Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons]: We are live. So we are back. We're looking at primary care payments report, S197. Thank you folks for being patient with us. Really are looking forward to your testimony. Why don't we move right ahead to Susan Drisson. Susan, introduce yourself for the record.

[Susan Britson]: Hey. Let's see. Hold on. All queued up. I can share my screen.

[Senator Virginia "Ginny" Lyons]: You know? So nice and thick. Yeah. Are you seeing Right? Yeah. It's great. Oh, I was 75 before. Oh, they're on the blanket. I'll just make sure.

[Susan Britson]: It's a window problem.

[Senator Virginia "Ginny" Lyons]: The windows. Oh, and we have this on. Yes.

[Susan Britson]: Yeah. Terrific, I'll write that. So good morning everyone. Thanks for having me today for the record and for those who don't know me, my name's Susan Britson. I'm the Executive Director of Vermont Health First. We're an independent practice association. And I'll just briefly go through this for those who aren't aware of us. We currently have 66 primary care and specialty care practices in 11 counties in Vermont. We have two thirty five physicians and ADTs who are at least twenty or more hours a week, there are more clinician better practices, but the way we do our membership, count them all, but a slight majority of our clinicians are caring, are working in primary care, caring for an estimated 90,000 for monitors, and then we have a number of specialty practices offering a whole host of specialty care services. You can see our member practices by looking at our website, there's a link there. And then just a couple things I wanna point out is that we have a growing sector of our membership, and that is the direct care and concierge care models. It's now 21% of our member practices, and this is a trend that is growing across the country, and frankly for good reason. This becomes a little bit broken. For those who may not be familiar with these terms, a direct care practice is one that charges a membership fee, but they do not accept insurance. The fee ranges, you know, can be under $100 or a couple 100 of dollars a month, and people can pay monthly, quarterly, annually. Wherein the concierge practice also charges a membership fee, but like a hotel concierge, they might work with several restaurants or whatever, they do accept insurance, so that's the difference there. The other thing that I'll point out is that several of our members were instrumental in bringing lower cost care options into Vermont. Those include Green Mountain Surgery Center, the Vermont Eye Laser Center, and most recently, Vermont Diagnostic Imaging. And I just want to

[Senator Virginia "Ginny" Lyons]: thank this committee for the work that you have done to support independence, increasing the CON thresholds last year, that was definitely helpful. I have a question for you. So, the bill we were just looking at previously will expand the ability for optometrists to do laser surgery. At some point, your comments would be helpful, given your, The work you did with the laser shine. I'm wondering the direct care and the concierge models, do those folks have a physical location? Are they embedded in a primary care facility or a hospital? Can you explain how that works?

[Susan Britson]: The ones in our network, they do have their own brick and mortar. Okay. And the majority work in primary care, although we do have at least one direct care from surgeon. Okay. Okay, thank you. First off, I'll just say Health First supports primary care and S197. We firmly believe that investment in primary care will pay for itself many times over in improved population health, lowering costs, and we appreciate that this bill addresses some of the barriers that are seen in primary care, such as admin burden, the need for increased investment, the new patient cross sharing, as well as some workforce support, although I'll say that much more is needed in that area and hopefully the rural health transformation will help with some of that. Some things we particularly like about S197 is just the focus on primary care. Thank you for that, it's so important. As well as thinking about capitated payments for practices that could, yeah, take your bed. That's not so good, is it?

[Dr. Toby Sadkin]: I got it.

[Susan Britson]: Helping practices to have that predictable income stream and actually paying them for services that they're doing in care of their patients. I like also that you've mentioned the hybrid model, because I think that's important to have the fee for service piece in addition to the capitation so that you're actually incentivizing those things that you want the primary care practice to continue to do. You know, they can do injections in the office and other things that you want to incentivize, having that piece is helpful. Of course, reducing the admin burden and the no patient cost sharing, That piece is huge, not only is it extremely helpful for the patient, it's also helpful for the practice, but not having to collect that money from the patient, sort of muddying that G Link relationship between the patient and the provider, I think that's huge, honestly. And then the billing which considers the unique needs of all practice types, whether it be FQHC, hospital, or independent, that's really important because they are different sometimes in how they operate, and not every model works for every practice type. Then we really like the requirement to update the report from the clinician landscape and site neutral reimbursements. This has been a huge, and as I know many of you know, been a huge issue for independents for some time now. How there's pretty significant pay disparities for providing the exact same service, and this has really hurt the survivability of independent practices. So we love to see that language. Even better would be to adopt the language in H585, which actually goes a step further in the site control arena, just throwing that out there. And then also really appreciate the elimination of the subset of the primary care scholarship program, and since I'm here, I'll mention even better would be a loan forgiveness, particularly for independence. This is an area where we struggle because independent practices aren't considered eligible employees, or employers for federal loan forgiveness, so what happens is, you know, somebody's coming out of med school, they have a ton of debt, they want to work in an independent practice, but if they can have their loans forgiven by working at a non profit hospital or an FQHC, they have no choice but to work there. Our practices lose really good candidates all the time because of this. I'll mention that because I have to, or I want to make people aware of that whenever I can. Just some considerations, I think you've heard some of these before, is we suggest that you name AHS as the coordinator instead of DAVA. And the mandated participation we find problematic, just not every model works for every practice, and we feel that practices need to be able to retain them right to make decisions on what's best for their practice. And we think, as Tom Boris mentioned in his testimony last week, the model is really good. They'll flock to it. And I think that would be the preferred method. Also, just wanna emphasize that we think the primary care steering committee really needs to be so involved in how this program is designed and rolled out. I know they're part of the language and the coordination, but really would hope that that group is highly utilized. And then, as Mr. Borys stated, I cannot understate the need support for the program and participating practices. You know, with the CPR program, with One Care, the back and forth between One Care and the practices was ongoing all the time and needed. So to roll this out, you really need to have ample resources to make sure that the program can be dynamic and respond to the situation on the ground and be able to provide really detailed analysis to practices and

[Senator Virginia "Ginny" Lyons]: work with them. So that's it. Any questions? Thank you, Senator Gulick. Thanks again, Susan. Quick question. So in the past, federal administrations, there's been a lot of talk about loan forgiveness. I'm just wondering, given this administration's interest in rural health, has there been any talk about loan forgiveness at the federal level? Because it seems like primary care is so important to rural areas.

[Susan Britson]: It's a great question. Last time I looked, there was no movement in this area, and then I see Doctor. Rouse is shaking her head as well, so I'm sure she's very interested in this topic I would hope it would change, but I've not heard anything.

[Senator Virginia "Ginny" Lyons]: Okay, good. Any other questions? No, this is good, and we'll stay connected as we go forward with Cherry Hill. Thank you for the opportunity to cheating. Pain for it is the problem. Thoughts that you have there would be very welcome. I did like the physician's testimony from Massachusetts. I thought he had some Yeah, right. Good That was good. We're gonna have another one in also from Massachusetts, and we have some other folks that were bringing you in to help us. Faye Holman is here. Faye, thank you for being here. Why don't you introduce yourself for the record and then we'll listen to your testimony. We have it in front of us, I think.

[Dr. Faye Homan]: Thank you. I'm Faye Homan, family physician at Little Rivers Healthcare in Wells River, but actually coming to you today from a chilly trailer outside of Waits River Valley School. Oh no. We have a fledgling school based clinic that we're working on. It's a lot of fun being around the kids, but it's also terrific for working parents to be able to have their parents, their kids seen at school. So that's one of the ways we're bringing primary care to where it's needed most. But I'm really here as the chair of the Vermont steering committee for comprehensive primary healthcare, which you all put into action in the last legislative session. And in that committee, we've been talking a lot about characteristics of a high functioning primary care based healthcare system. And those characteristics are things that will not surprise you at all. We believe in access for all Vermonters to a primary care provider. We believe that addressing administrative burden is critical for giving us the time that we need to care for our patients. We believe that patients should get their healthcare in a broad scope of healthcare close to home by providers who know them. And we really believe that the best primary care is team based care. Team based can mean a lot of things, mental health and substance use disorder treatment meshed into our primary care clinics, clinics, for instance, but also better, more effective communication with the designated agencies and with home health agencies and even with our specialists. There is nothing in our current payment system that incentivizes this type of care. In fee for service, the incentive is to move people quickly in and out of our offices and to shy away from the complex and needy patients. Many of us in primary care in Vermont, most of us probably have productivity expectations by our employers, and some of us are paid on productivity. And we have to keep our schedules completely filled at all times in order to meet the minimum financial requirements to keep the doors open for our practices. And that sort of a setup makes it impossible for us to have our doors open in the acute situation of a sick patient who needs care that day. And it causes us to refer more often to the emergency room than we should and more often to specialists than we should. So on the steering committee, we're very interested in S197. A per member per month payment or capitated payment can be built in such a way that it incentivizes the kind of care that we're really looking for. It can incentivize the broad scope of practice so more patients can get care close to home. It can incentivize us to keep some space open and have the breathing room to do the acute sick patient rather than sending them to the emergency room. And indirectly, that can help the problem that we're currently having with delays getting into specialists because we'll be doing more primary care in our offices. We very much appreciate the focus on decreasing administrative burden. The statistic in the bill, is startling and sad, and I think very true is that we spend 50% of our time caring for the computer and not for our patients. And so the streamlining of the quality measures and decreasing administrative burden is I think very critical here. I'd like to tell a patient's story. I know our time is limited and I promise I've timed myself and I'll get it in under the wire, but we always tell patient stories in primary care. That's why we're primary care providers, most of us.

[Senator Virginia "Ginny" Lyons]: And let me just say two things. One, we welcome your testimony, so if you send it in and we'll have additional testimony from you, but then this isn't the last day we'll be hearing from folks, and so if you feel compelled, we would welcome your further testimony another day.

[Dr. Faye Homan]: Thank you. I'm going to offer that as well. But an illustrative story occurred a couple weeks ago in my practice a woman showed up, I hadn't seen her in nearly a year. She has a lot of medical problems and I would normally see her every three months, but she has difficulty coming to the office. She doesn't drive and she has severe depression that kind of keeps her from getting out in the world and doing things. And so she was booked in a short appointment for a diabetes check, but she also has high blood pressure, heart disease and depression. It wasn't too hard to layer on the high blood pressure check along with the diabetes check. But in talking about her heart health, we realized she had never been back to her cardiologist after her heart attack last year. And we discovered she was on medications that were no longer necessary. We spent a good bit of time talking about her depression and how it gets in the way of her being able to care for herself. And she agreed to see one of our counselors and we're fortunate to have counselors in our office now. And that's felt like a big win. It's been many years since she's been willing to do some counseling. And as we were wrapping up the visit, she brought up two new concerns that we didn't even know she had on her mind that day. And they were significant balance issues, dizziness and falls, and abdominal pain, nausea and vomiting. So we had to do a quick pivot into doing a little quick neurology workup, a quick gastroenterology workup to see how serious these problems were, what we needed to do or could do that day to work on them. And we did that and again, as I was leaving literally hand on the doorknob, she said, is there anyone who can cut my toenails for me today? I can't see my toenails and I can't reach them and I can't get a ride to the podiatrist. And so we cut her toenails that day. So in that short visit, we did endocrinology, cardiology, psychology, neurology, gastroenterology and podiatry. That's the kind of care we know how to give and honestly the care we love to give in primary care and there's nothing in our current system that makes that possible for us. So we're grateful for the attention to S 197. And I just wanna close by saying that the steering committee is a really engaged group. It's people with all different windows and viewpoints on primary care. We're active, we're meeting monthly. We have a payment reform subcommittee that's meeting every other month. And we're here to serve and here to help in any way we can with this legislation. Thank you very much.

[Senator Virginia "Ginny" Lyons]: Well, thank you. Thank you for your work on the steering committee because I know that we've talked previously and I know that you're doing a lot. And we will ask two things of you. One is your written testimony and two, please be available to us as we look at this bill. Your work with the steering committee on the payment piece, I think that's what we need to have this bill go forward. It's something that has payment go forward. We're working very hard on that. We want that to happen. Thank you.

[Dr. Faye Homan]: Thank you. We're very willing to do that.

[Senator Virginia "Ginny" Lyons]: Good. We have Toby Satkin here.

[Dr. Toby Sadkin]: Toby? Yes. I I carry on.

[Senator Virginia "Ginny" Lyons]: Yes. So why don't you introduce yourself for the record and then offer your testimony.

[Dr. Toby Sadkin]: Okay, thank you. Thank you for the opportunity to speak with you today regarding the Senate Bill S197. I am Toby Sadkin. I am a family physician and I've been practicing in St. Albans for over thirty three years. I'm also the chair of Primary Care Health Partners since our group was formed twenty six years ago. In the context of thinking about the proposals in S197, I can share with you the experience that our group has had with the comprehensive payment reform program through One Care Vermont and our thoughts on potential future capitated payment reform programs. Primary Care Health Partners is the largest physician owned independent primary care group in Vermont. We take care of over 30,000 Vermonters. We have 10 practice sites in Vermont encompassing family medicine, pediatrics, and adult medicine. Our locations span from the North to the South, including offices in Ennisbrook Falls, St. Albans, Milton, Burlington, South Burlington, Bennington, and Brattleboro. We have 24 physician partner owners and employ approximately 200 people. Primary Care Health Partners faces the challenges shared by all independent primary care practices. We struggle to negotiate adequate primary care reimbursement with the commercial insurers. We also encounter difficulty recruiting and retaining staff, both physician and practitioner staff and also support staff, because we can't afford to offer the same salaries and benefits that can compete with those offered by the hospital based practices or the FQHCs. And also, as everybody's, our expenses continue to increase far faster than any adjustment in reimbursement. So this includes costs for things like health insurance premiums for our staff, as well as things like utilities, supplies, rent, and insurance. For years, our offices have struggled to make ends meet, and there were times when our physician partners took drastic cuts in their own compensation, paying themselves only enough to cover minimal living expenses and health insurance just to keep the practice open. And just as we're facing the difficult reality that some of the offices may need to be closed, the ACOs were created and offered alternative payment models. So in 2014, we made the decision to join One Care Vermont and through One Care we saw the first real investment in primary care, especially the comprehensive payment reform program for independent primary care practices. And this investment into independent primary care included things like monthly capitated base payments, which offered enhanced reimbursement paying more than we would have received from fee for service. Also, additional funding beyond the base capitation for things like a mental health initiative that focused on better access to mental health services for our patients, and also a population health model which had an opportunity for incentive payments based upon achieving quality targets for things like preventive visits, blood pressure control, ER follow-up, and depression screening. This payment reform model with monthly capitated payments for independent primary care allowed us to expand our services and supports to our patients through things like care coordination, community health workers, and increased mental health services. Very importantly, this model included both family medicine and also pediatrics. Across our 10 Vermont practice sites, we realized $3,000,000 more than we would have received on a fee for service basis from Medicare and Medicaid. Considering the additional funding from Blueprint and the state mental health expansion funds, this number was close to $5,000,000 The loss of this payment reform program has left independent primary care practices facing serious challenges. At the very least, we will not be able to continue some crucial services for our patients, things like care coordination and access to mental health services. Certainly, our pediatric practices find themselves with no alternative options because the national ACOs that might be available for potential Medicare shared savings are only available for our Medicare patients. Without ongoing mitigation of these losses, some of our offices may not survive. Primary care offices could close, leaving patients without access to primary care and leaving our employees without jobs or health insurance. Stable predictability of monthly capitation payments makes it possible for independent primary care practices to budget more accurately and to staff more appropriately to provide the best care for our population of patients. With proper investment into primary care, this type of payment reform creates a culture in healthcare that recognizes the value of primary care and places trust in primary care providers to use their expertise to create the team based care that provides coordinated, meaningful quality care to their patients. Ultimately, this leads to more access, better care, and better health for Vermonters. No less importantly, a payment reform program with significant investment in primary care sends a long overdue message to primary care providers in Vermont that the work they do to take the best care of Vermonters every day is valued. S197 is a good step in that direction. It is important that the voice of practicing primary care providers continue to be included. There is a lot in the bill and many details to be worked through, yet it does give independent primary care practices some hope for the future, and we are very grateful for that. Thank you.

[Senator Virginia "Ginny" Lyons]: Thank you. Thank you for your testimony. This is helpful. I mean, that you have included outcomes assessment is really important because as we move further and further up the capitation scale it puts more and more risk on payers and so it's important that we understand the benefit from that. Similarly, once we leave things at fee for service, we're putting the risk back on the providers of the balance ultimately. Thank you for your comments.

[Dr. Toby Sadkin]: Yes, thanks for your work on this. Thank you.

[Senator Virginia "Ginny" Lyons]: All right. So, we're going to move on. Is it Will or Will Everett?

[Dr. Will Everett]: Good morning, it's Will. Can everybody hear me?

[Senator Virginia "Ginny" Lyons]: Thank you, Will. Okay, why don't you go right ahead with your test?

[Dr. Will Everett]: I'll do so. Thank you very much to the committee for the opportunity to join you. I know we're short on time. I tend to speak quickly, and I will do so unless someone directs me otherwise. I'm Doctor. Will Everett. I grew up in a small town, Southern Vermont, and was very fortunate to complete my education and medical training in the state. I now work as a family physician and hospitalist at Grace Cottage Family Health and Hospital, which is the rural health clinic and critical access hospital in Townsend, Vermont. Within the first three years of my career where I am right now, my peers have elected me to the medical director of the clinic and med staff president, and I also serve as president-elect for the Vermont chapter of Academy of Family Physicians. I'm not specific speaking on behalf of those entities today, but most specifically as someone who's fully investing my career for primary care for Vermonters. From that perspective, S197 is quite intriguing to me as a rural family doctor. It feels like a real significant step forward for the belief in and investment in the bedrock of our healthcare system, which is, as we know, primary care. I think it sets the tone appropriately as ongoing policy progress and changes that primary care will remain this essential foundation. And I think it allows primary care to be a good example of successful innovation and change, as we often are, as we're the ones who most directly grow within the needs of our communities and patients. The reason that I chose to work in rural Vermont is not just because it's home, but because of the role that primary care has in the community. People really trust the physicians that are part of their community and have continuity in their lives. Unfortunately, the trust and the proximity doesn't always mean that the care is easily accessible, as you all know. In reviewing the bill, it really reminded me of a patient named Sarah. She suffers from chronic shoulder pain and significant anxiety, and we've navigated a really appropriate treatment plan of physical rehab support medications for essentially my whole time in practice, and the greatest barrier that she has is the simple fact that every office visit and prescription is a really significant financial commitment for her. This has led to a balancing act between what would clearly be an evidence based approach with really consistent follow-up, with the realistic knowledge that sticking to that plan, to the letter, would cause much more difficult circumstances in her life, and perhaps even prevent her from being able to access care at all. As someone at a different stage in her career than the wonderful physicians who just spoke, I recently transitioned from residency in a larger setting into a more rural one, and the thing that is most apparent to me is the immense amount of direct work that goes into interacting with insurance companies. Throughout training, the obvious burden of prior authorization, medication pricing, and associated time constraints with that are apparent. Since coming to Grace Cottage, I now share our small hallways with the multiple employees hired to navigate this complex system of simply getting paid for the work that we do. I witnessed the phone calls and messages and the hours been on hold with insurance companies just trying to get reimbursed for basic care. It is also much more transparent to see the differences in reimbursement based on insurance companies in a smaller place, and through peers and private practice, I've learned that those factors actually lead some providers to decide which patients they will see based on insurance type, As there's only more discussions about things like accessibility and administrative costs, the notion that we, as a clinic here at Grace Cottage, could have appropriate funding without as much of the struggle, it would significantly decrease the financial obligation of the administrative burden. And for hospital based practices, this could also provide a needed stability in budgets that continue to need to tighten in our state. My next comment is basically gonna repeat Doctor. Holman's comments about how the fee for service system kind of leaves out primary care, and essentially leaves volume as the only option for maintaining a budget. I'm happy to expand, but I think you guys are familiar with that concept and the difficulty it creates for the system. My comment about it is specifically that the the proposed bill and the idea of a stable payment structure with realistic volume goals could really help break that vicious cycle. Similarly, it could also really help from a recruitment standpoint. The idea of being able to offer a job with realistic volume goals and consistent funding for such is a really unique opportunity from a recruiting standpoint, particularly for us who are in the middle of nowhere in Southeastern Vermont when recruiting is quite difficult. This really works to mimic the older version of primary care that many in our community miss. The last comment is just to say that I have really strong views about what effective primary care consists of. Just to give a brief view of my workflow and life, a typical day for me includes seeing a couple wellness visits, a sick toddler in a hospital discharge after a stroke, subacute shoulder pain that I treat with an injection, a biopsy for a skin lesion, complex medication discussions for diabetes. I run over to the local assisted living during lunch to have an end of life discussion, and then end my day with a vasectomy consult procedure that I'll then do a month later. My afternoon today is back to back MAT appointments, hoping people have consistent access to Suboxone and support from our SPOKE program. While all this is happening, the counselors in our office are working to help Sarah, my patient with significant anxiety, navigate that process, and our financial coordinator is helping her ensure that the insurance plan she has aligns with her income and connect her with local resources. The reason I wanted to highlight that is, to me, it really supports key findings from the primary care collaborative via the Robert Graham Center's 2025 Evidence Report, which clearly notes that rural primary care is more comprehensive than urban primary care. Rural primary care physicians save our patients money through the comprehensive, timely, and accessible care that we are able to offer. And at least from my review, S197 has the opportunity to minimize the administrative burden and costs for rural health centers like us here at Grace Cottage, while stabilizing the funding that will keep these services here in my community and keep my colleagues here next to me so that we can continue to provide really high quality care. Thank you for your time today.

[Senator Virginia "Ginny" Lyons]: Thank you very much, Ann, Will. And it would be terrific to have your testimony sent in to Calista so we have it on record.

[Dr. Will Everett]: Absolutely.

[Senator Virginia "Ginny" Lyons]: Well, thank you. So we're gonna move directly to Doctor. Richter, who's on screen. And Doctor. Richter, I saw that you sent in some recommended language. Given where we are with our time, it would be helpful for you to you know, give us your thoughts. You still have some seven, eight minutes, so go right ahead.

[Susan Britson]: Can't hear you.

[Senator Virginia "Ginny" Lyons]: Oh, you're muted, of course. You're still muted. You're still muted.

[Dr. Deborah Richter]: Sorry, okay. You think I'd get used to it by now,

[Senator Virginia "Ginny" Lyons]: Yeah, well, we're all the same thing, it drives us nuts, doesn't it?

[Dr. Deborah Richter]: I know, right? For the record, my name is Deborah Richter. I'm a family physician and addiction medicine specialist, and I've practiced in Vermont for over twenty six years. I'm also past president of Physicians for National Health Program, and I've been deeply involved in supporting health reform efforts at the state level, always aiming at creating a system that ensures access and affordability to all Vermonters and all Americans for that matter, and saves money while delivering quality care. Thank you so much for the opportunity to testify on S197. I would like to also add my comments are my own and not from my employer. I'm testifying as a citizen. So in summary, I support the bill. I also have a suggestion for making it better to able to address the healthcare crisis we are facing, and that is the amendment language that I did send in. So first, let me say I think paying primary care providers by risk adjusted capitation is reasonable, because everyone needs some measure of primary care, even healthy people on a fairly regular basis. And the primary care needs of the average patient are far more predictable than a person's needs for specialty or hospital care. In the words of Barbara Starfield, the world renowned proponent of universal primary care, it's most of the care for most of the people most of the time. So barring a public health catastrophe such as an epidemic, the less volatile nature of primary care demand makes it simpler to set an adequate rate that would enable a primary care provider to meet their fixed costs, to treat all their patients coming through their doors without having to bill for individual services. And I think that was reflected in some of the comments made by some of the other physicians today. So that is, of course, as long as the capitated rate is adequate. The advantage of S197 from a physician or clinician's point of view would be the relief from the administrative burden of billing insurance companies, public programs, and patients reach service. The advantage from the patient's point of view obviously would be elimination of the cost sharing for primary care. So the elimination of cost sharing, in my view, would be an enormous step forward that would end the deplorable situation we have in which patients avoid timely care because they can't afford the out of pocket cost. That is neither good for individual patients nor for the overall healthcare system because when care is delayed, it can be far more expensive to treat, and I think that's reflected again in some of the stories today. So as we know, primary care saves lives and it also saves money for taxpayers and health insurance customers as well. I also support the effort to increase the primary care spend rate. The US lags far behind other developed nations in its percent of health expenditures for primary care. I think nationally, it's less than 8%. We are top heavy on the most expensive care and we under invest in primary care. And this contributes to our substandard health indicators compared to other countries in areas such as maternal and infant mortality, life expectancy, and chronic disease morbidity. So I listened to the outstanding testimony of Doctor. Wayne Altman of Tufts University last week, and he listed all the components of the Massachusetts legislation that are mirrored in S197, And he said the one missing component in S197 was the primary care stabilization fund that would enable avoiding ERISA, an ERISA challenge. I do understand that S197 would aggregate the insurer payments into a fund, but I think the purpose of the Massachusetts Stabilization Fund is to go beyond that, to ensure the financial stability of primary care practices so they can offer care to all patients and be relieved of billing insurance companies for primary care. My concern is that as currently written, S197 does not go far enough in addressing what I perceive to be the moral imperative to end treating primary care as a commodity that some can afford and others cannot, and instead make it a public good, finance like roads and bridges, public safety and public education. So we should not forget that the two actions of the federal government are undoubtedly increasing the number of uninsured Vermonters. One is the end of the federal subsidies under the Affordable Care Act. The other is changes to eligibility for Medicaid, and that we'll be seeing in 2027. We also have a growing problem of traditional Medicare who can't afford a commercial supplement to cover primary care copays. So billing the uninsured and underinsured is not a welcome task at primary care clinics. There's a lot of administrative overhead associated with that. We must recognize that our patients who have lost insurance but do not qualify for Medicaid also need payment reform. So without a stabilization fund, primary care practices, especially in rural areas, will be unable to serve the uninsured and stay afloat financially because these patients are outside the payment streams imagined in S197. So I do not have suggested financing for a primary care stabilization fund. You'd have to work that with JFO and other committees to develop that. Alternatively, however, in S197, you could require a study by the Green Mountain Care Board in consultation with JFO and DIVA to scope out how a uniform, publicly financed universal primary care program would integrate with the capitated payment mechanism you're proposing in S197. A study of publicly financed universal primary care was done in 2015 by the Agency of Administration. That study could be updated with particular emphasis on current cost, financing options, and implementation measures. I've submitted language that you could add to S197 to require such a study. If passed, the next legislature could then decide if it wished to proceed on the basis of the study's findings. Public financing would enable us to invest in primary care at levels that make the most sense for public health. In other words, we'd have an intentional system of care with a reliable funding stream. Another advantage relates to the primary care workforce. A system of care with sustainable funding would attract primary care practitioners to all parts of the state and not just in areas with the best payer mix and the least number of uninsured. My last point is just to emphasize, as I'm sure you're aware, that existing Vermont law Act 48 commits the state to the removal of financial barriers to care and to facilitating universal access. My suggested additional language references these statutes and would be a help toward fulfilling these mandates through the vehicle of S197. So I've provided a copy of my proposed language to your committee assistant, I will provide written text of my testimony. Thank you for inviting me and for your great work on these difficult issues, and I'm happy to answer any questions. Thank you.

[Senator Virginia "Ginny" Lyons]: Thank you very much. We will we will have questions, I'm sure. So we're interested in moving forward, and obviously when you don't have a place to move forward, you do a study. And and I know that the study you're asking for is a big one. It also is an update of something that was significant a few years ago and then for one reason or another resulted in failure. However, I think our goal in here is to put something in place where we can take the step forward and at the same time have further analysis of what we can do. So we'll stay connected with you because we need to have your input. We've been working on this for a long time and we appreciate everything you bring around the table.

[Dr. Faye Homan]: Thank you.

[Senator Virginia "Ginny" Lyons]: Say that again. So, and just given our time, I'm going to move along but you will be back. Thank you all. We're just getting our heads around what the needs are in terms of payment reform. So we'll continue to work on this. Thank you. Thank you. All right. So we're gonna move on to our next bill, which is S206 in behalf of folks who are ready to testify. Thank you all. You're sad. Can you text him? He had to go upstairs, I think. Yeah. But shared today. So he can't do it. I We're gonna have to We're

[Susan Britson]: gonna have to

[Senator Virginia "Ginny" Lyons]: be be really careful about ourselves over the next week. No. We're gonna move right on to S206, and we have Megan Meschette. Megan Leschak. You're on the screen, Laura. She's in the waiting room.

[Susan Britson]: Sit first.

[Senator Virginia "Ginny" Lyons]: Megan, welcome. Why don't you unmute yourself? There you go. We've been looking at 206 and thinking about licensure, and one of the things that has been brought into the bill for us is licensure for folks who are working in our early childhood world. So welcome and

[Megan Mezcat]: Thank you.

[Senator Virginia "Ginny" Lyons]: Introduce yourself for the record and give us your testimony.

[Megan Mezcat]: Great, thank you so much. Yes, I appreciate the opportunity. My name is Megan Mezcat. In my professional role. I'm the director of early childhood education for the Southwest Vermont Supervisory Union in Bennington. I do provide my written testimony to all of you in the effort to save a little time. Going go a little bit in a summary and not read verbatim, but I hopefully have the opportunity to answer any questions for you if anything you hear is interesting. I do want to say that I am here testifying not on behalf of the SVSU. I am the licensed early childhood special educator as well as a pre K-twelve principal, and I do work in the public education system. However, I have also been heavily involved in this work with Vermont AUIC for the last six years. I'm very passionate about this work and really see it as a huge benefit to the early childhood community as a whole. A big part of my role in the SVSU is overseeing early childhood special education services. So those are children ages three to five who receive services on an IEP. The majority actually, and in our school district, 80% of these services happen in community based programs, either center based or home programs. Only 20% of our IEP students attend a Pre K classroom in a public school. So I think this really frames why it is incredibly important that all individuals working in early childhood education have a system to support not only their professional identity, but the requirements you need to meet in order to work with young children. These young children require specialized carryover services to be supported in their classroom that our early childhood special educators, speech pathologists, folks who come in are helping them understand how to best support the kids that they're working with for eight plus hours a day to help them make the most gains that they can before they head off to kindergarten. So that's a piece that I think is really, really important and I really focused on in my testimony, I want folks to understand. Understanding developmental milestones, understanding how to flag kids that they might be falling behind is critically important for the caregivers that they have, and having a licensure system ensures that this knowledge is shared and understood by everyone working in these settings. Additionally, the simplicity of the system, the fact that it is building off of levels, it's a career pathway, are all things that in my work in helping to bring this to Vermont and support it, I think are wonderful reasons why this bill should be moving forward and how it would just greatly benefit all those in early childhood. So that was a brief summary, so I'll give you a chance to

[Senator Virginia "Ginny" Lyons]: That's terrific, that's absolutely terrific, and having your written summary, your written fuller testimony is very helpful. So please make sure we have everything that

[Dr. Will Everett]: Yes, we

[Senator Virginia "Ginny" Lyons]: you should. Oh good, and then as you're thinking about this, one of the changes that's in the bill is moving the oversight for licensure to the Office of Professional Regulation. So not CDD, not AFD, and your thoughts on that sort of new emerging oversight.

[Megan Mezcat]: Yeah. I'm gonna comment on that because I actually, one of the things that's really interesting about working in special education is you work with a lot of folks who hold licenses outside of the education system as well. I have speech language pathologists, occupational therapists, physical therapists, mental health counselors who work in public school, and really OPR has done a great job. I have all of the folks I've spoken to who interface with OPR for their professional licensure and then interface with the Agency of Education really feel like OPR, it's not that gets taken care of and then that gets passed on to the agency of education to receive your license to work in a public school building. So from that standpoint, I think that they've proven to be able to handle folks in the professional field and then understanding that there will be pathways for folks who do work in public school facilities to gain that additional AOE license. I don't see it as a huge barrier personally.

[Senator Virginia "Ginny" Lyons]: All right, thank you for that. Make sure, if you could include those comments, that would be great, thank you very much. All right, so we're gonna move to Jen Olson, Director of the Quarry Hill School, You're here? Yes, I am. There she is. I said, Yes, please. Yeah, great. The hot seat, we call it. Yeah, not comfortable. We need, I'm still, I'm really, we haven't gotten a cushion there yet.

[Jen Olson]: It's more comfortable than a tiny preschool chair. So,

[Senator Virginia "Ginny" Lyons]: you don't know us, we're going to introduce ourselves, we should have done that earlier. In Cummings, Washington, and I apologize. I have to leave for another meeting. Right. So we're gonna be left you're gonna be left with two of us, but it's you two, and we're not voting on anything, so we can continue to hear testimony. You're not going to be ignored. Right. Okay. Martine Larocque Ginny Lyons, Chittenden Southeast. K. Or Cory Hill is located. Thank you. Thanks, Robin.

[Jen Olson]: So I am Jen Olson. I am a co teaching director at Cory Hill School in Middlebury, and I am a parent of a three year old and live in Frankfort. For the last seventeen years, essentially my entire professional career, I've held an educator license from the Vermont Agency of Education with an endorsement in early childhood education. During that time, I taught in private, center based programs here in Vermont. I've spent approximately half of those years working with infants and toddlers and half of those years preschoolers. I've also mentored students in UVM's Early Childhood Education Undergraduate Program, Vermont Higher Education Collaborative Program, and have been actively engaged with the initiative to advance ECE as a profession over the

[Senator Virginia "Ginny" Lyons]: last six, seven years.

[Jen Olson]: I have a bachelor's degree in early childhood education and a master's degree in educational leadership. Thank you for the opportunity to be here today. I am here to express my full support for Bill s two zero six to create licensed profession of early childhood education in Vermont. As an AOE licensed teacher, I wanna be clear that I don't see a conflict with other educators in my field being licensed through another governing body. The need for professional recognition is critical for standing up in early childhood education education system that centers equity for children, families, and caregivers. As an AOE licensed educator, I have found it's easy to communicate my qualifications to potential employers and prospective families. I demonstrate competency and professional growth through licensure renewals. AUE licensure has made sense for a select group of ECEs working in public schools for UPK partners, and these educators share a common understanding of their qualifications. The reality is that the majority of early childhood educators do not hold AOV licensure, and for them, there is no shared system or common language to communicate qualifications, which makes it really difficult to communicate quality to families and difficult for educators themselves to understand and navigate career pathways. When we regulate educators by the same standards, regardless of whether they work in a home, in a center or at a school, we shift the focus to what truly matters, the competencies educators need to serve young children. So my pathway to licensure was embedded in my undergraduate degree program, and I've chosen to maintain it since whether my role required it of me or not. As I mentioned earlier, I spent several years teaching infants and toddlers, just holds a dear spot in my heart. That's the toughest place to be. It is. But so important, and one that I will note does not require an AOV licensed educator. And that work led me to serve as a mentor teacher at a university lab school for several years where I could support both the growth of very young children and aspiring educators. And later in my career, I chose to work in a forestry school, seeking an opportunity to be a part of a smaller school community and because I love integrating nature into curriculum and vice versa. And in that UPK partner program, my ALA license was essential. For a time I was the only licensed educator in the program. So it plays a role even if it doesn't show up in the role that I have at the moment. I've also been fortunate that I've never had to choose my career based on access to health insurance, and I sincerely wish that was true for more educators. For many, the appeal of public schools lies in compensation, time off, benefits, and those are important and compelling factors. But for me, it has always been more important to find the right fit. And I found that the philosophy and values of a program and educators within it matter deeply. When those align, they create the most productive and inspiring environments for learning and working. We need many different settings and options to meet the diverse needs of children and families. That diversity strengthens the entire early childhood education ecosystem and allows families and educators to find where they belong. And it is possible that increasing qualifications may set up more early childhood educators to complete AW life insurance, giving them the opportunity to choose to work in a public school. Should note, I was not aware of the emerging life moving of this all over to OPR specifically as I wrote this. But I would ask that isn't this a good thing? If licensure increases quality and recruitment across the early childhood education system and supports educators who choose non public settings to stay while also creating a stepping stone for those who eventually choose public schools. What concerns me far more is the number of highly qualified early childhood educators who are leaving the field They move into entirely different professions for higher wages, better benefits, more sustainable working conditions. Right now, early childhood education lacks the professional structure and clear career pathways to retain lead educators. So what I want is for the 8,000 early childhood educators in Vermont who currently have no system of individual regulation and for everyone who considers this career in the future to be supported by clear career pathways, accountability and transparency through individualized insurance under OPR. Our child care system is incredibly vital to this state and it serves a strong and stable workforce. I've never walked into a hospital, doctor's office, or other healthcare setting unsure of the qualifications or the credentials of the professionals treating my son, and I want to feel that same confidence when I walk into any early childhood education program, regardless of its setting. I want to know that the educators are highly qualified, well compensated and accountable. And it's my belief that professionalizing the early childhood education workforce gives families that assurance and it also gives educators the recognition they deserve for their work.

[Senator Virginia "Ginny" Lyons]: Thank you. This has been very helpful testimony. And as you continue thinking about moving to OPR, that would be helpful again. We haven't asked that question enough and we're going to have a a CDD and AOV and an OPR and again sort of figure out where we are with that. Thank you. Thank you. Thanks for being here. All the way from Chittenden Southeast. Sounds like Cory Hill's in Middlebury?

[Jen Olson]: Yeah. Cory Hill's in Middlebury.

[Senator Virginia "Ginny" Lyons]: Oh, it's in Middlebury. Oh, yeah. Oh, Oh, it's it's not in Middlebury. Well, you're

[Jen Olson]: in Pinesburg. Yeah. This is in Pinesburg. Yeah.

[Senator Virginia "Ginny" Lyons]: Thank you for being here. Good morning. Good Good morning. For the record, and we're really glad that you're here in spite of the scant appearance. We've got two people who have significant obligations in this building and one who is out for personal reasons. Understandable. But we are here the chair and the vice chair are paying a huge attention.

[Dr. Northey]: Thank you. So for the record, I'm Doctor. Northey and I am an Associate Professor of Early Childhood at the University of Vermont. Associate Professor. Associate Professor. I say, no, I can't do that to you.

[Senator Virginia "Ginny" Lyons]: We can't do that to you. I understand how important that promotion is. Oh, thank you.

[Dr. Northey]: Yeah. And so I'm here today in my faculty as a as a researcher and a teacher educator and someone that's working within this preparation system to provide some insights. And everything I'm saying is my own opinion. It doesn't reflect 2PM or its offices. I realized we were crunched for time, so I've prepared good things for you, but I'm gonna do the high level takeaways, and then I'm happy to answer any questions.

[Senator Virginia "Ginny" Lyons]: Good. And we might prevail on you to come back or be on Zoom.

[Dr. Northey]: I would love that. I would love that. So, at the University of Vermont, we do an undergraduate early childhood degree that upon, you know, program completion and graduation, students earn Bachelor's of Science in early childhood and an agency of education teaching license for birth through third grade. So I am in favor of S-two zero six proposed licensure system because I think the regulation of early childhood educators and childcare in non public settings is really important. And I think that S206 addresses gaps in our current system, and I think it will positively impact the preparation, qualifications, and regulation of the workforce and improve the quality of our education system for birth through 21, right? Because those first five years are so important. They set the foundation for all future learning and development. So four big points. The first is that S206 will license early childhood educators who are not individually regulated through the existing systems. So it covers individuals who are right now just kind of falling through those cracks, even though they're a large number of them, and they're working with children every day. Because of that, I don't think that any of the licensure categories that are proposed in S-two zero six are duplicative. I think that what is proposed will actually complement the existing regulatory systems, including those that oversee childcare programs and agency of education teacher licensure endorsements. Heard you asking earlier about OTR and what it would be like to have this other agency kind of involved. We often get a comparison to nursing because we're a female dominated profession that's involved in caring and caretaking, but nurses are licensed and regulated, to be honest, professional regulation. And one of them, you could choose to work in a public school and then you need to get an additional endorsement to work in public school to be a school nurse. So these, similar to what was shared by the other people providing testimony, I think there's already ways in which this system is working in a similar way that is proposed. My second big point is that ST-six recognizes the value, skills, and competencies and qualifications of the early childhood workforce. Supporting the learning and development of young children requires a lot of expertise and skills. And research consistently shows that early childhood educators qualifications is one of the key components to providing quality care and learning opportunities for young children. And the qualifications are recommended to be a degree and specialized training in early childhood. And so having those things together is an important part of what the research says produces these positive outcomes that we cannot then see cited. My third big point is that S206's licensure categories will establish clear, easy to understand terminology to describe early childhood educators' qualifications and competencies. This consistent terminology will actually increase alignment and coherence across multiple systems. So it will bring common understanding to our state's early childhood workforce, to the early childhood workforce nationally, and the systems that support early childhood teacher education and career advancement. This makes it easier for folks in the workforce and people that want to be in the workforce to understand what steps they need to take in order to enter or move through and progress in the field. Additionally, the proposed EC one, two, and three licenses can serve as objective criteria that higher education faculty can use to identify quality mentor teachers to support students' field experiences, like practicum placements, teaching internships. These field experiences are seen as integral to teacher preparation, and because we license from birth to third grade, we have to have placements in that space for our students. Finding mentor teachers who we easily identify as like, oh, you have the qualifications and competencies that will help mentor our students, is really difficult because there's no easy way to understand what they are bringing to the role, and that's not a problem we have in public schools, because public schools require an agency of education license. And so recognizing that these proposed categories will actually improve our preparation system and students' experiences. My fourth point is that S206 recognizes and values early childhood education and the collective power of Vermont's early childhood workforce. By recognizing the education and expertise required to be an effective early childhood educator, S206 will increase recognition and respect for these educators, which can incentivize educators to pursue or continue on in working in childcare settings. I work with students every day who are incredibly passionate about early childhood and state that they would stay in the, you know, working in a childcare setting or that they would like to do that. They want, pre service teachers want this type of licensure system to be in place because they want to know that that work is valued by society and that their education is valued. Our public investments are working. The things that we're doing to support access and quality and to support the education of our current workforce and pre service teachers. Anecdotally, I can report that the student loan repayment assistant program has helped incentivize a few of our graduates who have a bachelor's degree that agency of education license to stay and work in a childcare setting after graduation, which is really exciting because we want to keep our graduates in Vermont. So the future early childhood workforce is very excited about this. And I'll also share that UVM last fall launched a childhood studies major because we noticed that a lot of students across the university were interested in studying early childhood, but a lot of our courses may be aimed at licensure. So we launched this child study major that's interdisciplinary, and the first year, it enrolled 46 students and it currently has 89, and they're from a wide variety of majors, like dance, biology, zoology, neuroscience. Right? Like, across the university. And so we're seeing a lot of interest, which is exciting. And so S two zero six reflects these national recommendations that have been put forward, and it reflects the voices of early childhood educators. And I think it honors that their capacity and their engagement and their advocacy through the proposal to establish a professional board of licensees to kind of oversee and regulate this workforce. So I'm just gonna end with, that across the nation, the early childhood field is watching what happens in Vermont. A lot of the end of year 2025

[Senator Virginia "Ginny" Lyons]: reports highlight Vermont, right? This whole wall is our bill at '70 six,

[Dr. Northey]: so I've done it. We're on the map, and it's really exciting, and it feels good to be on national calls and have people like, oh, you're from Vermont, what are you up to now? It's fantastic.

[Senator Virginia "Ginny" Lyons]: Well, thank you for your enthusiasm, This both of is great to have that reinforcement. There have been some comments about improving the bill so that there are some folks who are currently working in the field who have exceptional experience and should be grandfathered in, so we're gonna be working on that. But your comments about the pathway for a profession is really good. You. Fantastic, and yeah, I think there's

[Dr. Northey]: also part of that work that's on our institutions of higher ed, right, to give our credit for prior learning and help support that they'll get recognized for the expertise that they do have. Questions? No.

[Senator Virginia "Ginny" Lyons]: We're good for now and we will invite your comments going forward. Your comments about the OPR were very helpful. We don't want that to be a stumbling block as we go forward between, within the administration of all of this. Thank you so much. Thank you. Thanks for your work. Did you