Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Chelsea Myers, can you hear me?

[Chelsea Myers (Executive Director, Vermont Superintendents Association)]: Now I can. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. I'm sorry.

[Chelsea Myers (Executive Director, Vermont Superintendents Association)]: I did not hear anything you said in just until just that moment, though. Well,

[Sen. Virginia "Ginny" Lyons (Chair)]: question is, do you have a schedule if you need to be? Is there a timing issue for you? I

[Chelsea Myers (Executive Director, Vermont Superintendents Association)]: have super quick testimony and would love to be able to get to another meeting. So if you don't mind me going first, that would be great.

[Sen. Virginia "Ginny" Lyons (Chair)]: Terrific. Now that's fine, and I'm fine if you're others in the room. Is anyone else up on Zoom with us? Lisa and are both phones now. Okay. Lisa and Shelba, are do you either of you have a time sensitive schedule?

[Lisa Lefferts (Science Consultant; former CSPI Senior Scientist)]: No. It's fine.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. Shelba? You're muted. That should

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: be fine with me. Okay. Good.

[Sen. Virginia "Ginny" Lyons (Chair)]: Can you hear me? Yep. Yeah. That's terrific. Thank you. Okay. So we'll start with Chelsea, and then we'll move through the list. Thank you.

[Chelsea Myers (Executive Director, Vermont Superintendents Association)]: All right. Good morning. My name is Chelsea Myers and I am the executive director of the Vermont Superintendents Association. First and foremost, superintendents support safe and healthy schools. They show up each day committed to creating environments where students can learn and thrive. But I would be remiss if I did not reiterate a point you hear from us often. Each year, committees all over this building discuss new proposals to add to schools and in the same breath discuss how expensive schools have become. I took the time to read the testimony provided on this bill by other individuals and entities. I have no doubt about their passion, credentials or research. However, several said that this would create no additional burden for schools, and even the Agency of Education reported to the media that it thinks that this would not be a problem. I respectfully suggest that we hear directly from those who would need to implement this. Assumptions about impact are not the same as understanding the day to day operational realities in our schools. Each year, the General Assembly passes very well intentioned legislation, and each year, additional requirements are placed on schools, often with hidden time commitments and costs, paperwork, training, communication, procurement adjustments and compliance oversight. To be frank, I do not know if this is one of those cases, but I believe we should find out before moving forward. I attempted to line up a few food service directors to join me today, but as you can imagine, they are very busy nourishing Vermont students. I would be happy to continue working to organize that testimony but would just need a little bit more time. Until those directly responsible for implementation have had an opportunity to weigh in, I respectfully request that you pause taking action on this bill. Thank you for your consideration.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so thank you for that. And actually, when we were looking for someone to testify, we were thinking of food service folks, but didn't have the luxury of names. So, if you can send names of food service folks who might be helpful with this to Calista, and then we can organize the testimony, because that would be very helpful. I know they have certain constraints about their funding and the USDA and everything else. And just the language in the bill is introduced is consistent with what is being recommended at the federal level right now, so maybe we won't see a disconnect there, but you never know.

[Chelsea Myers (Executive Director, Vermont Superintendents Association)]: Yeah, I I frankly don't know. I'm in touch with a couple of food service directors, but I haven't been able to, like, make that. It's just been through email so far. So if I can just get a little more time, I can help Calista organize that and get some folks in for you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Alright. So I mean, send her the names and she's Yeah. That would be great. And I know in the past, the Burlington folks have been extremely helpful when we Yep.

[Chelsea Myers (Executive Director, Vermont Superintendents Association)]: That's who I'm in touch with. Yep.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, that would be good. Okay. Well and and others that you think would provide information would be great. Absolutely. Well, you. Thanks for your time. Appreciate it.

[Chelsea Myers (Executive Director, Vermont Superintendents Association)]: Yep. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Alright. So we'll move on to Shilpa Rivelia, a gastroenterologist. So is doctor Rivelia? Are you here?

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: Yes, I'm here.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, good morning.

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: Good morning.

[Sen. Virginia "Ginny" Lyons (Chair)]: You're sitting with the Senate Health and Welfare Committee. We've got one member who is away for personal reasons and another one who will be coming in for the meeting. The others are Senator Benson, Senator Gulick, and Senator Lyons, myself.

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: Nice to meet you all virtually.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Yeah.

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: So, chair and members of the committee, thank you for the opportunity to testify here today. My name is Doctor. Shulpa Rovella. I'm a practicing gastroenterologist and author with expertise in nutrition. Previously for the better part of a decade, I served as a full time faculty member at Columbia University Irving Medical Center in New York City. I'm here to speak from a clinical and a public health perspective on S26. Thank you for considering this bill, which focuses on foods and beverages served in school settings and restricts certain synthetic food dyes. From a medical standpoint, there are three points I'd like to highlight. First, the scientific evidence. The body data on artificial food dyes and children's behavior has been growing consistently over the years, and the results are cause for concern. This data includes diverse studies in both humans and animals, including randomized controlled trials, which are long considered the gold standard in scientific research and observational studies. The data points to associations between synthetic food dye exposure and changes in children's behavior, such as inattention, hyperactivity and restlessness. We also have some literature highlighting plausible mechanisms through which food dyes can cause harm, like neuroinflammation or inflammation of the brain, as well as neurotransmitter disruption and oxidative stress. Overall, here we have an important story emerging regarding how these dyes may affect both animals and humans, as well as plausible mechanisms behind their effects. Second, the clinical context and nutrition perspective. In my gastroenterology practice, I frequently receive questions from patients and families about diet additives and overall health. While I don't treat children clinically for attention or behavioral issues, my work in GI nutrition and my research on inflammation gives me insight into how dietary exposures can affect overall health. How children eat is immensely important for their overall health. Diet is one of the few modifiable factors that parents can control, and schools are where children consume a large portion of their daily food. Importantly, these synthetic dyes provide no nutritional benefit and are not essential to food safety or quality. In fact, foods containing synthetic dyes also tend to contain additional additives that are harmful to children's health. For example, foods and drinks sold by the top 25 US manufacturers in 2020 with synthetic dyes contained on average 141% more sugar than products without synthetic dyes. We know that there is a wealth of literature on the health harms of excess sugar for children. Third, the policy question. FDA safety determinations largely focus on acute toxicity and cancer risk. Behavioral and neurodevelopmental effects are more difficult to study historically and have not driven regulatory thresholds. States often step in when emerging evidence raises concerns in children's environments. FDA safe when it comes to taking additives off the market often actually means absence of proof of harm, not proof of safety. In contrast to The US, the European Union's public health protection policy follows the precautionary principle under which credible evidence of danger to human health merits protective action despite scientific uncertainty. Many major food companies in The US use artificial food dyes in America while selling the same food in Europe without dyes or with natural color. It's possible for American manufacturers to produce dye free alternatives of their foods. Some already do, and several states and districts have transitioned to die free foods in schools without major disruption. In line with testimony previously that you have heard regarding expanding this bill, I urge you also to consider the mounting data on potential health harms of additional additives, including preservatives, BHA, potassium bromate, and propyl paraben, which are currently covered under three statewide bands, and titanium dioxide, which is in several state bills. Titanium dioxide, a color enhancer and anti caking agent, was banned in The EU in 2022 after a safety assessment concluded that it can damage DNA and harm the immune system. Other additives to consider with potential links to cancer include BHT, TBHQ, propyl gallate, and aspartame. Many of these additives serve superficial functions in food and can easily be omitted or replaced with safer alternatives. In medicine, we often act under uncertainty when certain conditions are met. Potential harm, broad exposure, and minimal countervailing benefit. S26 fits that framework. The bill does not ban these dies statewide, nor does it restrict parental choice outside of schools. It simply sets a standard for foods provided in a publicly regulated setting to children. From a physician's perspective, this is a reasonable precautionary step that aligns school food policy with child health priorities while evidence continues to evolve. The benefit of these dyes is essentially cosmetic. S 26 protects one of our most vulnerable populations in an environment in which they are attempting to learn, grow, and thrive. I urge you to vote accordingly. Thank you for your time. Happy to answer questions.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you very much, Doctor. Rivella, and you've included some references for us in each of the areas. Do you have you testified in other states or other states do you know about other places that have acted on this policy?

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: There are other states that have acted on this policy. I actually was a part of the initiative in California with Lisa Lefferts to ban food dyes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Good. So and remind me, how long has the EU had had this ban? Do you know?

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: So so they have had warning labels on many of their food dyes. They have warning labels with items that contain food dyes, but most manufacturers actually don't even put those dyes into the foods that they produce in Europe because they know they can't get away with it because of those warning labels. Here in The US, American companies use dyes that they would not use in Europe. So even if some of those dyes don't have an outright ban in Europe, they're they're not typically used.

[Sen. Virginia "Ginny" Lyons (Chair)]: Wow. But they do have warning labels.

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: I'll say that again, please.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. So and and and your is it your do you know if these foods are allowed in their schools, or is it is it with the warning labels only and then manufacturers not putting them in? Sounds like they're doing the right thing regardless.

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: Correct. Some of the dyes were banned, some have warning labels in Europe and the global effect is the removal of of these dyes from the food system and and from school food systems because American manufacturers cannot sell the same foods in Europe using the same dyes that they use in America.

[Sen. Virginia "Ginny" Lyons (Chair)]: We hear this all the time. EU reaches ahead of us. Yep. All right, questions committee. Okay, thank you very much for being available. And if we have questions, we may reach out again.

[Dr. Shilpa Ravella (Gastroenterologist and Author)]: Sure, absolutely. Thank you for your time.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, terrific. And so we have Rosie Krueger here. Here you are, Child Nutrition Program. And you've heard the comments from the superintendent's group that we're going to try and get some folks in and maybe you can help us with those people. Sure.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: So for the record, Rosie Plugger, I'm the state director of Child Nutrition Programs Agency of Education. I did submit written testimony, but I submitted them a little late, so I brought copies for you as well. Oh, awesome. So, we have it. Oh, great. That's good, awesome. So, at the Agency of Education, my team is responsible for implementing the federal child nutrition programs, including the school meals programs. And so we are out in the schools all of the time looking at what is actually being served, looking at menus, recipes, ingredient labels for both the school meals and also for the other foods that you've mentioned in your bill. They're called, at the federal level, smart snacks, but they're the foods that are sold to kids outside of the meal program during the school day, which is defined as midnight the night before and then thirty minutes after the school day. So we're all over the state looking at these statewide all of the time. And I have good news for you, which is that we're really not seeing a lot of these products in Vermont schools. So we had given a comment last year that we think it would be terribly difficult for Vermont schools to comply with the food dye restrictions because we're really not seeing those food dyes in Vermont school meals or crafts. The one place that we're seeing those is in a handful of breakfast cereals. Those breakfast cereals, I believe, are sort of either being reformulated or on the way out because there's some recent federal restrictions that went into place around the amount of grams to add sugar that are allowed in breakfast cereals, school meals programs. So we are seeing these natural manufacturers actively reformulate their products in response to some of the same restrictions in other states. So even as we've been looking at this, we've been seeing fewer and fewer of these items included in the ingredient labels as they're being reformulated. The other place that we see food dyes is in those smart snacks that are sold outside of the school meals programs. Again, not extensively, as you heard in previous testimony, a lot of food manufacturers have a specific school meals formulation for their product that is branded exactly the same as the grocery store formulation, but it's reformulated to be cold, red, and rich, and to meet the sodium and that restrictions in the school meals program. And so we've already seen the manufacturers take steps to change those special school meals, school food formulations. But we do still see a few food dyes in a couple of those products. Again, those aren't part of the school meals programs. There are plenty of other products on the market that would comply. So we don't see food diets particularly as a significant consideration. The draft 1.1 of the bill includes some additional additives. So we did recently take a look at food labels to see if any of those are included in Vermont schools. And we're only finding two of those. So most of them are just not in Vermont school meals right now. But two of them are, and they're mostly in things like packaged crackers, breakfast sausage, and pepperoni. And there are products on the market that don't have similar products that don't have those additives. And again, we're seeing manufacturers actively reformulate these products. So by the date of implementation, we're anticipating that either of those products would be reformulated or other products would be available. If you decide to go further than this, further than those ingredients that are listed, we would want to be part of that conversation because depending on what you do, I know there's conversations in general about about ultra processed foods and packaged foods. And in general, in Vermont school meals, we have a lot of scratch cooking. The programs are really doing some amazing stuff with local foods. If you haven't looked at a school meal recently, I'd really encourage you to go to your local school check the box. They're really good. Where we do see some packaged foods is at breakfast, and that's one to deal with labor issues, but also to deal with offering breakfast in the classroom, grab and go breakfast between class periods. And that's a situation where a convenient, portable, prepackaged food works well for that situation. And so if you were to take further steps that might impact those products that are being offered, we'd want to have that conversation with you about weighing the pros and cons of potentially schools having difficulties continuing to offer those options, those breakfast in the classroom, that kind of thing, versus restricting those. But with the ingredients specifically in the spell that you're looking at, we don't think that that would much better.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh good, thank you. This is really helpful because as we heard from the superintendents, they were concerned about the ability to implement in the kitchen.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Yeah, and we would absolutely share those concerns in general, But looking at these specific ingredients, we think that it won't.

[Sen. Virginia "Ginny" Lyons (Chair)]: So those ingredients, it's not a big deal. Also the date of implementation is It's a year out. So there's time to sort it

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: out a little bit. The other place that we've noticed is the bill does not currently have any compliance or enforcement, you know, penalties for non compliance. So if you wanted to do that, that's an area where That's we have

[Sen. Virginia "Ginny" Lyons (Chair)]: some

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: a shot. And we have some suggestions about how to do that in a way that would be, require as little additional work as possible for both the schools and AOE. Because again, as the Superintendent's Association shared, if you did this poorly, you could add a lot of administrative burden to schools and to the AOE, and we would discourage you from doing that. Because we're Oh, sorry to I just wanted to quickly chime in on the package with the piece. Okay, let

[Sen. Virginia "Ginny" Lyons (Chair)]: me finish the compliance and then we'll do that.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Okay. I mean, don't if it's already gone by, but Alright.

[Sen. Virginia "Ginny" Lyons (Chair)]: No. We'll come back to it.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Don't forget your question. Well, it's I have a couple. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Okay. Finish the compliance. Said you got three or four subjects.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Yeah. We can look at those. So because we're out in the schools on these federally required reviews, we're in every SU, SD, at least every three to five years, but more often for technical assistance visits as well. So during those federal required reviews, we are having the schools submit menus and recipes and labels to us and we're reviewing all those to make sure that they comply with the federal nutrition standards. So if you limited the compliance review and aligned it to that administrative review that's already occurring, the schools would not need to submit additional documentation to us. We could look at that existing documentation. Again, that includes both the school meals and those competitive foods sold outside of the school meals program or both of those. And so we could review that documentation for this list of ingredients and it would be no additional work for the school food authorities and it would be a very minimal amount of work for the AOE, assuming he left it to that list of products, of aggregates that's in the bill permanently. So that is our suggestion. If you do want to add a compliance mechanism, that would be the simplest and would not add the short term burden.

[Sen. Virginia "Ginny" Lyons (Chair)]: Senator Gulick. You're welcome. Packaged foods.

[Sen. Martine Larocque Gulick (Vice Chair)]: I just would like to speak to that because this is my concern. Burlington had a award winning food service program and then Burlington High School was shut down. We had to stay to Macy's. Guess what? Department stores don't have kitchens. They don't have like industrial school kitchens. Oh, right. So we had to go from this really great food service program to prepackaged breakfast bars or whatnot. That's just the reality. It's I mean, that our the quality of the food definitely suffered, but I worry that as we, you know, with the PCB mandates and the schools possibly having to close because we no longer fund school construction aid and there are a variety of issues in our schools. You know, this what we experienced at Burlington could play out across the state over the next, I don't know, how many years and I am worried that we will have to rely on packaged food that may not comply with what's in the spill. As much as I would like to ban red dye along with a lot of other chemicals like carapat and key fast. It's just the reality of it is more complicated. So what is your thinking on that one? So specifically the items that are in this bill, there are plenty of package suites that don't issue those items. If you went beyond that and started to get really into other sorts of restrictions, then definitely we might have a non issue.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, and if there were a compliance piece where they're reporting to you and listing those things that might be non compliant and have a reason, don't want to poison kids, but nevertheless, Burlington had to go without the package.

[Sen. Martine Larocque Gulick (Vice Chair)]: Again, really don't think that there's a need. There's plenty of other packaging items that don't suit these ingredients. That's good. That is good. My only other piece is if you would be willing to speak to what we can call them unfunded mandate. But things that we ask the school to do. We keep. Yeah. Keep piling on. And yet they don't come with appropriations. In fact we're in the midst of potentially destabilizing a lot of the schools in our state. So, I'm wondering how you feel about what because you you did just mention this could mean more staffing and more administrative burden. That is a financial that has money attached to it. Absolutely. So I was just wondering if you could speak to that as well. So that's another concern. Yeah. Again, as much as I want to No. It's always a balance for policymakers. And if you were to go beyond this and have lots of restrictions on packaged foods, or if in your compliance you were to require that they actively submit stuff to us or go beyond that, you certainly could get into the world without funding mandate. Based on our review of the foods that are currently being served in Vermont schools compared to these ingredients, there's only a few of these ingredients that we're actually seeing, and again those manufacturers are constantly basing those out. So, and there are alternatives. Do you think it's helpful for us to hear from some food sources? Absolutely. They're always, you know, I can speak very well to the statewide situation, but an individual food service director can tell you a lot more about what goes into their individual purchasing decisions.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: And so the School Nutrition Association is sort of that statewide organization to speak to about that. And they have lots of great food service directors who have thought a lot about this and are doing really great work.

[Sen. Virginia "Ginny" Lyons (Chair)]: What, can you send the contact information to the collection? We'll get that. That makes it good. Thank you. And then beyond compliance,

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: there's, you could ask the agency to do a compliance check. Do you want to do a penalty? Right now there's no penalty for non compliance in this bill. We gave you some suggestions that you could think about if you want to do that, ranging from VA, we would require corrective action. Corrective actions can be things like writing a plan for how you're going to phase the product out or submitting documentation to us or attestation, you stopped offering the product. Those are the sorts of typical corrective actions that we would assign if they were serving a product that sounds fine with the federal requirements. You could do something like requiring that they notify households that they've served this product. There's not a lot of a basis for that, but that might be a sort of encouragement to follow the requirement. And then you could do a fiscal action. I think we certainly wouldn't recommend doing that for a first offense when we're talking about We've served group groups last Wednesday. Yeah. And so in the school meals programs, the federal requirements, we typically only issue a fiscal action if it is a repeat offense, and even then it's restricted to certain categories. You cannot, I do want to caution you, you cannot take back the federal funds for non compliance with the state requirement. So if you wanted to do a fiscal action, it would need to be on the state funds, the universal meal supplement or one of those state funds that we provide. Again, maybe not on a road you want to go down, we're just trying to present you with what your options are if you want to No, get

[Sen. Virginia "Ginny" Lyons (Chair)]: that's helpful. It helps us to look at it holistically. Appreciate that. Not inclined right now to think we need to have a huge penalty. It sounds like things are already in good

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: position across Yeah, and that's really why we don't have a lot of concerns, because we're not seeing these products. I do want to clarify, earlier testimony you said that AOE supported the bill, and testimony you heard from last week. And I want to make clear that we've not taken a position on the bill. We did give a comment to our reporter last year that we just thought it wouldn't be particularly difficult for schools. Understood. Go ahead. Quick question. I think the idea of penalizing schools, especially in a financial way, not productive. How would the AOE, instead of using a stick, how would you be able to support stools and insulin so that they don't end up facing negative consequences down the line? I'm glad you asked that. At the end of the testimony, there is a whole list of things that we are already doing to really encourage stretch of the animal. We do a lot. We do a lot of free training. We have a whole seasonal cycle menu toolkit that was developed by a wonderful Vermont Food Service Director that gives a whole menu and the associated recipes for scratch cooking seasonally adjusted based on local foods available in Vermont, different times of the year. So that's just sort of a plug and play resource that any food service program could use. We operate the local foods incentive already, which gives additional funds to schools that are purchasing a certain percentage of local foods. And we've just issued our report on that for this year. We're seeing really good success there with that program, including having a Vermont school district. When I say school, I'm thinking School Food Authority, which is the NUSD, that is serving 31% of their foods as local to Vermont. So really impressive stuff. That's great. Do you do anything to help with a Macy scenario? So we have a school both a state and a federal school equipment grant. The state grant federal, we don't have a lot of control over, and it's actually been cut in recent years. But for state one, we have recently made a bunch of updates to it to try we were seeing folks not really taking advantage of it. So we removed the required matching requirement and we increased the dollar value, the maximum dollar value, We and simplified the questions and we did see some success with that. This most recent round, it was fully we were able to fully expend the funds. So we offer that equipment. We also just offer a lot of training and technical assistance. So when somebody's in that situation, we're available to go in and help them figure out, okay, what can we do with what we've got? Who can we work with? In a neighboring school district, how can we bring in meals? What makes sense here? I know if you did help Burlington in that space. I'm sure we had conversations with them. Burlington has very competent food service staff, and so I think they really took it on, but I know that we did answer various questions about sort of what was allowable in terms of when the kids were dispersed off-site as well, how they could get their meals to them. It's a very challenging situation and I know we did provide a lot of help to them.

[Sen. Virginia "Ginny" Lyons (Chair)]: So we're gonna Those are good questions to ask and I think we've got a lot of information here that we can use as we go forward. Appreciate it. And we know where to find you. Certainly. Great. Thank you for your work. This is terrific. I suspect that if we move forward with the bill, which I'm thinking we might, I'm interested in doing that. Senate Education may wanna check-in with the chair. Thank you. So

[Owen Foster (Chair, Green Mountain Care Board)]: okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Committee unless I hear different from you we'll continue to get testimony and we'll get the food service folks in. On the bill. Thanks for your words. Okay so we are moving on to S197 which is the primary care payment reform bill. Melissa Blum sort of Sorry? Sorry.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Mean, she can lean on me.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, I don't worry about this. I'm here. I need a doctor. Oh, wait. Wait. Wait. Wait. Before we do this, Katie, we have No.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: I'm

[Sen. Virginia "Ginny" Lyons (Chair)]: sorry. Lita I Leopards, I didn't realize that you were still there. My huge apologies. And we can we can we really would like to hear your testimony of my oversight. No problem. Go right ahead, please, on your testimony. Okay.

[Lisa Lefferts (Science Consultant; former CSPI Senior Scientist)]: Well, thank you so much. I'm Lisa Lefferts, a science consultant. Previously, I was senior scientist at the Center for Science in the Public Interest, and my focus was on chemicals added to food. Before that, I served on FDA's Food Advisory Committee when it considered the issue of synthetic food dyes in 2011. And I also was the primary author of the successful petition to FDA to ban RED III, which is a cancer causing synthetic food dye. Thank you so much for this opportunity and for considering this bill to prohibit synthetic dyes in school foods. So my bottom line message to you is that S26 is grounded in science. It's very doable. And it's really needed. And I also would like you to encourage considering to expand it, to consider additional chemicals of concern that I think are very doable, and I'll say more about that. Synthetic food dyes can cause or exacerbate neurobehavioral problems in children. That's actually a quote from the best assessment on synthetic dyes ever conducted. And you don't have to take my word that it's the best. 30 other scientists and over 20 health based organizations said that too. And we said that it's the best because it was the most comprehensive and rigorous such assessment ever done. It was over 300 pages. It took over two years. And unlike some other assessments, it looked at it used a state of the art systematic approach to examine all of the evidence. It was open for public comment and it was peer reviewed. Now we can use the word cause, which is a word that scientists do not use lightly. In part, because as Doctor. Rivella already mentioned, the evidence includes 27 clinical trials considered the gold standard for showing a causative fact relationship. These trials were conducted on children and are designed to hold all the other variables constant except for whether dyes were present or not. So we know that the effect is really from the dyes and not from something else. It's very rare, in my experience, to have this kind of human evidence on an additive in food. Not only do we have all that human evidence, we also have evidence from animals and test tube studies. More importantly, all those three lines of evidence, the human, the animals, the test tube studies, all converge to reach the same conclusion, and that strengthens our confidence that this really is a true effect. Now by neurobehavioral effects, we mean that dyes can cause or worsen hyperactivity, inattention, sleeplessness, and restlessness. Just what kids in school need, right? Those are serious side effects that can have long term consequences. Synthetic fruit dyes can affect neurotransmitter systems in the brain and actually cause microscopic changes in brain function. They are completely unnecessary. Their purpose is only cosmetic. They can be omitted entirely, replaced with safer alternatives like grapefruit skin extract for example, or even better, real fruits and vegetables. Now we know that they are unnecessary because many companies, both here and in Europe, have reformulated their products to eliminate them. The bill is very doable since few schools contain synthetic dyes and dye free alternatives are readily available. You heard that already from the previous speaker. And I have heard that there have been a number of analyses and other states have found that to be the case. In fact, by the 2025, at least nine states had enacted laws that restrict the use of dyes and other additives in meals served in schools. Many schools nationwide eliminated synthetic dyes and other additives of concern well before states required it. I had the privilege of working with schools back in 2014 to identify additives of concern, and many schools have been adopting that guide that was developed. Three states, Arkansas, California, and West Virginia, have adopted statewide bans on certain additives. Now, you've already heard previous testimony asking you to consider expanding the bill to include additional additives. And I think that's a good idea. The three statewide bands cover BHA, potassium bromate, and propylparaben. BHA is a preservative, and it's listed in the official US report on carcinogens, which is a congressionally mandated report as, and I quote, reasonably anticipated to be a human carcinogen. It's been listed since 1991. What is it doing in our food supply? Potassium bromate is added to flour to increase bread volume. Bromate is considered a probable human carcinogen by the U. S. EPA and it's banned virtually worldwide. Propylparaben is another preservative that has effects on sex hormones and causes endocrine disruption and reproductive issues in animal studies. The US is really an outlier in allowing these chemicals. None of those three are permitted in Europe. You don't need them in food. How many of you have BHA, purple paraben, or potassium bromate in your kitchen cabinets? In addition, I'd suggest you consider three other preservatives which some evidence suggests that they may pose cancer concerns. And that's BHT, TBHQ, and propyl gallate. These are also unnecessary. They can be replaced by safer chemicals like vitamin E, by packing foods under nitrogen instead of air, or just left out. Chips that don't have them taste just fine. Two others, titanium dioxide, as you've already heard, is banned in Europe from food. And it's due to concerns that extremely tiny particles of it, called nanoparticles, could accumulate in the body and damage the mold. Titanium dioxide is in several state bills and it's prohibited under Arizona's Healthy Schools Act. Aspartame is considered possibly carcinogenic to humans by an arm of the World Health Organization and it's prohibited in certain school foods in Louisiana. It just doesn't make sense for children who are at school to learn to be fed unnecessary chemicals that make it difficult for them to learn or possibly increase their cancer risk. It seems to be up to states to protect their citizens from chemicals in the food supply since it seems to be so difficult for FDA to act. I'm happy to answer any questions you might have and urge you to vote yes on S26. Thank you so much.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you very much. This has been really good, comprehensive assessment of the chemicals that we have put into the bill and the references are hugely helpful. Committee questions. We don't have any at this time, but they will pop up, I'm sure, and it would be great if you might be able to answer them for us either by email or coming back.

[Lisa Lefferts (Science Consultant; former CSPI Senior Scientist)]: I'd be happy to, and I just want to mention that there's a free online tool that schools can use, I've put it in my sites, that can help them identify which school foods contain these various additives, not just dyes but some of the other ones I've mentioned, and identify alternatives to those foods. The analyses I've seen is that it's a very small percentage of school foods that contain these chemicals.

[Sen. Virginia "Ginny" Lyons (Chair)]: Do you have that link in your references?

[Lisa Lefferts (Science Consultant; former CSPI Senior Scientist)]: I do.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, good. We can find it there. Alright, thank you. Might be something good to mention in the bill, I could. It's called green onion, the tool. Green onion. Okay. All right, thank you very much, Doctor. Leppard. We appreciate your time and your patience with us. Thank you. All right, so committee, we're going to move on. Now we're going to move to 01/1997. And we have Juri Song from the Harvard Medical School who's also being patient with us, available for the next forty or fifty minutes. Doctor. Song, thank you for being here. And you are unmuted, that's great.

[Dr. Zirui Song (Harvard Medical School)]: Thank you so much for having me. It's an honor to be here with you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, thank you. And I believe that you have sent us You have not yet sent us any information, but will you do that after we've heard your testimony?

[Dr. Zirui Song (Harvard Medical School)]: Yes. And I have a few minutes ago sent over a PDF. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: We just need to refresh. We'll get it on our web pages.

[Dr. Zirui Song (Harvard Medical School)]: I'm happy to share screen and share with you now if if that works on your end.

[Sen. Virginia "Ginny" Lyons (Chair)]: It it will.

[Dr. Zirui Song (Harvard Medical School)]: Okay. Got it. I just sent over a request to share screen.

[Sen. Virginia "Ginny" Lyons (Chair)]: You're getting it.

[Dr. Zirui Song (Harvard Medical School)]: Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: All right. Oh, terrific.

[Dr. Zirui Song (Harvard Medical School)]: Do the slides appear on your side?

[Sen. Virginia "Ginny" Lyons (Chair)]: We're all set to go. Perfect. Thank you. Go right ahead.

[Dr. Zirui Song (Harvard Medical School)]: My plan here was to share with you the motivation, both from a national perspective and more locally at the state level, for this bill and also this general era of efforts to support primary care. And I'm going to break this very briefly into three parts, the federal, state, and private sector responses to what's happening in primary care today, that I'm happy to talk more about specifics in any aspect of this. We all know from various sources of data that there is a profound primary care shortage in this country. Many states face this to various degrees. And national bodies like the Association of American Medical Colleges have put estimates of these shortages out there in the literature. The exact number matters a little less than really the general degree of these shortages. We know that access to primary care is very much lacking in many communities across the country, and it's gotten worse in recent years. It turns out that, strikingly, less than onethree of residents who have applied to and matched into primary care residencies those are primary care tracks of internal medicine residencies actually stay in primary care by the end of their third year. Less than onethree will stay by the end of graduation. And this has also declined from a little bit closer to forty percent, maybe a decade or a decade and a half ago, to now less than a third. And this data on the right shows us that many of the primary care residents are heading into hospital medicine careers or other subspecialty careers. This further adds to the shortage of primary care, especially at a time when the population is aging, prompting many states and our nation as a whole to try to do something about primary care access. Let me first review quickly the federal response. Medicare, as a program, has tried to support primary care in many ways across the years. Largely, this has been through adding new billing codes for new types of office visits or counseling or coordination of care that primary care clinics or practices can receive Medicare dollars for. These billing codes have been studied. There's a new wave of them just last year and this year. Last year, there was a set of three advanced primary care management codes, which I've listed here on the left. The details are less important for our current discussion. But advanced primary care is essentially defined in this table to the left. And that allows practices to receive, in the study down at the bottom left here, anywhere from, let's say, for a middle intensity or middle level advanced primary care visit code, anywhere from $36 to $49 per patient per month. For a more complicated or medically complex patient case, the practice could receive anywhere from $80 to $107 per patient per month. So that's potentially substantial support. And this year, in January 2026, there is a second set of new codes for behavioral health integration that offers the dollar seen here, again, on the bottom left, per patient per month, depending on the type of behavioral health integration the practices do. And this is the latest representation of these federal efforts to help primary care through the fee schedule. The challenge, however, has been that for the vast majority of these codes that have been added across the last fifteen, twenty years meant to help primary care, they are rarely billed. They're rarely actually used by practices to garner additional revenue. In the vast majority of cases, less than 10% of eligible patient visits that could have garnered one of these codes for extra dollars was actually billed by the practice. There are many compelling reasons why this is the case. These include that practices may not have the capacity to actually do this extra work. They may not have the bandwidth or staffing to do this work. Importantly, these new codes have also never been designated as a preventive service, and therefore, they are not free from patient cost sharing. Thus, by billing these codes, practices are actually hitting patients with a second copay, and it's understandable how many primary care providers would be quite reluctant to do that, understandably so, for the well-being of their patients. And so this federal response has been well intentioned. It's been persistent through the years. It has not resolved the primary care crisis in front of us. And this is one of the reasons that these codes have not really reached the front lines or generated the type of revenue that we think might be able to stem, stop the bleeding in primary care, if you will. Another reality that's been underappreciated is that every attempt to add a billing code for office visits, which is the bread and butter of primary care, has also been received in large part by specialties. In this study currently under review with many colleagues, down at the bottom right, you basically see the take home point that only 28% of federal subsidies or dollars put into primary care billing codes actually reach primary care. That's about a fourth. The other three fourths of these dollars going into office visits are actually received by specialists. And that's because specialists do office visits too. And in aggregate, specialists do more of these office visits and receive a higher share of these total dollars. So if we take a quick step back and look at 2017 versus closer to today, 2023 on the top right, it turns out that despite all of this need for primary care and all of this urgency to help the aging population as patients become more medically complex as they age and get a little bit sicker and primary care gets more complicated with new drugs and new services and new specialties to coordinate, it turns out that despite all of that, we as a country have been spending less, not more, on primary care. Just over time, it's the level and the shares are going down. That's what the top right shows. So that gets us to the state response, which is more germane to our conversation today. And in a short review article on the top right here, which I've just cut the title of, I can report that, as many of you know, many states across the country have taken steps to concretely do something about this primary care crisis. My colleagues and I studied Rhode Island as an initial leader in this trend. Rhode Island, as many of you know, used its affordability standards as a way to increase the share of health care spending allocated to primary care initially by one percentage point per year till it reached a certain threshold. And this policy has evolved over the years and has also been paired with other efforts to improve the value of health care spending, which we cover in this article. But it's meant to be a representation of what many states are trying to do. Here in Massachusetts, where I am, we currently have three bills going through the state legislature that also aim to support primary care in the same spirit rowing in the same direction as our colleagues in Rhode Island, Oregon, California, and Can here in

[Sen. Virginia "Ginny" Lyons (Chair)]: I interrupt you briefly? What is the goal that Rhode Island is headed for within 1% per year?

[Dr. Zirui Song (Harvard Medical School)]: It's a great question, and this next slide partly addresses it. As you can see, this vertical dotted line here on the left is when the affordability standards began. And I'm happy to talk about our first evaluation of this policy, perhaps as a precursor or reference point for what Vermont is considering. But essentially, when we look at what primary care spending looked like before this policy versus after, basically this blue line shows you that total aggregate primary care spending in terms of millions of dollars in the state increased. It certainly increased. There's no doubt about that. And this increase was driven specifically by non fee for service primary care spending. That is support or investments in primary care delivered in a lump sum fashion, analogous to the per member per month or per patient per month subsidies that Medicare has tried to do. And there has been a lot of discussion, and I'm happy to go through this more, of the conceptual basis underpinning why non fee for service efforts to support primary care might make more sense than fee for service new fees. But those remain two potential avenues for helping primary care. At the end of the day, one might argue that the amount of help is what matters rather than the mechanism of the help, but the mechanism of the help also gives you some different financial incentives. Here in Rhode Island, in this example, we see that non fee for service primary care spending rose from somewhere around $3,000,000 before the policy to somewhere around $52,000,000 by 2023. And that is a large increase, which leaves this middle gap, the fee for service portion. So as you can see, the fee for service portion on primary care spending has not really changed all that much, But the increase was really driven by this prospective payment or per person per month type of support.

[Sen. Virginia "Ginny" Lyons (Chair)]: So in Rhode Island, does that include a community, a health team approach, or is it strictly for the primary care provider?

[Dr. Zirui Song (Harvard Medical School)]: Great question. So the support for primary care was tied, at least initially, to patient centered medical home certification. We've also seen that much of these non fee for service investment dollars went to physician organizations, so accountable care organizations or provider groups that were taking on responsibility for a community or an attributed population of patients. The accountable care organization concept has deep roots here in New England, in the Northeast, in large part thanks to our colleagues at Dartmouth. And this is an approach that Rhode Island has also built on. And so it remains a question of intense interest from us in the research community, how the dollars flow from payers down to the front lines of primary care practices. That funds flow remains less well understood. But what is better understood is that after the state made this deliberate effort to support primary care in the face of the common challenges we all face, it was able to deliver more dollars to primary care. And we are currently studying the impact of that on total health care spending and on quality of care. Let me just finish up here by touching on what the private sector is doing in response to the primary care crisis as well. And this is important because when the federal approach and the state approach, let's say, when they are not yet adequate to meet perhaps what patients and frontline clinicians want or need, then often the private sector will step in on its own to provide people relief and solutions. And we're seeing this in the form of the rise of free market models of primary care practice. As many of you have undoubtedly heard, primary care physicians are increasingly leaving traditional models for concierge primary care practices. What does this offer them? It gives them much smaller patient panels, more time with patients, more face time, which is very much valued. It reduces their burnout, their administrative responsibilities. It many times allows them to lengthen their clinical careers rather than retiring early. They might practice for several more years with a smaller panel. What does this offer patients? Well, for those who can afford it and have the means to enter this market, patients receive much quicker access, same day appointments, next day appointments. They can call their patients on the phone. Their physicians will often come to the house to do home visits. They may even accompany the patient to their specialist visits. This is obviously not the vast majority of the primary care system in this country, but it's important to note that it is certainly a growing trend. And especially here in the Northeast, we see a lot of this. This has essentially made primary care go from more of a common good, which many of us in society believes it sort of intrinsically is, although people have varying opinions of that, to a free market commodity, at least more of a free market commodity. And that has a lot of implications for what it means to be a primary care clinician and be a patient with primary care in our communities or in this country. Certainly, are benefits to both the physicians and the patients. But because this hinges on the practice panel size being much, much smaller, it means that only a portion of society is able to access this type of primary care. And for every primary care physician, at least in the short run, who leaves for this type of practice model, there are many more patients on that physician's panel who are necessarily left looking for a new primary care doctor, just at a time when there are no new primary care doctors or capacity to take on those patients. So in the short run, this actually exacerbates our societal primary care shortages, even as it solves the primary care crisis for a small portion of society. And this is not just happening in primary care, as you can see in this graph on the right. This is happening in many, many specialties, many internal medicine subspecialties, in imaging, even in procedural specialties, and certainly in behavioral health for decades. So this is increasingly a trend that is just happening alongside what the federal response and the state response are trying to do. And you can either interpret this as sort of a test or judgment of how well our public response is doing. Because if the public responses were handling the primary care needs well, then perhaps the private sector would have less of a need to step in. Or you can simply think of this as the private sector seeing opportunities where there is a market and creating a market where there is demand, regardless of what the public sector does. In either case, the federal level, the state level, and the private sector are all responding to the primary care crisis in different ways. And I know today we're talking about the state level here, but I just wanted to put this in the context of what's going on more broadly. So let me stop there. I'm happy to answer any questions or talk about any of these studies or areas of research in more detail. Thank you for your time.

[Sen. Virginia "Ginny" Lyons (Chair)]: No, thank you very much. This is very helpful and I know we struggle with the whole direction with direct and concierge practices right now because it does pull away from what I call the risk pool or the patient pool across the community, the common good, is that.

[Dr. Zirui Song (Harvard Medical School)]: Agreed.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, with all of the work that you've done and the research that you have before you, understanding code expansion and the rest, we're in a place right now where we're looking at how do we fund an increase in getting to a higher percentage of primary care. And so within our bill, thinking about code expansion is one thing. You've indicated that. It will be a balance, of course, across the regulatory world. And what other options are there for increased funding for primary care based on your thinking, your research?

[Dr. Zirui Song (Harvard Medical School)]: Well, thank you for the question. The main paths for investments in primary care are doing it on the fee schedule through either augmenting the value or the prices of existing codes or adding new codes into the fee schedule, or doing it off the fee schedule through a per person per month or per person per year lump sum kind of basis. There are trade offs to both of these options. On the first one, the fee schedule options, often states do not have as readily available of levers as the federal government for that because almost all payers in this country use the Medicare physician fee schedule as the backbone for negotiating payment contracts, for the relative pricing of services. So for example, the fact that a fifteen minute cataract extraction is valued at 10 times a fifteen minute office visit, which is the backbone of primary care, is a relative pricing that is originating from the Medicare fee schedule. And it basically spreads across the health care system because private plans and Medicaid often use basically the same RVU or relative value unit or pricing relativity of services in the fee schedule. That same relativity basically means that if you want to support primary care, you might have to start with the Medicare fee schedule. With that said, however, the concept of an accountable care organization, or a physician organization or provider group being paid in a prospective manner, managing risk, having that budget ahead of time, the conceptual basis for that does include the ability to determine your own fee schedule. You've already got the budget at the beginning of the year. You already have the lump sum amount you're using to manage your attributed patient population. You do not, in theory, need to abide by or live by the existing fee schedule with all of its relative price distortions between procedural services and nonprocedural services. It is easier to live by and just rely on that. It's certainly easier to simply use what's always been there. But in theory, one of the advantages of an accountable care organization is that you can decide that if you believe primary care is worth more, at least relatively speaking a little more than other services, you can price it a little higher on your fee schedule. There are some legal aspects of this that are a little trickier, but conceptually, that lever is available. We simply have seen that very few to basically no accountable care organizations across the country, at least that we know of in the academic literature, have really taken on that task of redoing the fee schedule to value what they value. Many would say they value primary care, mental and behavioral health care, maternity care, just as a few examples. But few have really taken on what is admittedly the hard work of redoing the fee schedule. But you can do that. So that's the fee schedule path. And a state could also give a provider organization the budget, allowing them to then shift around the relative pricing in their fee schedules to invest in primary care. Again, it's an unchartered path empirically, but conceptually, it's available. Many provider organizations would know this from the inside that primary care improves health. I mean, the evidence on that is abundantly clear. Primary care improves health. It's even associated with longevity and lower mortality. Areas of the country that have more primary care physicians available happen to also be areas of the country with lower mortality rates. Whether that's strictly causal can be debated, but the association is quite strong. And the value of primary care for patient well-being, for having the longitudinal relationship, walking through the stages of life with a trusted doctor, that we can all relate to and has really been shown for many, many years in the literature. So physician organizations arguably know the value from the inside and would have the motivation to do some work on the fee schedule if you take the fee schedule path. If you don't take the fee schedule path, you actually can find some further advantages. What do I mean by that? Well, many states only have jurisdiction over certain parts of the payer population. As you know, states have authority over their own Medicaid programs and over their self insured state employee covered lives and over the fully insured, rather than self insured commercial lives. Nationwide, about 60% of the population with commercial insurance, most of whom have it through an employer, have it through a self funded plan or a self insured employer. States do not have the authority to tell a self insured employer what to do. Only the federal Department of Labor has that authority. So states are limited in dictating what can be done given a patient's insurance mix or insurance status. So states can really only touch Medicaid state employees and the fully insured commercial lives. But if you move to the second option of supporting primary care off the fee schedule, now that opens up that span of possibilities by giving practices a lump sum amount prospectively, the same way you would pay an ACO contract conceptually. You can now do that and support lives in the practice no matter what type of insurance that life has. You can support a practice based on the number of patients it has, based on perhaps the social determinants of health faced by those communities, by that patient population. You can subsidize more disadvantaged populations directly through the prospective payment, the per person per month payment that's off the fee schedule. And you can really count one life as a life regardless of the insurance status. There is some simplicity and appeal of that, that your subsidies, your investment need not only go to the lives under your jurisdiction, but you can help the residents of your state directly for primary care, regardless of what type of insurance they have. And that allows you to get around the ERISA or self insurance issue. And that also allows you to dictate where you think the support should go more or go less. You might think that not all practices need the same types of subsidies, the same level of subsidies. And you might think that practices associated with hospitals or in certain areas or in certain systems or whatever it may be locally might need a little bit more or a little bit less of the investment. And you can titrate that from a policy perspective much more easily in option two, off the fee schedule. So there are some of these trade offs. And I don't think that by studying states thus far, we in the research community have learned all of the lessons yet. We certainly haven't figured out everything, and there's a lot left to learn. But I think the initial states that have undertaken this journey have taught us a lot. And I think all the federal efforts over several decades and the private sector responses have also added a lot of important insights to this area of work.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. This is good. I mean, it resonates with some of the thinking that we have going on and trying to sort out where we land. We're in the process of guiding ourselves to the target and center field. Any questions committee for Doctor. Song? This is a start for us. Jen, I'm gonna turn to you. Do you have a question that you'd like to ask? So, I think we're good. But we may come back to you. And I know that you've been in touch with Elliot Fisher at Shartmouth, and I've been talking others have been talking with him as well. So we'll try and try and put this all together so we can build a Vermont model. We have looked a little you know, as we were talking about global budgeting for hospitals and we're moving in that direction, it's almost like global budgeting for primary care, so at other end of the spectrum, and then trying to sort out who gets what and how. So

[Dr. Zirui Song (Harvard Medical School)]: Yeah. Agreed.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Okay. So we're good. I say thank you very much. I appreciate your

[Mike Fisher (Chief Health Care Advocate, VT)]: time

[Sen. Virginia "Ginny" Lyons (Chair)]: and your patience with us this morning, and we'll we'll get back to you as time goes on, I'm pretty sure.

[Dr. Zirui Song (Harvard Medical School)]: Sounds great. Thank you so much for your time. It's an honor to be here. Thank you for all of your work and service of Thank the

[Mike Fisher (Chief Health Care Advocate, VT)]: you. Terrific. Right. We

[Sen. Virginia "Ginny" Lyons (Chair)]: do have S-one 189 coming up, which is scheduled at 10:00, and now at 10:15, so we're right on schedule. So we're gonna move right along to 189, and we've got, but I don't know where to begin with this joint. I have a new I have language that Why don't we begin with that? Post whenever you are ready for that. Yeah. I don't think do that. Freeze. Thank you. Yep. And thank you for the reminder. I had you last but let's let's do that first and then people can look at the language that's there. Yes. That's

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Madam Chair, may I for what it's worth. Yeah. So I'm I'm Diane went for Fremont and Fair Forks. I just wanted to

[Sen. Virginia "Ginny" Lyons (Chair)]: say because Emily, who was scheduled to join Jill on this this morning, is sick. Very sick this morning, and

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Owen is on his way over his Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Now that's good. Wanna try to At least we had a replacement. So Okay. So you're just posting that now, right? Yeah, is posting it now and I'm just pulling it up.

[Jen Carvey (Office of Legislative Counsel)]: Alright, good morning. Jen Carvey from the Office of Legislative Council. So I have here a historical amendment to S 189 that shows proposed changes from the bill as introduced using markup. And so, sort of from an overall perspective, the main changes that this draft would make is to still require notice and public engagement process, but not create a specific approval mechanism for proposed possible service reductions or elimination. So this is S-one 189. It's an isolating to an approval process for reducing or eliminating hospital services, although you'll see at the end that I proposed changing the name of the title of the bill as well. So this would amend the new section that is being added on hospital service reductions to instead of saying approval required, saying notice required, and it strikes the specific language at the beginning saying hospital shall not reduce or eliminate any service without approval from the Secretary of Human Services, and then just carrying that any service concept into the new language saying, hospital that proposes to reduce or eliminate any service shall. And then, as I said, keeps this whole notice, been providing notice of intent to the agency of human services, Green Mountain Care Board, Office of Healthcare Advocate, the legislators who represent the hospital service area, explaining the rationale, describing how it is consistent with the statewide healthcare delivery plan, and the community, the hospital's most recent community health leave assessment. It keeps the requirement to post the notice of intent on the hospital's website, and publish it in a newspaper of general circulation. Conduct a public engagement process, including at least one public hearing, and to provide a summary of the community's response to the proposal, including the public comments received to the Agency of Human Services. Takes out the weekly requirement, but just says following the conclusion of the public engagement process. So they would kind of compile all of the public comments received and provide them to the agency. Then it strikes the language requiring the agency of human services to review the proposal, proposed reduction or elimination, and the criteria for approving it, and instead simply says, so we've had the hospital provide the notice, we've had them do the public engagement process, and now, a HOTS, and with the RISE proposal, if a hospital elects to proceed with reducing or eliminating a service after completing that notice and public engagement process, then the hospital must notify the Green Mountain Care Board within five business days following its decision to reduce or eliminate service so the board can review the impact on the hospital's budget. And then keeps language in the hospital budget review section, keeps the striking of the process added last year, and just revises the language for consistency with that new approach, which would say upon receipt of notification from a hospital, pursuant to 9,405 D. B, that the hospital intends to reduce or eliminate a service following its completion of that notice and in public engagement process, code 9405A, the board reviews the impact of the reduction or elimination on hospitals budget, and still allows the board to adjust a hospital's budget if necessary to reflect that elimination or reduction, and we're keeping language saying that may include directing that any savings related to the reduction or elimination are returned to payers and from doctors to address portability concerns or are reinvested in primary care prevention and other community based services. I would still take effect on passage, but the title would be amended to say an act relating to establishing a process for reducing or eliminating hospital services without a formal process. So it shortens the process significantly, puts in the formal engagement process. Right, so it doesn't change any of the timing of the process except taking out the agency human services approval component. Okay. But there's nothing here that has the agency evaluate the recommendations for service reduction or additions in the company? We address addition. There's no addition as an added process. I mean, it may through the Green Mountain Fair Board But and their budget no, it strikes the language that has the agency review the proposal and consider the community's response and the impact of the proposal on access and then takes out language saying that the agency can approve the proposal if the agency finds it not inconsistent with the strategic plan or community health needs assessment, that it doesn't undo the burden access and the advantages outweigh any disadvantages. And the notice that is sent out goes to the legislators in the area, the hospital area, and doesn't go to HRAC or any other joint slinging that. Right, it goes to the Agency of Human Services, the Green Mountain Care Board. This is the same as in the bill that's introduced. Office of Healthcare Advocate and members of the General Assembly representing the hospital service area. Okay. We can certainly add anybody else on I just think maybe changes When was thinking about when the problem decision hit the fan, was asked to We need to put maybe HRAC in there for the people who are keeping my performing. Yeah, and you can have the committee's jurisdiction during the session, or HRAC outside of Yeah, the something like that. Okay, all right, so those are some of the areas that we're gonna hear about. All right? Thank you. We're gonna listen to, why don't we, this was a board request to bill S-one 189. Owen, do you wanna kick us off with this one?

[Sen. Virginia "Ginny" Lyons (Chair)]: Morning. Good morning. Welcome.

[Owen Foster (Chair, Green Mountain Care Board)]: Owen Foster, the chair of the Great Mountain Care Board. I called in to chant a little last minute, so I apologize. I'm away when I thought she's ill today. It's okay.

[Mike Fisher (Chief Health Care Advocate, VT)]: In short, I disagree with

[Owen Foster (Chair, Green Mountain Care Board)]: the change striking AHS' review. The reason for that is, Miranda's bill currently exists, is there would be no review or approval process at all. The hospitals make the decisions, and that's fine, except when the hospitals have made the decisions in the recent past, they haven't done so with a view towards the system. They've done so with a view towards their institution, which is not along the equity of their communities to institution, but it doesn't have the overview of how does this going to all fit and work together. I believe that review should be at the agency community services. This committee, the legislature has tasked AHS transformation. AHS has received $194,000,000 a year of scribe transformation. HS and S 126 last year was tasked with transformation in Act 51 in 2023. My concern with the board is that we get some the review pieces ad hoc. So we get one without any resources to consider how it fits with all of the other changes that are happening, and without any consideration of the agency's strategic plan and vision as to how they want to finish this. So if I get a review decision, and I don't know what the agency's perspective is on how they're going to spend rural health funds, or what their statewide strategic plan is going towards, I might make decisions that are not consistent with what they want to do. That does not make sense to me. When I was applying for the CARE board, one of the discussions that with the Center Alliance, you asked me was policy versus regulation. I think we've all kind of landed at the CARE board's regulation in policy since the agency. Redesigning the system, to me, is policy, the policy choice, looking what where. And when you have a statewide strategic plan, why would you have another entity make decisions, thumbs up, thumbs down, and have somebody else design the plan? It doesn't even make a whole lot of sense. I think if we go through the recent history of some of the changes that have happened, you can see how they're actually harmful to the system. So having no review may actually leave us with a number of things that we really want, right? And that is what happened. Let's start with UBMs. UBMs cut primary care, it cut dialysis, it cut inpatient psych. There's no one in this room that can tell me that that's what we wanted in the state system. So if we have no review, you will have that. That's not what we want. Second, cut the cut bourbon. I don't believe anyone ultimately believes that cutting birthing was the right decision at the state from a strategic standpoint. If we have no reviewer, we will lose more burning centers. You will have maternity desolates. And then most recently, we had rotten cut inpatient pediatrics. And that also looked like it very likely would have added cost to the system. It would have saved rotten bunny, yes. But for the system, if you're trying to improve affordability, it very likely would have made it more expensive. I say that because the patient still would have gone to Rutland, they would have gone to the ED, they wouldn't have been inpatient pediatrics there, they would have been put in an ambulance if they could get an ambulance, they would have been moved to Burlington, they would have then been inpatient at Burlington or gone into the ED first. You're duplicating the services that are being provided. That adds cost to the system, it doesn't remove them. So if we're not reviewing from the system perspective whether these are good or bad, I think we're actually gonna make costs more expensive. So I just don't agree with having no review, because I've lived this and I've seen the changes, and I can't point to one of these where I said, oh that was the right thing for the system.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so let's suppose that this would forward without that system review that you're talking about, then what would be the consequences of that? What would happen after the public engagement process and then the decision comes to you possibly during the budget process.

[Owen Foster (Chair, Green Mountain Care Board)]: Really good question, incredibly concise. Yeah. Because if you may, like let's take the Rutland example, or even the coffee burning example. So those birds at coffee, very likely are going to go to UPM or CPMC, they're double or maybe triple the cost. So again, we've added cost to the system if that's actually approved or not even reviewed. So then it comes to the board, but now everything's out of whack because the insurer might need more money to cover that additional expense, that now they're paying 30,000 rather than 15,000. And also, if UBM is losing money on those birds, they may come to us and say, hey, we need more rate. We just took off these birds. Burbank, right? So it really makes it very complex from a regulator and a budget standpoint to get a whole mess of these in the process that may not even be beneficial to the state. I think theoretically, the way the statute's written is probably the best we can do without an approval process, and what the board could do is say, okay, rather than you cut inpatient pediatrics, that was $5,000,000 in revenue, 5,000,000 revenue's gone. Or we could say, you had higher prices to cover the losses, we're gonna lower your prices because now you don't have those losses. But then you're shifting it somewhere else and maybe adding on two or three more touch points or higher prices. So it throws all of it into a very confusing. And keep in mind, when we're doing this, we are doing 14 budgets in two and a half months. So you're adding significant complexity.

[Sen. Virginia "Ginny" Lyons (Chair)]: So an added question to that then, with this process, does it change what you went through at the board, you, the board, went through when these other changes were made. Does it change what you know and how you act?

[Owen Foster (Chair, Green Mountain Care Board)]: Yes. So the way, I think I can, so the way the statute was originally written for the board, did the review and said yes or no, but again, that was complicated by, like, didn't have that system view or the strategic planning of where we wanted to go as a system. So this would change it and that the board wouldn't be doing a review, the agency wouldn't be doing a review, and the hospitals would be making their own decisions.

[Sen. Virginia "Ginny" Lyons (Chair)]: So going back to my question that it doesn't really change where we are, Except there is a public engagement process.

[Mike Fisher (Chief Health Care Advocate, VT)]: Which I very much I think

[Owen Foster (Chair, Green Mountain Care Board)]: I'd really do with that. Okay.

[Unidentified Committee Member]: Questions? I think that's very complex. I understand the system piece, try to maintain the system, But in reality, you know, hospitals are a business. And when they're losing money on a business, that's their general reason why they want to eliminate a certain service. Even though we may say, we really would like to maintain that service in that event, somewhere then that cost gets shifted to other costs. And if we're trying to go to a different way of paying for hospital services, where does that get made up? We now establish what the cost is that they can get from these other services. So we are pushing the hospital to working into the negative. So that's a concern I have in in where this would go. Also, you have a situation where some of these hospitals may have one person providing that service, that key service, they don't control that individual. That individual could retire from move on to another location, And so then they're faced with

[Sen. Virginia "Ginny" Lyons (Chair)]: Senator, what I'm gonna say is do you have a question? Because what you're getting to is discussion on the bill.

[Unidentified Committee Member]: Well, I'm looking for from the Greenbelt Care Boards indicating they wanna maintain this control over the system, and I'm asking how you're gonna do that in reality when in fact the hospitals don't really have total control over their staff, right? I understand the question, so I think

[Owen Foster (Chair, Green Mountain Care Board)]: I understand the question. I'm not there. Two things, the Green Medical Care Board does not want to maintain control over this. We believe it should be at the agency of the services, because they are the ones dividing, thinking about the system and the resources to do what's needed. So, and then your point about people can leave and quit and retire, or whatever it might be, yeah, that will happen, and they will lose the service. In terms of like working and driving them into the negative, the point is that there are some things we need to maintain in communities, and we, that's why you have regionalization, you have centers of excellence. Not everyone can have, we all recognize that. Not everyone can have inpatient centers. There's gonna be decisions made. That's my overall point here, is that we want a strategic thought as to what goes where, and to prioritize what we must have in the communities. And when the care board does it, we're not doing that because we're not redesigning the system. The decisions that are being made are not with that overview, and that's not good for the system. If you allow the hospitals to just cut what they need to cut the lowest losers, then you're just gonna have a very, very bad healthcare system. The whole point of the healthcare redesign that the state began in 2022 was to have an intentional system. If we were to look at this all today, is this what we would want? And the answer is not at all. Now, how did we get here? It's really by Catholic stance, how things got built, but it wasn't intentional. So states put a lot of money in to let's make sure we do this intelligently. And that might mean that there are some services that lose money. It might mean that you have to pay for some things differently. But what we don't want to do is the exact same thing of how we got here, which is by Kaplan's stance, have what we got, right? That does not work for patients. When you talk about access, we want maternity deserts where people can't have births. No, we don't. We need to make sure we're actually having the services that we have to have prioritized in the community. We're gonna have that health system that we already do.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: One more question. I don't want to split hairs, but I actually want to ask a question about something that you said, because I think it's important to the discussion. Are hospitals businesses, or are they nonprofits providing them public goods? I think the distinction is really important.

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, all Vermont's hospitals are nonprofits. I think the points are kind of similar, actually. Mean, they have to be solvent, and part of that might mean, like the way I look at it is you're losing money on birthing, but you're making 10x margin on MRIs. Maybe you need to lower your MRI prices, move the prices over to further. Maybe need to negotiate with the insurance companies so you're actually keeping the services that we really, really need. It shouldn't be run just like a business. It should be run-in terms of what the community needs, but there is also the reality that they need to be solved, and they're really pressured, a lot of them, especially the wrong communities.

[Unidentified Committee Member]: That is my concern. It's a good concern.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's all concerning. Thank you for your testimony. I understood. I understand what you're saying. So this is gonna be a discussion, we think, going forward. Mike Fisher. Welcome.

[Mike Fisher (Chief Health Care Advocate, VT)]: Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: You haven't been here much. I've been in a little while. We need to be brought back to the real world.

[Mike Fisher (Chief Health Care Advocate, VT)]: To the real world. Send it to HealthMonthra, it's the real world.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Thank

[Mike Fisher (Chief Health Care Advocate, VT)]: you. Mike Fisher, healthcare advocate. And I do not have something in writing for you because I am literally listening and reflecting on the conversation that's happening with the team. So I do have a few thoughts. One of them is and and we find ourselves at an interesting moment right now. We you know, this sort of broad recognition that the task of repricing our systems such that we can afford it is going to hurt, and it's going to be a tough transition. You have, you know, built out a runway to move towards a different way of paying hospitals, reference based pricing, global budgets, and we're not there yet. And the the financial pressure is being applied today. You know, the Green Mountain Care Board's hospital budget, draft hospital budget guidance has negative 1% growth rate. So the pressure on hospitals is by last year, it's going to be applied this year. On top of that, we have this history of hospitals. Think I there's evidence that hospitals have been interested in their co advocate bottom line and have at times put their revenue baskets in certain things like, you know, sort of generally things like orthopedics and not things like family medicine, you know, or delivering maintenance or inpatients. And so when we apply pressure financially, in order to be able to afford the care that Brahmachics needs, the right business decision for a hospital in the short term might need to not deliver this, because they make a lot money doing it publicly. And so I do I I I appreciate the addition of a public process. I think it's a step forward for the hospital's community to out of the process, but I don't think it's enough. I think in this return time, hopefully not fantasy, that when we get to a place of having reference based pricing and global budgets, that this will be so these dynamics will be captured by those processes. But at this moment and in the transition to it, I think we're exposed in a different way and have a great deal of fear. So I think if you want to just reflect a little bit of irony at the moment, I've been sort of asked the question of what's it look like when you tell a hospital you don't want to do something that's got to do it anyway? You know, can we do that? Here we have a moment where you have the likes of me, and I think the board saying, this is important, it's got to be done, and you have parts of state government saying, I can't do it. So I spent a lot of time around this process these processes. I you know, the the board I don't want the board to be punished for its own success here, but the public process, the typical public process that the board undertakes for a thing like this makes a difference. It you know, I you know, there's a thousand details about the experience of the Rattling Inpatient story that you would get witnesses coming and telling you different stories about, but from where I sit, there was a big community of providers in that who didn't feel like they had an opportunity to speak until there was a public process in place for them to come. And then, if they speak, And it would be interesting to hear their perspective. And ultimately, at least for the moment, Rep. M. Lester, this proposal composes the patient can get to. And, and from my perspective, that was good process. People got to come to the table and speak out loud, and that doesn't mean that I can draw the conclusion at the end of the day whether the outcome is right

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: for a retina system,

[Mike Fisher (Chief Health Care Advocate, VT)]: but process is important. So just to say it again, I think it's a step forward to have a public process at the hospital level. And it is, I think, very important, particularly at this moment, to have a decision maker have to entertain based on some parameters that you might frame up, whether it makes sense, not just for the hospital, but for the region and the people who manage it.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Hi. So we have Jill Nelson is here. Hey. Good to see all.

[Jill Mazza Olson (Agency of Human Services – Medicaid and Health Systems)]: I'm Jill Mazza Olson, adding the HS Medicaid and Health Systems So, I just want to take a little bit of a step back just to make sure we're all oriented to the current law versus what this would do. So under current law, it's actually the Green Mountain Care Board that has this oversight obligation to extend this decision making process. And that's what the original version, that's what S-one 189, the original version sought to change. It would have moved that process over to AHS. So current law is that this oversight process belongs with the Green Madam Care Board. And there is an exception clause for the agency of human services so that if a change is happening, sort of pursuant to the transformation work that we're doing and planning with hospitals, it would be accepted from that process. So that's where we're starting from. And so I think the question, honestly, that you're still wrestling with, and you hoped that we would come to agreement with the Green Bank Care Board, is if you want to have this sort of regulatory oversight, where does it live? Right now it looks at the Green Bank Care Board, Chair Foster is suggesting it looks to HHS. As I testified when we first started talking about this bill, we don't think we can regulate what we help create. And that's what you would be asking us to do. So we are working on transformation plans with hospitals in a consultative way with technical assistance and helping to provide some of the antitrust sort of protection by having conversations with one hospital about what they're thinking, having a separate conversation with another hospital about we're thinking, and then potentially bringing things together in a way that doesn't violate some of these federal rules that make some of this collaboration harder. And so we are actively engaged and involved with the development of all of this work, the regionalization, the internal work to create new efficiencies, the clinical collaborations. So I don't see how we can then take a step back from that and be the regulator. We've never thought, and this is what I testified before, we've never thought that it made sense to have essentially the innovation work and the regulation in one shot. And so, it's in two now, and if you want to keep it somewhere, would, honestly, would keep it where it is with the Green Med Care Board. They are a regulator over hospitals. AHS really isn't a hospital regulator. And also, they do have the authority over the hospital budget, and these do ultimately become a question of hospital budgets. Why I've actually, I'm comfortable with this language as introduced, or this amendment, because I do feel like, so I think there's like near agreement except on the nitty gritty of what do we do. So the concerns about hospitals making decisions that don't consider the whole system, I think there's broad agreement that that's a concern and that's something that we're paying really close attention to. I think there's broad agreement that we want to preserve certain kinds of services that under current payment models are some of the things that hospitals look to first when they are financially struggling because literally of how they're reimbursed. In my view, we have a fair amount of letters already and are developing more to, as long as we have the notice and the public process so that we understand what's happening in communities before hospitals can just announce a closure. I think we have a lot of levers and we're building more. Reference based pricing is gonna be another lever. We have Medicaid hospital global budgets. We're moving toward other kinds of global budgets. So we have all these other payment mechanisms and regulatory levers that I think will help us influence how these things go without necessarily building this sort of regulatory structure. So I think we would be comfortable with the approach in this amendment. I hear that Chair Foster is not, but if you really want to keep a process in place, we would ask that you leave language essentially as it is today.

[Sen. Virginia "Ginny" Lyons (Chair)]: So we're we're getting used to this investment. But both your comments, I would say both, all three of the comments you've heard this morning are very compelling. And so I'm not sure we're at a final place yet. Somehow, in the development of the regionalization and the discussion that HHS is having with the among hospitals and decision making. There are decisions in there and some of it will be left to hospitals. We understand hospitals are very much independent, autonomous organizations and they're trying to work together and we get that. Ultimately, the healthcare delivery strategic plan is gonna be something. There will be decisions made within that. Somehow it needs to inform any decision that's made around budgets that happen at the board level. At the same time, I think it's really difficult. I'm hearing what you both say. It's always been a question of mine. Policy versus regulation. And we're caught between a rock and a hard place because everybody's doing everything. So here we are. I guess what I would say is let's have a short conversation and then from my perspective, we're not finished with this yet. I don't think we can say, yeah, it has to be this way, it has to be this way, and this is the group that's the decision, and the rest of you are gonna have to live with it. I'm not sure we're there yet. And I do respect the comments that Chair Foster has made and Mike Fisher has made. Having this is me, I don't know, everybody can disagree with me, but having the public engagement is important, absolutely critically important. Who's involved with that? What information is taken in there? Is it all local? Is it regional? Is it information that comes from AHS based on the strategic plan? What is it? We'll have the public comment on it and then maybe we'll make some changes and then we'll go forward. Sometimes, I don't know how this all will sugar off, but I'm just So here we are again with competing interests. I think the interests have common goals, there's no question about it. So I will end there for now. I'll look around the room for comments. I know you're sitting there, if you wanna

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: Should I just lay here or move? I take

[Sen. Virginia "Ginny" Lyons (Chair)]: that so we can have a broader conversation with folks and just for a few minutes because we do have some time to do this. We're eating until Ledge Castle's time and I know it. She's really unhappy about that. Play upstairs at eleven. You're here at eleven, I know that. From over 190 in three minutes, but I just Go ahead.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Devin Green, Vermont Association of Hospitals and Health Systems. We appreciate the public process piece and the notification piece. We think that's really important. Question my members have had from the outset is what happens if you say no to our proposal? Is the state going to subsidize these services so that they can be available? Are you going to give us the specialists that left? Like, what happens next? That is where we are struggling in this process.

[Sen. Virginia "Ginny" Lyons (Chair)]: Understood. So, with that in mind, then the process that currently happens, whether it's kind of a negotiation between board and hospital or other interested parties, That's a process that you're not opposing.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: We don't totally understand how it works.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, okay. Right? Any Yeah. Comments? I

[Owen Foster (Chair, Green Mountain Care Board)]: would tend to agree with Ms. Green on that. Think it is very difficult to point if somebody retires and the board says no. Keep in mind the board's five people, and you get three different viewpoints, it can put them in a difficult position because you have three people making an ad hoc decision that moment. To Ms. Mazza Olsen's point, I agree with a lot of what she said, the only thing that distinguishes to me, we still have the regulatory side, we still have the budget side in this bill. Yeah. Right, but the policy decision is as to what goes where, and as AHS is developing a strategic plan, and as they're working with hospitals today, there are decisions being made. So I don't understand the distinction about why there can't be a decision. They're making decisions every day on what it looks like. Why are there decisions in this process?

[Sen. Virginia "Ginny" Lyons (Chair)]: Is it a decision or is it a recommendation? I know, so I'm just caught between here.

[Owen Foster (Chair, Green Mountain Care Board)]: Well, could be, I think you could to a middle ground of a recommendation or an opinion on it, right? Because where we're struggling with is what is, is this good or bad from the system perspective? That we So don't if it's a recommendation from AHS, I think that's, we believe, so to be fair to AHS, think also this is developing as they go. So they're getting these today, or they would be getting these today or tomorrow, but the strategic plan isn't done. So is it really fair to say, hey, thumbs up, thumbs down? It could be a recommendation. It's the same thing with the board. If we don't even have a vision as what the strategic plan is, how do we bounce up from that?

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, so, I mean, now it's the hospital that's saying we fit in with the plan. But maybe there's some other suggestion on the part of AHS that, yeah, it does or does not, this really fits in with the plan, it really doesn't, and these are the concerns, these are the budgetary concerns I know hospitals will have. Ahead, Jo. Thanks so much, Jo Olson. So, one of the

[Jill Mazza Olson (Agency of Human Services – Medicaid and Health Systems)]: things that I worry a little bit about is that there's an idea that we're gonna create a static strategic plan that just sort of lays out exactly what is going where, rather than actually what's really happening, which is we are living in a dynamic process where there are changes constantly happening. And so I don't think there's ever gonna be sort of just like a laundry list we can go up against and say yes, no based on the laundry list. So I'm a little worried that people think that we're creating something that I think

[Sen. Virginia "Ginny" Lyons (Chair)]: is more important than ever this table thinking that. Great. Always been an action plan. Yes. Always been an action plan. And so the changes are coming. And we've seen that. Yeah. I mean the list that Chair Foster gave us with dialysis, birthing, pediatrics, that's a dynamic process. So the concern is, does that decision fit with the ongoing regionalization decisions or actions that are being taken? So for me, it's not, is it the decision that goes, you decide you can do this or you can't do that? Or is it a recommendation that it's fitting in with the negotiations that are going on and there's a public hearing that's gonna help inform them? So, trying to figure this out.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Devin Green, I think a public hearing provides a lot of accountability to that hospital, and we are willing to do that piece. And what I would ask going forward is if these decisions fit into the plan, that the Green Mountain Care Board and AHS come to those public hearings and support those decisions and stand behind them.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: I know you're full agreement care board.

[Sen. Virginia "Ginny" Lyons (Chair)]: But as a planning piece, the just might I don't

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Or legislators. We've just asked for state support on some of these decisions.

[Rosie Krueger (State Director, Child Nutrition Programs, Vermont Agency of Education)]: To I don't think planning We're

[Devin Green (Vermont Association of Hospitals and Health Systems)]: gonna make you drive to North Country. But we like, one way to get like, we understand we need to be accountable to our communities. We think it would be very powerful if the state stood behind some of these decisions that these very difficult decisions that we're gonna have to make. And if the state doesn't stand behind them, their absence will be noted. And a lot of times there are consequences that come from those decisions.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, here we are. Such a good one. Okay. So my suggestion. So this committee really enjoys the hallway conversation. And if there's a way that folks could get together and make suggestions. You've heard our comments. I mean, I'm thinking your comment about having AHS or board put information in during the public hearing process, that's one. AHS or board making a recommendation, that's the number two, and who does that. But I think given the work AHS is doing on regionalization and on the plan, a comment would be helpful or a recommendation would be helpful. Not convinced that it's a cut and dry decision. I don't know if we're there yet. We're gonna have to come back to this. I know we're gonna have to come back to this regardless of what we do. Let's hold that thought and we'll continue the conversation. We it is important that this bill have a path forward this year and I really respect the recommendation that the board has brought within the original bill. And it does begin to look at how we separate regulation from policy making. We have to keep doing that. And I do respect the AHS and that's because they're not. Okay. Great agenda. Oh, okay. She's. Yeah. Joe, I'm I'm gonna say let's take a a six