays. It's kind of the basis for the negotiated price. They might set Why does

[Sen. John Morley III, Member]: they even have it on there that it's a negotiated price?

[Sen. Virginia “Ginny” Lyons, Chair]: That's a good question for the hospitals. Yes. And for the regulatory body. Good. Just That's why we have reference based pricing.

[Jennifer Carbee, Office of Legislative Counsel]: Right. I mean, really is, I think, a lot of the basis for having reference based pricing so that you're not looking at, so that there is some general understanding. You can compare kind of the apples to apples of what each hospital charges for a service, whether, you know, the and that's what they'd be getting paid, essentially. And some transparency around what the pricing is and whether it's appropriate for each individual item or service. Typing of them. Yes. And yes, there are others who can tell you more about the whys of how hospital prices came to

[Sen. John Morley III, Member]: be I'm sure I'll hear that.

[Jennifer Carbee, Office of Legislative Counsel]: But, yes, but they are generally not what they're just a starting point. And it might be, you know, an insurer might do a percentage of that price, which is generally less than 100. Here we're talking about potentially doing more than 100% for medical.

[Sen. John Benson, Member]: Just a clarification on John's comment, and it says the reference base will be in place by 2027. My assumption, correct that that should end what he was talking about? Because now there is an actual base of reference which

[Jennifer Carbee, Office of Legislative Counsel]: So reference based pricing, the words here are intentional, will start as soon as practicable, but not later than hospital fiscal year 2027. It doesn't mean they will all be set and in place by that point, but at least they will be starting. So they may not be in place for all services at all hospitals. Hospital fiscal year 2027 starts in October. So the Green Bank Harbor will be coming in, I think, next week or so to tell you how it's going with getting this set up. They did hire a couple of folks to focus directly on this issue, but it's fairly novel, I think, particularly to do on a statewide basis. So there is some limited reference based pricing happening in public employee programs in some other states, but this is significantly broader and with the potential for a lot more variability among the hospitals as opposed to some of those other states where they said 185% Medicare is what will be paid for all services at all hospitals. Vermont is taken before anyone's approach than that. So yes, I mean, theoretically

[Sen. John Benson, Member]: Should end.

[Jennifer Carbee, Office of Legislative Counsel]: Yes. Could end all of that. End that very well.

[Mike Fisher, Office of the Health Care Advocate]: Thank you.

[Jennifer Carbee, Office of Legislative Counsel]: Yep. So the Green Mountain Care Board is the one who will be setting these reference based prices. They will then review the reference based prices for each hospital annually as part of the budget review process. So check-in and make sure that the prices that they have set continue to make sense and make adjustments as appropriate. Balance billing is not permitted with this. So if this is set up as the maximum amounts that hospitals can accept as payment in full. So that's it, that's the maximum amount. They can't take the $1,000 from the insurer and then bill you for another 2,000. That would be balance billing, billing the patient or the insurer for something in excess of the reference based price. The reference based price is the top, the cap. And the act directs the Green Mountain Care Board with the Department of Financial Regulation to monitor implementation. The goal here being that decreased payments to hospitals should result in some decreases in health insurance premiums. It's not gonna be one to one, but there should be some downward motion, there's specific directive for them to look at how that is playing out. The Green Care Board also regulates health insurance premiums for the major management plans, so the individual small group and large group plans. The act also allows, the Green Mountain Care Board allows, but does not require, the Green Mountain Care Board in consultation with the agency of human services and providers and others to set reference based prices for services delivered outside a hospital, like primary care services. Some of the conversation around this last year was about potentially setting higher reimbursement rates for primary care services in an effort to shift some of the care that should be done in the primary care setting out of hospitals and into the communities. And it did specify that the, and as we've been discussing, the board's reference based pricing authority does not apply to Medicare because we can't set prices for Medicare and would not apply to Medicaid either because there's a separate process that the Department of Immaculate Health Access is already doing around setting. They set all the prices as it is.

[Sen. John Benson, Member]: We heard yesterday, one of the discussions about EMS services being able to provide additional care without a transport, which right now they would not actually get reimbursed for those services if they don't transport. So I'm just curious if that is allowed, how does that fit in here, and is the board looking at that, or could that be sort of whatever that EMS service sides to Josh?

[Jennifer Carbee, Office of Legislative Counsel]: So I think that's potential in the future that it could become part of this. I think there's a few pieces on the treatment without transport. I think the particular issue around that has been with Medicaid and there was some directive last year, two years ago, getting all confused, to require some Medicaid reimbursement for treatment without transport. I'm not sure what the private insurers do. I think there were already some requirements in statute for insurance to pay services of emergency medical services. But it's possible, you know, in setting rates going forward, it's possible that that could be part of rate setting, but I don't because they're not generally, they're not hospitals. They're community or privately owned entities providing services. They're not

[Sen. Virginia “Ginny” Lyons, Chair]: part of this first pull out. All

[Jennifer Carbee, Office of Legislative Counsel]: right. So that was reference based pricing. As I said, I think you're gonna hear a lot about that. It's a big initiative the state is embarking on. The act also required the Green, sort of required, required the Green Mountain Care Board to establish global hospital budgets if resources to do so are available. So you'll have to hear from the board about whether they have been able to start a comment. Because no there additional funding added to the bill. No. But that keeps sending, it would need staff to be. When did

[Sen. Virginia “Ginny” Lyons, Chair]: we first start the request for global budgeting? This isn't the first time that staff

[Jennifer Carbee, Office of Legislative Counsel]: Talking about, I mean there's references to global budgets and global payments in the Green Act Care Board rate setting statutes from 20 A long time ago.

[Sen. Virginia “Ginny” Lyons, Chair]: But they've had the authority. Have never

[Jennifer Carbee, Office of Legislative Counsel]: been required. Never done it, I they've never been required to do think they would be thinking, they will tell you they

[Sen. Virginia “Ginny” Lyons, Chair]: would need resources. Yeah, so there's a lot of discussion here about what works in terms of net patient revenue or total cost of care and all of those things that sort of fall into place when you start talking about budgeting for hospitals. Well it's more complicated than that.

[Jennifer Carbee, Office of Legislative Counsel]: So it requires the board to establish budgets if resources are available for one or more non critical access hospitals. So that's certain federal hospital designations by hospital fiscal year 2027, so again, that's the one that starts this coming October, and for all hospitals by hospital fiscal year 2030. So you'll want to

[Sen. Virginia “Ginny” Lyons, Chair]: hear from the board about where they are

[Jennifer Carbee, Office of Legislative Counsel]: with any development in that area. The Act requires a hospital that proposes to reduce or eliminate any services to comply with its hospital budget order to provide notice of intent to the Green Mountain Care Board, the Agency of Human Services, the Office of the Healthcare Advocate, that's the beneficiary's group, and legislators representing the hospital service area at least forty five days in advance. And it allows the board to modify hospital's budget or take other action as needed to preserve access to necessary services. Here's some more on this here. The act gives the Green Mountain Care Board the authority to oversee hospital networks that derive 50% or more of operating revenue from Vermont hospitals. They have not had authority specific authority over hospital networks. This is like the UVM Health Network, which I think is the largest UVM Health. But a grouping of hospitals with a board overseeing it. And they can recommend, the board can recommend actions.

[Sen. John Benson, Member]: I ask one to clarify our front list. There are some networks that deal with hospitals outside of the state. Right. What authority?

[Jennifer Carbee, Office of Legislative Counsel]: We have no authority over something that is based out of state. We have authority over Vermont hospitals. We have authority over Vermont hospitals' participation in activities with other you know, with entities in other states, but we cannot tell, for example, Dartmouth Hitchcock Right. What they can do.

[Sen. John Morley III, Member]: And a stupid question on, like, our hospitals. Hospitals are are all hospitals basically nonprofits?

[Jennifer Carbee, Office of Legislative Counsel]: All Vermont hospitals are nonprofit, but that is not a guaranteed profit. All Vermont hospitals are nonprofit.

[Sen. John Morley III, Member]: Okay. Okay. And it seems like, it seems like we're trying to stem costs with more oversight to them, for them, I guess I should say. At which county, so that's good, so I'm kind of getting it. Right to me. Okay.

[Jennifer Carbee, Office of Legislative Counsel]: All right, so the board, in addition to overseeing any hospital network that derives at least 50% of its operating revenue from Vermont hospitals, the board can recommend actions necessary to correct aspects of the network itself or its financial operations that are inconsistent with principles for health care reform. These are sometimes referred to as the Act 48 principles from Act 48 of 2011. They're codified in statute. Or the statewide health care delivery strategic plan, which is something you'll see coming up that this act directed to be established. So once that is in place, that will be guiding a lot of the healthcare delivery for a lot. Separately, there's a lot of bullets that sort of don't connect because this is just in the order that the bill itself was. The act requires payers and providers to provide an unredacted copy of an executed or proposed healthcare contract, so a proposed or executed contract between a payer and a provider to the Department of Financial Regulation or the Green Mountain Care Board upon request. And I'll defer to Madam Chair, it's our interest for a long time.

[Sen. Virginia “Ginny” Lyons, Chair]: This is important. So you're talking about more regulation as a way to get forward, but really what it's doing, what we're trying to do here is to increase transparency, increase transparency of pricing, negotiations, because health care is so personal for folks and we need to know what the costs are. One of the things that I had discovered a few sessions ago was that our insurers Blue Cross and Blue Shield is so critically important to the state. We're not trying to diminish the benefit of our insurance companies in any way, but as I said before, to increase transparency. What we understand is that the insurers are negotiating with providers, whether it's a hospital or a clinic or an individual provider, about reimbursement and other conditions within the insurance contract. So apparently you could have a non disclosure agreement within these things. You could have a very high reimbursement rate for some and an extremely low for others, and it's a way that insurance companies were using to balance the bottom line. And the effect was that some of the providers who are down here, their bottom line was going further and further away. So having some transparency at the level of regulation, which is the Department of Financial Regulation, and then the Green Mountain Care Board for evaluating rates makes a whole lot of sense to me. And I was somewhat surprised actually that DFR didn't have a full hadn't had a full look at the contracts nor the Green Mountain Care Board. And and DFR has responded really beautifully with some guidelines and criteria for contracting and making sure that they're done equitably. And the board is now able to look at the contracts and make sure that what the insurance companies are doing is in sync with what works for the whole system. So that's my interpretation of it all and I think it has proven to be fairly accurate. It was a great concern to me. If you want to talk further about it, why don't you talk to that person? So, that one little line the bill, big story. It's been an ongoing concern both here and in finance, regulates health insurance that more and more primary care, but more and more services are becoming part of the hospital. Independent primary care docs See, according to them, are paying significantly less than doctors that are affiliated with There's the really one hospital that's been buying up a large number of independent practices. And that ability to survive financially it has been very difficult for them and part of there was a global payment right to some groups, the primary care, I think, under the ACO that we had to they were getting like a flat paper. Yeah, there

[Jennifer Carbee, Office of Legislative Counsel]: were some comprehensive, yes, comprehensive payment reform. That we had

[Sen. Virginia “Ginny” Lyons, Chair]: to do, we had to take care of last year when they

[Jennifer Carbee, Office of Legislative Counsel]: State Building for a period of time, and yes, and one of the reports that you'll see, call for in here and coming up on the website, there was looking at whether there's some capabilities from the ACO that the student should take on, which may fix some of that methodology based upon itself. Some of the hospitals control or own or run some of the primary care.

[Sen. John Morley III, Member]: Yes. I was thinking so.

[Sen. Virginia “Ginny” Lyons, Chair]: I can't think of one independent primary care doc in this. I can. May be We have we have independents, but they are far and few between. And try to think in your area. I think they're they are, but they're not. It may just be I'm being Shane with Randall affiliated with Gifford, but some of them are I don't know if you have any independence.

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

[Sen. Martine Larocque Gulick, Vice Chair]: know. Interesting. That would

[Sen. Virginia “Ginny” Lyons, Chair]: That would be a homework. Know?

[Jennifer Carbee, Office of Legislative Counsel]: Yes, and they may reach out to you. And you may be able to ask health first as well.

[Sen. Virginia “Ginny” Lyons, Chair]: Right. We're gonna have some

[Jennifer Carbee, Office of Legislative Counsel]: of the risk in

[Sen. Virginia “Ginny” Lyons, Chair]: the end. We're gonna have when we start talking more in-depth about primary care, we'll have all these folks in who can answer all our questions. The survival of independent. Yeah. Sure. I mean, you name it. Yeah. Physical therapy. Yeah. Yes. Exactly. Seems to be significant difference in what they're paid and in what's charged. But prices get a whole lot higher when you start to work for the hospital. Right.

[Jennifer Carbee, Office of Legislative Counsel]: And there's also facility fees. Yes.

[Sen. John Morley III, Member]: So they have more bargaining power. The hospitals must have more bargaining power with Blue Cross Blue Shield or whoever the insurance provider is.

[Sen. Virginia “Ginny” Lyons, Chair]: Around here. Well, they're a teaching hospital. So every time I set forth in a UVMC, and that's also my son from my local hospital, when they first started, there was a note on the desk along with the doctor's charge, which sometimes also goes up, I get paid a 2 I get charged and my insurance company does a $200 facility fee. And if I go in and do blood work and have an x-ray, you know, walk across the hall, I pay a $200 facility fee both times. You're getting into some of the that's and the payment fees gets I see. Really, we have an independent practice in Richmond. It's been in here. Right. In Richmond, we have one in Williston. Yeah. Yep. This is Jules Ravies, and they and they live there. Jules is laughing there. Independent service. He was on the picket line on his one hundredth birthday at the party's office. Alright. So we'll get independent care. We know we need to get that data because it's part of the whole regionalization work that we've heard about from my AHS. Moves here. It tends to put more of the geographical guys. Hello. Can you go back up? Yes, please. Alright. Stop.

[Jennifer Carbee, Office of Legislative Counsel]: And let me start right there. Okay, so here is the part I mentioned around a statewide healthcare delivery strategic plan. Act 68 directs the agency of human services in collaboration with a number of stakeholders to lead the development of that plan. It is due to you by 01/15/2028, and then it will be updated every three years after that, with the first updated plan due slightly before it's been three years, so that you're in a cycle of getting it before the session starts. So they're coming in by 12/01/2030, as opposed to waiting until early one hundred thirty one. There were a number of committees created. The AMP created the 18 member Health Care Delivery Advisory Committee. You'll be hearing, I think, from the Agency of Human Services a bit in there when they come in and do some of their reporting on the activities of that committee. Also this new 16 member Vermont Steering Committee for Comprehensive Primary Health Care, just on primary care. The act directed the agency of human services to collaborate with the existing Health Information Exchange Steering Committee to continue developing the unified health data space and specifies some elements of the development process, including determining whether it makes sense to integrate clinical and claims data, and if so, how to do so in a way that protects proprietary information. Some of the nuances of this were worked out in the conference committee. Vote on. They worked. So integration of integration of clinical claims data, if it is to occur, cannot happen before January 1, and then only if a majority of the Health Information Exchange Steering Committee is appropriate. And there's a retour to do by next week on integration of clinical and claims data, including recommendations about weather and how, and then annual updates on the development and implementation of the Unified Health Data Space would be due starting next January. So,

[Sen. Virginia “Ginny” Lyons, Chair]: what's the difference between clinical and claims data?

[Jennifer Carbee, Office of Legislative Counsel]: Claims data has to do with what's what's billed and what's paid.

[Sen. Virginia “Ginny” Lyons, Chair]: And so how's that determined? Is through, is there insurance involved in that? Yes. Yes, I mean you're billing from the provider, there's payment from the payer. And so any prior authorization that would say no, and you have to pay for it yourself?

[Jennifer Carbee, Office of Legislative Counsel]: I don't know that the claims is just about services that were actually delivered. If there was prior authorization required, so if somebody self pays, don't the claim because the claims data that we have is through the All Pair claims database, which again is now, some payer There's claims a US Supreme Court case that says we can't require the self insurance to report. So if there's claims, it's all from the

[Sen. Virginia “Ginny” Lyons, Chair]: From voluntary or Yes, from the

[Jennifer Carbee, Office of Legislative Counsel]: self insurance, it's all voluntary, but otherwise if somebody self pays, they do not report to the All Care claims database. And on clinical. Clinical data has to do more with the, I think what the patient is presenting with, what the issues are, what treatment's ordered, what the treatment plan looks like.

[Sen. Virginia “Ginny” Lyons, Chair]: Trying to understand what actually transpired as a result of the assessment.

[Jennifer Carbee, Office of Legislative Counsel]: Separate provision down at the bottom, often writes with the Green Mountain Care Board and has existing subpoena authority and this language authorizes the board to share any of the materials it receives pursuant to a subpoena with the agency of human services or department of financial regulation as appropriate to those entities who work. It allows them to collaborate with others, even if material was received through SPIA. There are certain sections in the bill looking at kind of short term pressures and directing the agency of human services to facilitate healthcare providers response to the urgent financial pressures facing the system and identify opportunities to increase efficiency, improve quality, reduce prescription drug spending, and increase access to essential services, while reducing hospital spending by not less than 2.5% for hospital fiscal year 2026. That's the year we're in right now. And there was a report due from the Agency of Human Services on the proposed reductions it had approved as of July 1 due on that date. They have submitted that report and Katie and I are gonna come in in an hour and go over lots of reports, you'll see these are monthly updates. Check out many of the pages of the list of reports we're gonna go over with you. Monthly reports due during hospital fiscal year 2026, so from October 2025 through the September 2026. I've put the link here to the Agency of Human Services website, but they're also on the legislative website. The act also directed the Agency of Human Services to identify specific outcome measures for meeting health care system transformation goals. So I'm gonna pause there for a moment. We looked at Act 167. We talked about, some more about transformation work here. There was interest in having AHS identify how they would know if they had met what the goals should be and what the outcome measures should be for determining whether those goals have been met. So there were some goals listed in the legislation itself, but whether and how those have been met is hard to tell if you haven't identified outcome measures to look at. And so that information was required to be reported to monthly from both the goals itself and how we're doing and meeting them from August 2025 through the end of this calendar year, those are on the agency's Some of those are on the agency's website, again, notes or links to those that have come in that we will look at at eleven. And the act appropriated $2,000,000 to the agency for incentive grants to hospitals to encourage them to do some of that short term transformational work. The report due by December 1 on how much had been obligated and dispersed as of November 15, that report has come in as well. Separately, there was a plan, a requirement for the Department of Financial Regulation to provide a plan for preserving the sustainability of domestic health insurers in Vermont. That's really statutes speak for Blue Cross Blue Shield of Vermont. If you were following the news last year, may have heard about some issues with their solvency and some concerns about their continued presence. There's been significant work to right that shift, but also the department provided a plan for helping to preserve their sustainability going forward. That report came in in November, and there was a report due and submitted from the Agency of Human Services on this is what I was alluding to. Opportunities to retain useful capabilities developed by or on behalf of an ACO and funded with public dollars. This is looking at some of the capabilities that particularly One Care per Month had around payments to providers that may be worth trying to continue even after March 30 has wrapped up his work, is at the

[Mike Fisher, Office of the Health Care Advocate]: 2025.

[Jennifer Carbee, Office of Legislative Counsel]: Finally, I think this is the last slide on this, so I guess our time in will be good. The Act required the Board, or requires the Board to report on its implementation of this Act by the middle of next month. So you will be, and you'll probably be hearing even before the report, some of those activities. It also requires the Green Mountain Care Board annual report. There's an existing annual report requiring a lot of stuff in it. And starting with the 2027 report, they must include updates on their reference based pricing and global hospital budget work. The Act also has a new annual reporting requirement for the Agency of Human Services relating to the status of its development and implementation of the Statewide Healthcare Delivery Strategic Plan and the activities of that new Healthcare Delivery Advisory Committee. The act created three new positions at the Green Mountain Care Board, two focused on reference based pricing and one for operations, procurement and contracting. It also appropriated $2,200,000 to the Agency of Human Services for their transformation work and for the creation of the strategic plan and work on developing alternative payment models. And it appropriated $1,212,500 to the board for those new physicians, its contracts and some language that was in the act that we didn't specifically talk about requiring standardization of electronic hospital budget data submissions so that the board is more easily able to compare hospitals using the same terminology and same categories, so that we're more able to make comparisons of expenditures across the board. Nolan provided fiscal notes or prepared fiscal notes for several acts from last year, including Act 68.

[Sen. Virginia “Ginny” Lyons, Chair]: So if you want to book that, use fiscal note on Act 68, that's good. That's the money. Just a note about the notes, fiscal notes. When no one comes in and we have a bill, you know, we'll start working on whatever it is. Prescription drug bill, primary care bill, a hospital something bill. We'll start talking about it and then we'll ask the question, golly, how much is this going to cost? We want to know that. Nolan, can you do a fiscal note? And he'll say, no. I'll do a fiscal note after you've finished completing your health doctor. So we're probably gonna

[Sen. Martine Larocque Gulick, Vice Chair]: be a rock in

[Sen. Virginia “Ginny” Lyons, Chair]: a hard place. But just a heads up on that. And I'm guilty of asking that question as much as he can.

[Sen. John Morley III, Member]: To quite

[Sen. John Benson, Member]: yeah. I understand what the implications are.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. Sure. So but so it's a it's a fine

[Sen. Martine Larocque Gulick, Vice Chair]: line to walk and try

[Sen. Virginia “Ginny” Lyons, Chair]: to sort it out. I have a Questions for Jen.

[Sen. Martine Larocque Gulick, Vice Chair]: Go ahead. Did you mention the hospital ombudsman or watchdog or everyone

[Jennifer Carbee, Office of Legislative Counsel]: Different act.

[Sen. Martine Larocque Gulick, Vice Chair]: That was a different act.

[Jennifer Carbee, Office of Legislative Counsel]: Yep. Also in here. Confused. Yes. Happy to Maybe I should wait a couple minutes if you want me to get those other things.

[Sen. Virginia “Ginny” Lyons, Chair]: As long as you're probably one of the biggest things we should do.

[Jennifer Carbee, Office of Legislative Counsel]: I would say that and the mapping of the outpatient administered drugs is a big piece of-

[Sen. Martine Larocque Gulick, Vice Chair]: But I was also wondering, because I think Senator Morley had a really good question about the fact that the hospitals are nonprofit and in an environment that's for profit. I think it would be interesting to talk a little bit about how, yes, they are nonprofit, but they can amass monies in reserves. That was something that came up a lot last year. Much is appropriate? Much is How

[Jennifer Carbee, Office of Legislative Counsel]: much is cash on hand?

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. I think that would be

[Jennifer Carbee, Office of Legislative Counsel]: a good question for the Green Mountain Care Board because they are in the lead to unhospital budgets and what's appropriate. But I it's a great question. How do you balance what it means to be not for profit with the need to have reserves and cash on hand and to be financially sustainable but not Part what of it means to be nonprofit is simply that you don't have shareholders who are entitled to be paid. Not for profit doesn't mean you don't actually generate profit. It has to do with what happens with that and who you're accountable to. Okay. Sorry. I think maybe I will have to come back to the act another time because it is 09:59, and I'm gonna go upstairs in one minute, and I think you might

[Sen. Virginia “Ginny” Lyons, Chair]: be able We'll give you a break. Great thank you. No, thank you very much. This is good.

[Sen. John Morley III, Member]: Thank you.

[Sen. Virginia “Ginny” Lyons, Chair]: Yes. No problem. Every time we hear this, it helps us internalize it.

[Sen. Martine Larocque Gulick, Vice Chair]: I mean, maybe a part of what

[Sen. Virginia “Ginny” Lyons, Chair]: we're thinking of this topic. Yes. And

[Jennifer Carbee, Office of Legislative Counsel]: or get more confused. And I know you're having your time with Katie tomorrow, I think about some of the acts, the human services related acts. Yes. Do you want me to come in and do the rest of the health care related acts sometime next week or something like that? Yes. We'll do that. Awesome. Let's see my calendar. Pencil then and some work. Excellent. Great. Great. Alright.

[Sen. Virginia “Ginny” Lyons, Chair]: Thank you, Jess.

[Jennifer Carbee, Office of Legislative Counsel]: Yes. I'll see y'all in an hour to talk about the quotes.

[Sen. Virginia “Ginny” Lyons, Chair]: Yep. Yeah. Okay. And, Mike, I'm gonna ask you how much time do you think you're gonna spend the full hour on this? Or just a I can spend at the full I know you could. I can spend I'll take it. You could Maybe within this, we could take there'll be a time for a little break. Can we do that? I'm I'm

[Sen. Martine Larocque Gulick, Vice Chair]: wondering.

[Sen. Virginia “Ginny” Lyons, Chair]: Let's and we can talk well, what we'll do is as you're testifying, we might have a little hiatus, take a break, and then come back in. I'll also

[Mike Fisher, Office of the Health Care Advocate]: do that. Anything. Could have many meetings.

[Sen. Virginia “Ginny” Lyons, Chair]: Have you met everyone? I'm just gonna do a little, Okay, so what did you mean? Senator Benson and Senator Morley, and then you're

[Mike Fisher, Office of the Health Care Advocate]: And I'm Mike Fisher, the healthcare advocate. And I think Senator Morley and I overlapped. What years were you in the house? 2004 to 2010. Yeah. Yes. Yeah. We're former house cooks. We are. Cool. So thank you for having me in, and I decided to come in with a little bit more of an informal discussion, you know, with your permission, chair, that I think the job of taking all of this policy stuff and trying to put it in human per human context and having a conversation about what it means or what you're hearing from your constituents is what made most sense to me. And how the changing landscape is impacting providers today. Just a word or two about the healthcare advocate's office for the new member states were created in statutes, funded fully from a single contract with state government and through an R and P process land at Vermont Legal Aid since its inception. Sorry. It's the inception in '99. And so, you know, not an insurance company, not a hospital, not a state employee, but designed to be something a watchdog with eyes and ears on this system, very complicated system on behalf of her watchers and for you. I think, you know, it's really clear in their statute that you're supposed to be a resource to you. And so we take that seriously and having to talk for hours about any of the stuff you're hearing in here about health care. And also very happy to help out with constituents. If any, I think it's always important to say the pieces that come to me through legislators are people who are often a little bit more desperate and a little bit less knowing where they turn. And so we take them seriously because you provide us connection with a set of honors that often. We run a helpline. I have eight advocates on the phone today who are responding to individuals who launch their challenges getting through this crisis system. And we run a policy team that and our job is to show up where there were discussions about health care or access to care is happening. Decisions are being made that impact Vermont's access to care. A lot in front of the Green Mountain Care Board, a lot in this building, a lot of Diva, EFR, and even sometimes, you know, over at Blue Cross or over at, you know, at private entities too. Thank you. Could I ask one question? Just hearing

[Sen. John Benson, Member]: that you're an advocate for all, I'm just curious because I got a note from an individual who has some concerns about the VA, and there, is that something that you should deal with? Because certainly not a state issue.

[Mike Fisher, Office of the Health Care Advocate]: So we help There's no income eligibility. There's nothing about whether you're on Medicaid or Medicare or private insurance or other government insurance. We help for vouchers who are struggling with the complexity of this system and certainly VA. And so just to teach you, you should be able to card that I can have.

[Sen. John Benson, Member]: I could send this individual your way.

[Sen. Virginia “Ginny” Lyons, Chair]: I I have I have a a permanent link in my email.

[Sen. John Morley III, Member]: There you Yes.

[Mike Fisher, Office of the Health Care Advocate]: So no wrong door. We wanna make this as easy as possible. This has both this has my cell phone number on it, the middle number. I think let's just connect. Thank you very much. And just to say for everybody, you the process of referring somebody to me, to us, if you ask them first, can I refer you to the healthcare advocate? And they say, yes, I just need a name, phone number, hope that was going on for them, or even not, their name and phone number, something's going on, and we'll reach out to them. Simple as that.

[Sen. Virginia “Ginny” Lyons, Chair]: All right. So there are

[Mike Fisher, Office of the Health Care Advocate]: a handful of different categories of the people who we think are in particular trouble today. And I walked through three stories at the fiscal briefing a few months ago. Where who was at the where do you who?

[Sen. Virginia “Ginny” Lyons, Chair]: Say that again.

[Mike Fisher, Office of the Health Care Advocate]: You you two were at the fiscal briefing.

[Sen. Virginia “Ginny” Lyons, Chair]: Yes. We had a slate of The lights that are breaking. Yeah.

[Mike Fisher, Office of the Health Care Advocate]: I'm going to sort of base my discussion today on those same three sources. That's I think it's dearest to these populations of people. And so the first one is about a population of people that we have, as a policy matter, allowed to buy to go into Vermont Health Connect, get coverage for their care in the qualified health plans who were had lower income but were ineligible for Medicaid based on their immigration status. And so I'll just do this. You know, so Veronica, these stories are based on the cases that come to us. The names, the details were changed for obvious reasons. They're based on real good people. Veronica Collins. She relocated to Rutland County from Brazil a few years ago to be closer to her daughter and care for her children. She has a green card, so she's legally residing and now works a few weeks a few hours a week doing administrative work for her daughter's business. She'll be 63 in January. And she was she has a chronic condition. She's she's dealing with a chronic condition, so she has ongoing care and medication. She's very low income. She's below 100% of the federal poverty level. And I was wondering whether the chart on your wall is a year decline.

[Sen. Virginia “Ginny” Lyons, Chair]: Well, we haven't gotten a

[Mike Fisher, Office of the Health Care Advocate]: new one yet. We're at 25. So she's below her family of one fifteen thousand six hundred.

[Sen. Virginia “Ginny” Lyons, Chair]: Oh, yeah. So she's below 100%.

[Mike Fisher, Office of the Health Care Advocate]: So in 2025, she was able to buy a plan through Vermont Health Connect. And because of her income, she got a very generous cost sharing subtilisia. She had no wraparound coverage for about $12 a month. And so in 2026, due to changes in HR one, she her income her monthly cost for insurance for the same levels is about 1,300. So, again, her, you know, let's say her income is $10,000 a year, and she's getting a $1,300 per month charge to get the same level of company. So, you know, even if she steps down to a bronze plan, a very, you know, a lower value plan, the premiums are more than her entire. So obviously, nothing, no options for her for affordable coverage. We helped her get financial help from her hospital because she qualifies for financial assistance. One of the federal requirements for nonprofit hospitals is that they have a free care policy. And Vermont has standardized free care policies. So, she benefited from that. But I wanna recognize, uncompensated care at hospitals, either people who don't pay their bills or people who get free care, those costs go divide and nine, and part of that charge master, one of the factors that drive those charges. Just to pull everything together and set up.

[Sen. Virginia “Ginny” Lyons, Chair]: Good question for the hospitals. Percent Everglow? Uncompensated care, is there? Do you have that?

[Mike Fisher, Office of the Health Care Advocate]: Don't have it at my but we keep track of it. It's something that the HCA spends a lot of time focused on. And Green Island Chair Board Club that's in every budget year. So we can we can get you that number.

[Sen. Virginia “Ginny” Lyons, Chair]: Spend a lot of time looking at that.

[Mike Fisher, Office of the Health Care Advocate]: Yeah. First Okay. Oh, no.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. Oh, yeah.

[Sen. John Morley III, Member]: And that it ranges depending the.

[Mike Fisher, Office of the Health Care Advocate]: Sure. I mean, it's a little counterintuitive. In counties with lower income, with more people on Medicaid, there's less uncompensated care.

[Sen. John Benson, Member]: So sort of Yeah. So just kind of backwards. Yeah. Was thinking it was.

[Mike Fisher, Office of the Health Care Advocate]: Yes. Then let me also just recognize that people, low income people on Medicare, only to get to the Medicare story in while, but also are very susceptible to knocking up payments. Now we'll talk about that in a minute.

[Sen. Virginia “Ginny” Lyons, Chair]: One other thing that I focused on, she's not eligible because she's not a citizen.

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

[Sen. Virginia “Ginny” Lyons, Chair]: She has a green card. She's working. Boy, the first news to me during COVID is all our illegal farm workers. Their employers are taking taxes out of their wages. They are paying taxes, but we couldn't, well, I guess in the end, keep covered at state expense, children and pregnant women Mhmm. During COVID. Mhmm. But they are paying into the system, but because they don't have a Social Security number, they can't get any benefits back. Okay. So they can't be on Medicaid then? They can't be on Medicaid.

[Sen. John Morley III, Member]: They can't be on Medicaid. No.

[Mike Fisher, Office of the Health Care Advocate]: So the interaction between immigration law and health care law is what we can come in and spend a whole day on. It's really complicated because immigration law is really complicated. There's a lot of different categories. And so I want be careful not to make broad statements here. Yes, but it's always gonna be. But I did wanna recognize so there's a set of people it would be good to get an accurate an updated number from Diva, how many people we're talking about in this under 100% of poverty currently on Vermont Health Connect last year and no longer eligible this year. It may be 50 to 100 people. It's not a ton of people. There's another set of people who are going to lose their Medicaid October, again, because of HR one and their immigration status. That may be a couple 100 people too. And I guess I just want, I'm gonna move on from this topic with recognition that we have taken steps. Senator Cummings just mentioned that, you know, a few years ago, we created a program that's state only funded for children in pregnancies known as iHIP. And so we do have an infrastructure, if you will, to cover the costs of care. So that's a policy choice about whether there's something that could be, should be done. For that population. The next population that I want to talk about is premium tax credits, people who are on the exchange in the individual market who are who have just experienced the loss of the enhanced tax revenues. Mhmm. So here's the worst case scenario. Oscar and Willow are self employed in Lemoyle County. Willow is an independent mental health provider, and Oscar works at a local auto shop. Together, they earn about $141,000 a year, a little over 400% of the federal population. They have two children, eight and 11, and who are doing great. Though their 11 year old has asthma and requires daily inhaler in an emergency. In 2025, the family was on their MontelthiConnect MVP Gold Plan. They received a little over $2,000 a month in tax credits. This year, they got noticed that they lost their tax credits due to the end of the enhanced tax credit premium tax credits. And so this family lost a little over $25,500 of subsidy in the twenty sixth. So what are they supposed to do? And so there were about so there are about 30,000 Vermonters in the individual market. There I should say, in 2025, there were about 30,000 in the individual market. We don't know if it would be good to get an update at the end of open enrollment from Geneva about how this open enrollment went. There were about 6,500 Vermonters above 400% of poverty, so in this category. But all Mhmm. Almost all, many of those of the 30,000 lost subsidy this year. So their costs went up.

[Sen. Martine Larocque Gulick, Vice Chair]: My question I mean, did they talk about what that would mean for them in terms of, like, how they're going to live? How they're how are they gonna I'm assuming that a 140,000 goes to to pay their either mortgage or rent or I mean, that's Yeah.

[Mike Fisher, Office of the Health Care Advocate]: There was 25,000 over $25,000 of subsidy. No. I I mean, they were sick about it. They were awake at night and are. And so what they decided to do

[Sen. Virginia “Ginny” Lyons, Chair]: I was just gonna say, and and I've heard some pretty astronomical costs for a family Yep.

[Mike Fisher, Office of the Health Care Advocate]: So you wanna Yeah.

[Sen. Virginia “Ginny” Lyons, Chair]: I because what is that pill that they're Yeah. I They're not getting subsidized.

[Mike Fisher, Office of the Health Care Advocate]: Yeah. I I actually don't. Well, I have it a little bit here in the story. Let me tell you what they did. They decided to go without insurance and to buy a bronze plan for their two kids. Kind of a typical story. We're hearing a lot of people say that they went from a gold to a bronze. They bought a lower value plan, or that they decided to buy a plan for their kids and and are hoping and praying that they're okay.

[Sen. Virginia “Ginny” Lyons, Chair]: A little bit about the difference between gold

[Mike Fisher, Office of the Health Care Advocate]: and gold So one of the sort of incredible successes that we were able to do here is in the last couple of years, no shameless self promotion that they they HCA promoted and for a number of years, and the Green Mountain Care Board ultimately did it for 25 and now for 26, is a behind the scenes pricing to be able to draw down some more federal dollars, increase people's subsidies, and can actually make gold a higher value plan that is there's less out of pocket costs at the doctor's office. Gold is less expensive than silver. Sort of a miraculous thing. Higher value point in. It is known as silver loading, though that refers to a few different things. So

[Sen. Virginia “Ginny” Lyons, Chair]: Senator Benson had a question.

[Sen. John Benson, Member]: Just a quick question. And then there's an awful lot on all these different Yes. So I'm just trying to make sure I understand. I thought that children would be covered under the Doctor. Dynasty. Yeah.

[Mike Fisher, Office of the Health Care Advocate]: So so they're a little bit over 400% of poverty, and the doctor dinosaur cutoff is 317. So they yeah. Just missed. But Many, many, many Vermont children qualified for Doctor. Ginny Lyons. This family is about

[Sen. Virginia “Ginny” Lyons, Chair]: Even more affluent families are having tough time meeting all of their financial obligations. Well, what's

[Sen. John Morley III, Member]: really hard, right, is this, the the federal sub the federal dollars aren't coming in for these subsidies. I think they're So they're pushing the expense from the federal government on to the state government.

[Sen. Virginia “Ginny” Lyons, Chair]: I think, you know, exactly.

[Sen. John Morley III, Member]: And and some of us are caught in this, and now we're trying to figure out ourselves how we're going The to families.

[Mike Fisher, Office of the Health Care Advocate]: Right. The state. So so

[Sen. Virginia “Ginny” Lyons, Chair]: How much would it be? $65,000,000 if we're gonna cover those loss subsidies? And we have about a 100,000,000 more or less in reserve fund and we're going to save that to pay for education?

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

[Sen. Virginia “Ginny” Lyons, Chair]: And so the general fund gets depleted? And how do we continue that over time? We can. So once you start it, becomes part of the base budget. What a herculean. Plans. I've had families talk to me, and they are I've heard anywhere between 36 and $45,000 a year.

[Mike Fisher, Office of the Health Care Advocate]: Mhmm. Yeah.

[Sen. Virginia “Ginny” Lyons, Chair]: Mhmm. And that's you're going to be getting $25,000 in subsidy. These are returnable tax credits, so you get a check if you don't lower that tax. You're seeing $2,520,000 dollar increase.

[Mike Fisher, Office of the Health Care Advocate]: Well, so so this family uninsured for mom and dad, find a low value kids plan for their two kids, are gonna pay about $22,000 a year in premiums for

[Sen. John Morley III, Member]: their kids.

[Mike Fisher, Office of the Health Care Advocate]: And they're above the limits for the free care that I talked about from the previous family. So this is the poster child of the kind of family who gets a really bad diagnosis or accident and can't pay the bills. And again, those costs for that stabilization costs at the hospital come to all of us.

[Sen. Virginia “Ginny” Lyons, Chair]: Doctor. Ginny, welcome to our I

[Mike Fisher, Office of the Health Care Advocate]: It's deservates. I just have to say,

[Sen. Martine Larocque Gulick, Vice Chair]: when we're talking about affordability, it is important to know that a lot of the affordability issues we're facing are coming from the federal government. We spent chunk of time the other day looking at the tax new tax laws that are who also have

[Mike Fisher, Office of the Health Care Advocate]: a negative effect on. So so this is also an opportunity for us to say this loss of the enhanced tax credit hits Vermonters particularly hard compared to other states because we are particularly expensive. Vermont premiums are maybe the highest in the country.

[Sen. John Morley III, Member]: Is that their age mostly? Or

[Mike Fisher, Office of the Health Care Advocate]: It you know? Yes. It may have some I think it's due to many factors. I understand. It for sure has to do with our age. So, again, remember, in this case, we're talking about people 65. Yeah. But and it may have something to do with our rurality. It's hard to provide. Much easier to provide care for 670,000 people in a city than it is spread out across Vermont. But it also has to do with the crisis of Vermont hospitals. Going back to your chargemaster question earlier, Vermont hospitals are particularly expensive compared to their peers. And this and this goes to the reference based pricing discussion you had earlier. This is our, I think, really good time lead effort to get a handle on the crisis. And And it's not gonna be easy. It's gonna be really hard to do, so we have a lot of grief about it. But we don't have a lot of those.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. We are significantly higher, I could double, on the exchange from Maine. It's a similar demographic. Older. They're older. Well, are they? I mean, we keep switching.

[Sen. John Benson, Member]: But

[Mike Fisher, Office of the Health Care Advocate]: Yeah. I I mean, I wanna I wanna question this on on two things about those comparisons. Often. Those comparisons are based on silver. Remember I said Vermont has

[Sen. Virginia “Ginny” Lyons, Chair]: higher cost silver than Gold plan and silver.

[Mike Fisher, Office of the Health Care Advocate]: And the other reason why those national comparisons are are inaccurate, and I can't tell you how inaccurate, but it's just something to keep in mind. Vermont does not do age reading. Vermont is one of only two states from New York who don't do age reading. And that and because I think those national comparisons are based on the age of 40, it makes us look more expensive than we really are. I can't think of how much. That's interesting. Yeah. That's interesting. But and and it might be that age rating comes up this year. Some discussion of it. It's it it is I'll just say an interesting discussion about whether we think it's good to shift costs from younger people to older people. At this time, I think there might be good policy reasons to do that. I have always cut my head a little bit at it.

[Sen. Virginia “Ginny” Lyons, Chair]: Well, the administration has a provision in the bill that they've introduced. I don't think we've gotten it yet. Know it's introduced in the House. That has a age related community ratings piece, and then that gets to the age we talked about.

[Mike Fisher, Office of the Health Care Advocate]: We'd love to talk more about that. We will. I have one more story, and I think, you know, maybe ten minutes or fifteen minutes we can Cool. Yeah. Depending on questions. So the last category, I don't have a story about the small group, and I think I'm remiss about that. I think it's important. So everything I've been talking about for insurance has been for small employers under a 100. I'm sorry. I've been people who don't have employer sponsored insurance. Okay. Who don't have no offer of insurance. There is also the small group that is people who do have an offer employer sponsored insurance, but there's employers under a 100. And so they're in a different market, and they are rated differently. You know, most of the rules are the same about, or the rules are the same about what's covered. The plan designs are the same, but they're rated separately. The small groups in Charlotte, the rates in the small group have been broadly at a non sustainable rate. And those guys had no subsidies available to them. And What do you mean by small groups?

[Sen. Martine Larocque Gulick, Vice Chair]: Sorry. Okay.

[Mike Fisher, Office of the Health Care Advocate]: So, say, small employers underfunded Small employers. So so what's the difference between someone in individual group and in small group? The individual group has no author of employer sponsored insurance, and the small group person does have an author of in employer sponsored insurance. They might might both work for a, you know, company with 10 people.

[Sen. Martine Larocque Gulick, Vice Chair]: But they're using Blue Cross Blue Shield or Aetna or whatever.

[Mike Fisher, Office of the Health Care Advocate]: Blue Cross Blue Shield or NDPA to the carriers in that market. I have been afraid for some time that we've been seeing adverse selection that is a sorting of the small group into healthier small groups, healthier people moving to self funded and sicker staying in the, you know, And that just drives up the rate really more when the average cost, when the average lightness more expensive. I just say that it's something that I've been writing about for years and years. I think we see it happening before our eyes. It's a politically, probably impossible thing for you to do anything about or recognize. I would call for a straight out prohibition on stop loss insurance for very small employers. But I would get very little support from the business community and from

[Sen. Virginia “Ginny” Lyons, Chair]: I'll be back. And

[Sen. Martine Larocque Gulick, Vice Chair]: You were explaining that, right? Sorry.

[Mike Fisher, Office of the Health Care Advocate]: I I can I I realized I've got so

[Sen. Virginia “Ginny” Lyons, Chair]: hard to into finance? We'll need

[Jennifer Carbee, Office of Legislative Counsel]: to talk to our associations.

[Mike Fisher, Office of the Health Care Advocate]: Thank you. So this is the conversation that will happen down the hall. But

[Sen. Virginia “Ginny” Lyons, Chair]: but there. You'll get it.

[Mike Fisher, Office of the Health Care Advocate]: I think we see active sorting of the population into healthier people going to small into the individual target. I'm sorry.

[Sen. Virginia “Ginny” Lyons, Chair]: I'm still doing that. Active sorting. People who are quite ill or have Well, you've never had illness You're the a small employer and you try

[Mike Fisher, Office of the Health Care Advocate]: to figure out how to cover your own employees, and you shop. And you go to a third party administrator who does small, who does self funded plans, and they give you a better rate because the age of your employees is healthy, you know, because of the factors of your employees. Or they give you a worse rate or don't offer you a rate at all, and you're stuck in the. So that's Exactly. Really happy. But small group's in trouble. I really want to recognize that. Small group's in trouble. I think, don't My job is to advocate for blemontious access to care. I don't necessarily care more about the individual group than the small group. Both of them are.

[Sen. Virginia “Ginny” Lyons, Chair]: Everybody's informal. We know that. It's top to bottom age wise and bottom to top. We could try to balance that with are those groups joined, are they separated? And we have limited control. We don't regulate ESI and so we try to look for some volunteer support in building our risk pools. We do regulate stop loss insurance. Yes, we do.

[Mike Fisher, Office of the Health Care Advocate]: And nobody buys self funded land without getting stop loss insurance. And so that's the hook. Okay, Medicare appointments. So Betty and Hal. Betty worked as town clerk for twenty seven years, and Hal worked as a contractor doing carpentry in the winter and landscaping in the summer in Bennington County. They raised three kids, were growing up and doing great, and they have two grandchildren who live nearby. Betty is 71, and Ann Cummings is 73. Between them, their Social Security checks give them an income of $46,500. That's approximately 215% of the federal poverty. That's something to sneeze at. That's a decent amount of money, you know, for a couple. But as they transitioned from 25 to 26, they freed up. They they had a very hard transition that particularly hard transition, and I'll explain why. So no surprise, they spend their money on their mortgage, their taxes, their groceries, and their health care. Betty's healthy, but how man is a chronic condition that requires medication and appointments with specialists. So in December, they learned that their Medicare Part C plan ended, And so they started to shop for coverage for 2026. They make too much money to qualify for for Vermont's Medicare Savings Program.

[Sen. Virginia “Ginny” Lyons, Chair]: 400% of the

[Mike Fisher, Office of the Health Care Advocate]: So Vermont's Medicare Savings Program currently caps out at 202% of the federal poverty level. And so let me just say this again. This family earns $3,800 a month, and the cap on MSP, Medicare Savings Program, is $3,600 a month. So it's just above.

[Sen. Virginia “Ginny” Lyons, Chair]: Like, it's very intense, and I don't I don't wanna cry.

[Sen. Martine Larocque Gulick, Vice Chair]: But, I mean, do they we don't know if they have savings and things like that. Right? This is just

[Mike Fisher, Office of the Health Care Advocate]: It's true. This is based on their things. Okay. And and their income is all fixed. Social Security. When people talk about their income, people often think, oh, there's things you can do with your income to make yourself qualify for something. Not so in this world. You get what you get, and it's it's best.

[Sen. Virginia “Ginny” Lyons, Chair]: And the number Beth Pierce did a study when she was treasurer, and the number of Vermonters that have no retirement savings was staggered, which is one reason we started the state, and I'm forgetting the name, but if your employer's willing the state you can contribute shuffle dollars a month and your employer can contribute.

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

[Sen. Virginia “Ginny” Lyons, Chair]: And the state will manage your IRA, essentially. You could set up an IRA. But it came out, you know, the number 80% sticks in my head, but I have no idea if that's correct, but it was staggering to think that you are dependent on living on social security.

[Mike Fisher, Office of the Health Care Advocate]: So between them, their cost for their Medicare Part B premiums and their Part D premiums for drugs and the cost of a Medigap plan, they're looking at premiums of about $16,500 a year or 35% of their fixed income. If we try to count that's how you're counting their out of pocket costs. I want to remind you that Medicare has no stamp on out of pocket costs, no annual or lifetime cap. And so it's generally part A and part B hospital and calculation parts of Medicare. A that's generally 18% of the costs, 20% of a hospital stay. Just too much. So they decided that they couldn't afford a Medigap plan. So they went without secondary coverage. For Part D, we're talking about the plan that people buy to cover that 20% cost savings.

[Sen. Virginia “Ginny” Lyons, Chair]: Oh, so we're talking about the Medigap or supplemental Medicare.

[Jennifer Carbee, Office of Legislative Counsel]: Yes,

[Mike Fisher, Office of the Health Care Advocate]: everything in Medicare has at least two names, just to keep it confusing. And so they lost their guaranteed issue. You know, they, you know, in Vermont, you have a generally a six month period from for where you can buy a Medigap or Medicare Supplemental Plan and get guaranteed issue. That is, the plans have to offer it to you, and they don't charge you extra if it's based on your health status, medical underwriting. So they lost that. They had no choice. And had can this family can get financial assistance from the hospital. So they can get some help there for their Part A and B cost sharing. And Vermont also does have a prescription drug program called V Pharm, which still exists today, which they also qualify for.

[Sen. Virginia “Ginny” Lyons, Chair]: What's the FPL on G Pharm?

[Mike Fisher, Office of the Health Care Advocate]: I am going from the I know. Memory. Think it's a 100

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. It's not high.

[Mike Fisher, Office of the Health Care Advocate]: I'm not gonna say it because I can't remember

[Jennifer Carbee, Office of Legislative Counsel]: it. I have

[Sen. Virginia “Ginny” Lyons, Chair]: the Don't worry about it.

[Mike Fisher, Office of the Health Care Advocate]: I don't have that check-in sheet

[Sen. Virginia “Ginny” Lyons, Chair]: in front front of of me. Me. Do Don't you have my cheat sheet up there somewhere? No. We need to. Oh, is that cheat sheet?

[Sen. Martine Larocque Gulick, Vice Chair]: We should Oh, I forgot. Have it in my drawer.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. We have it. Yeah. Can I ask you a question while you're while I'm looking?

[Sen. Martine Larocque Gulick, Vice Chair]: It's the green sheet, right?

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah.

[Mike Fisher, Office of the Health Care Advocate]: It's green or blue?

[Sen. Martine Larocque Gulick, Vice Chair]: Yeah. When you say the hospital is able to mold them, is that a local? Can you explain that?

[Sen. John Benson, Member]: One of the only things in my throat

[Mike Fisher, Office of the Health Care Advocate]: is gone.

[Sen. Virginia “Ginny” Lyons, Chair]: I I deliberately left that in your drawer. Between us, we're

[Mike Fisher, Office of the Health Care Advocate]: gonna figure this out. So VPARM three goes up to 225. Okay. $2.25. Yeah.

[Sen. John Morley III, Member]: There's like, I do want to remember. There's like four or five V farms right Just three? Okay.

[Mike Fisher, Office of the Health Care Advocate]: And and they cover the exact same thing, but they have different premiums. So sorry. Sorry to get the leads. But when

[Sen. Martine Larocque Gulick, Vice Chair]: you say the hospital's able to help them, I

[Sen. Virginia “Ginny” Lyons, Chair]: don't Yes.

[Mike Fisher, Office of the Health Care Advocate]: So the hospital is the free care policy at their Oh, okay. Got Vermont Hospital, they get care would be able to help them at this income. Okay. Safe saving I made earlier. This is a great safety net for many Vermonters to have a free care policy. We'd very much support it. Now the costs go down to the bottom line that possible. So this is, so this last family is an area where this, the legislature has done a great job in recent years of expanding the safety net. And it wouldn't be a testimony from the healthcare advocate if I didn't at least say, hey, we can go further. It's incredibly inexpensive for the value.

[Sen. John Morley III, Member]: So we cover, as I recall in one of these studies, John, I get briefed on, we cover a lot of add ons in the Medicaid side of things, correct? Yes, yes. There's the basic. Yes. Then Which which is majority of the costs you said, no one said were in there. Yeah. And then it did cost a lot to do the add ons. Am I saying that?

[Mike Fisher, Office of the Health Care Advocate]: Yeah. I think Medicare. I believe it's Medicaid.

[Sen. Virginia “Ginny” Lyons, Chair]: Medicaid. We can do add ons. I might say it just a little bit differently. Yes.

[Mike Fisher, Office of the Health Care Advocate]: I think we'll talk about Medicaid as if it's an a program. It is a incredibly complex set of programs that serve different populations in different ways and with different rules. And so, generally, it is broken into two major groups. One for well, I should say three. One for children that we dub Doctor. Dinosaur, and one for people 65, adults 65, and one for adults 65. There's much, much more than that, but those are sort of major components. And the Medicare Savings Program I'm talking about is even a complexity of the 65 program. But it take requires very little state dollars to draw down significant federal dollars.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. We've got we got some significant eighty eighty twenty matches. We get fifty fifty matches depending on

[Mike Fisher, Office of the Health Care Advocate]: programs we It's sitting here. Yeah. You got it. And, yeah, this case, it's not even the match rate. It opens up eligibility for programs that are 100% federally

[Sen. John Morley III, Member]: Yeah.

[Mike Fisher, Office of the Health Care Advocate]: Covered. And so love to come talk to you more at a There's better very little good news on the landscape. The the incredible change, the positive change that went into effect just this past January 1, just a few days ago, that you guys accomplished for MSP is sort of miraculously good news for a set of about 14,000 Vermonters who are gaining ground or able to cover their healthcare costs in a reasonable way.

[Sen. Virginia “Ginny” Lyons, Chair]: We have, AHS coming in on a federal update. And then it would be good to have you come back in and sort of underpin that as well. I mean, because it's Yes. Always happy to answer questions.

[Sen. John Morley III, Member]: We're gonna take a break. We are about that. Think one of overarching things I'm hearing from folks like Mike is what that concerns me is, more and more people are gonna become uninsured, essentially, I I'm guessing. And

[Mike Fisher, Office of the Health Care Advocate]: And can say uninsured or underinsured? Correct. Both. Mhmm. Both. Mhmm.

[Sen. John Morley III, Member]: And then we're we're trying to make the hospitals be more efficient, effective.

[Sen. Virginia “Ginny” Lyons, Chair]: Correct. That'll the money that we have in the system and move it somewhere else.

[Sen. John Morley III, Member]: Well, I'm concerned because these individuals are gonna be going to the hospital, in my mind. Yeah. And that's where you're gonna see the cost drivers come up at the hospital level too, mean, chair, maybe I'm wrong, I

[Sen. Virginia “Ginny” Lyons, Chair]: don't Well, know, predicting the future, this is one of the things we have to be careful about. What we need to know is the data about what does it look like for the numbers that are coming up, more under insured and uninsured. Right now the hospitals are also looking at that, AHS is looking at that, healthcare advocate is looking at. So we need to bring all of that information in here and then say, okay, right, how far can the Green Mountain Care Board go in its regulation or DFR, go in its regulation of rates overall to make sure that we maintain a solvency, insurance companies, financial sustainability at the hospitals, and people have access. So, yes.

[Sen. John Morley III, Member]: I'm just concerned.

[Sen. Virginia “Ginny” Lyons, Chair]: You know, you should be concerned.

[Sen. John Morley III, Member]: I'm very concerned. I think, ultimately, it's gonna be less services.

[Sen. Virginia “Ginny” Lyons, Chair]: It's what?

[Sen. John Morley III, Member]: There could potentially be less services, is one of the concerns.

[Sen. Virginia “Ginny” Lyons, Chair]: That's one of the things that we hear. We're in for when we hear from DIVA, and we hear from the Department of Vermont Health Access, and we hear about what's gonna be slashed and burned at Medicaid, it's scary. And what's gonna happen to the people who need it the most? Totally scary. And the other thing that we don't deal with in here, we deal with down there that I'm concerned about is like that couple that bought bronze plants for their kids. Pretty likely that younger, healthier people may look at that bill and say, I'm just gonna put my money in the bank and roll the dice and hope I don't. And if I had one guy call up and say, Oh, my grandson smashed up his motorcycle and he got all the care he needed. He didn't have any insurance. I said, No, I'm paying for it. But Somebody pays for it. As nobody wants everybody wants free free free As we take those younger Vermonters out of the insurance pool, I've got a bill on my wall that says we should let people up to 26 stay on Doctor. Dinosaur. If I take those younger, healthier people out of the insurance pool and leave more older

[Sen. John Morley III, Member]: I hear it it.

[Sen. Virginia “Ginny” Lyons, Chair]: Goes up. We need those younger people in that pool because we do community rating. Right. We don't do age rating. When we did, my son went to Europe. It cost him $300 for a six month comprehensive plan. Life was good. He was 21 years old. Once he's working, he needs to be in because he's only can up and

[Mike Fisher, Office of the Health Care Advocate]: say I think your assessment and your recognition of how tricky this is correct. I I would say the way I've been thinking about it is this sort of financing question. How fast can we reasonably ask hospitals and providers to cost less without destroying them? And how fast do we have to ask them to cost less so that Vermontrix can afford the care? You know, those there's the conflict in my mind. And Yeah.

[Sen. Virginia “Ginny” Lyons, Chair]: And

[Mike Fisher, Office of the Health Care Advocate]: and I and, know, that's sort of the concept of transformation. What do we have to have in rural communities? What services do we have to have within so many miles? What should we not be doing spread out all over the state? You may be only doing a few centers of excellence. That kind of planning and organizing is, I think, necessary. And my fear is if we don't do that kind of planning and organizing, the market is gonna do it to us.

[Sen. Virginia “Ginny” Lyons, Chair]: The market's already coming to us, haven't we?

[Mike Fisher, Office of the Health Care Advocate]: In a sloppy, horrible way that we've just closed hospitals.

[Sen. Martine Larocque Gulick, Vice Chair]: But we are doing our planning, right? We're doing it. Which studies? That's why

[Sen. Virginia “Ginny” Lyons, Chair]: we have one hundred sixty seven and fifty one, 68.

[Mike Fisher, Office of the Health Care Advocate]: From a healthcare advocate perspective, I think maybe it's part of my job to be inpatient. You're inpatient. Is to say, I wish we were further along.

[Sen. Virginia “Ginny” Lyons, Chair]: Okay. I wish we were further along too. And that's that is what I talk about. You can't turn the Titanic.

[Jennifer Carbee, Office of Legislative Counsel]: Yeah.

[Sen. Virginia “Ginny” Lyons, Chair]: And it's a this is the And you know what, What we did was we got everybody on board. Now everybody's on board. Yeah. Now they can start to roll over to the good. But they're gonna have to It's a rolling. It's not Right. At your own prices.

[Mike Fisher, Office of the Health Care Advocate]: But the market is happening, you know Yeah. Know, okay. We made it through this year. How's next year gonna go? What kind of a rate increase are we gonna give insurance companies that

[Sen. Virginia “Ginny” Lyons, Chair]: But but, Mike, think of this. July 1 put a huge cavity in the work we're doing. Yeah. And now do we need your reaction and throw the baby out with the bathwater? That's a concern. We can't do that. Well, we can push it up a little bit, you know, go a little bit faster. And I agree with you, we have to move faster and that's why we have a truck and that's why we have a U to keep us honest about going faster. You got to

[Sen. Martine Larocque Gulick, Vice Chair]: do it. The thing that you are all referring to, as Ann just said it too, Senator Cummings, they need to be faster, the hospitals need to be faster, let's just need Planning process, the advisory committee, the AHS, the

[Sen. Virginia “Ginny” Lyons, Chair]: Green Mountain Chair Board, the hospitals, us, the primary care, all of them.

[Sen. John Morley III, Member]: There's so many of them.

[Sen. Virginia “Ginny” Lyons, Chair]: It's just,

[Mike Fisher, Office of the Health Care Advocate]: And we saw

[Sen. John Morley III, Member]: it's so slow. It's gonna go

[Mike Fisher, Office of the Health Care Advocate]: slow. 1850 So have the the the retreat independent with their own private boards making decisions, and how do we make this into a system? It's a big task and good people are working on it. I don't mean to swipe them. I just mean to recognize, I see the clock and I see the, you know, I see the regulatory process churning around again and its impact and its sort of expecting.

[Sen. Virginia “Ginny” Lyons, Chair]: So here's a concern that I might have. We put millions of dollars into this process. I don't want it all going to consultants coming back a year later. I want it going right into the infrastructure changes and So going that's a question we're gonna ask when we have folks.

[Mike Fisher, Office of the Health Care Advocate]: And maybe I'll just, one more thing as I part, I just wanna say, everything we're talking about, the urgency of this problem isn't mitigated, isn't reduced one bit by this huge boatload of money, which is said to be coming through rural health. Thank you for saying that. That money can be very useful. It can help us. It can help us with some of this task, coordinating care between hospitals, for instance, I'm hopeful about it. But even though it's five years, it's still one time. And so it's,

[Sen. John Morley III, Member]: I didn't know that. It's one time for over a period of five years. So we gotta be careful.

[Mike Fisher, Office of the Health Care Advocate]: We can't use it for, we're not allowed to use it for provision of care anyway, but we can't come to depend on it exactly.

[Sen. Virginia “Ginny” Lyons, Chair]: We have, AHS coming in to talk about RHT, World Health Transformation Grant, next Wednesday, and we'll also have others in to talk about it and what it means. It is it is aside and separate, And I think thank you, Mike, for for saying that because it is aside and separate. However, it has an effect. And we don't want the we don't we would not want the public to interpret this as the godsend. It is Yeah. It is it is against it. We'll find out what it is. I'm not gonna talk about what it is.

[Jennifer Carbee, Office of Legislative Counsel]: It has

[Sen. Martine Larocque Gulick, Vice Chair]: the potential to lower costs long term. Right? I know.

[Sen. John Morley III, Member]: Right? I with it.

[Sen. Virginia “Ginny” Lyons, Chair]: Potential. But eventually, but because

[Mike Fisher, Office of the Health Care Advocate]: Thank you. I love spending time with you.

[Sen. Virginia “Ginny” Lyons, Chair]: Yeah. Well, this has been

[Jennifer Carbee, Office of Legislative Counsel]: good

[Sen. Virginia “Ginny” Lyons, Chair]: conversation all around, and I thank you. And

Vermont Legislature SmartTranscripts:

Senate Health and Welfare - 2026-01-08 - 09:00AM

Meetings

Transcript: Select text below to play or share a clip

Meetings

Transcript: Select text below to play or share a clip

Share