SmartTranscript of House Appropriations - 2025-02-20 - 3:05PM

[Chair Robin Scheu]: Welcome to the House Appropriations Committee. It is Thursday, February twentieth twenty twenty five. It is just after three o'clock, and we are continuing our tour of the f y twenty six budget, And we're delighted this afternoon to have the Green Mountain Care Board with us. And as I mentioned on the break, you haven't been in here yet with this committee and this biennium. So we will go around and introduce ourselves so you can meet all of us, and then we'll have you introduce yourselves and tell us about your budget. Good afternoon. I'm Dave Yacobucci. Dave Yacobucci. Represents the Lamoille Washington district. [Member Tom Stevens]: Bob. Hi. Mike Magro. I represent Bennington. Tom Stevens from Waterbury with presenting the Washington Chittenden District. [Vice Chair Jim Harrison]: Good afternoon, Jim Harrison. Chittenden, Menden, Kellington, and Fitzio. [Chair Robin Scheu]: And Robin Shai from Middlebury. Fitz Loomley from Burlington. [Vice Chair Jim Harrison]: Trevor Squirrel, Jericho and Unveil. [Member Tom Stevens]: Wayne Rush, Highgate, Franklin, Berkshire, and Richford. Mike Berwicki from [Member Michael Mrowicki]: the Wyndham Ford District of Putney and Deverston. [Member Eileen Dickinson]: Hi. Lynn Dickinson. I represent Saint Albans Town, and I just wanna point out the vacancy that's John Kosanke who is from Burke. He represents ten towns in my kingdom. [Chair Robin Scheu]: Maybe most of the Burke towns have been in district. Larry Weaver has twelve. Oh, he knows. Okay. [Member Tom Stevens]: And two gores. [Chair Robin Scheu]: Yeah. And two gores. Alright. So welcome, and tell us about who you are and what you do. Thank you, chair Gey, members of the committee. [Chair Owen Foster]: It's a pleasure to be here. We always have enjoyed our opportunities to send to the House Healthcare Appropriations Committee. I'm Owen Foster and I'm the chair of the Green Mountain Care Board. I worked as a chair since October first of twenty twenty two. And I'll give an overview of the board and some of our work, and then we'll turn to the details of the budget that pleases the chair of the committee. [Executive Director Susan Barrett]: Hi. I'm Susan Barrett. I'm the executive director of Green Mountain Care Board. I feel really old saying this. I've been in this position for twelve years. Oh, I'm sorry. I'm really good. Likewise. I'm Jean Stutter. I am the administrative services director for the board. [Chair Robin Scheu]: You brought somebody else to you today. Oh, yes. We did. [Member Eileen Dickinson]: We did. We're chatting. Oh, [Chair Robin Scheu]: I'm Diane. I work in the, Green Mountain Care Report. Probably the newest hire on this team right now. Thank you. And is somebody online also you received? No? Okay. [Chair Owen Foster]: Great. So, first, the Green Mountain Care Board, those of you who have not heard us testify before, we're an independent, regulatory board. We're quasi judicial. And what that means is we operate in a judicial like setting. Number of the procedures we have are reviewing audits for insurance companies, hospitals, accountable care organizations, and the like. Those are quasi judicial that there's evidence presented. We receive the evidence. We question witnesses, and then we have deliberations and votes issued written legally binding opinions and orders on the matters before us. We have five board members. I'll give you a brief background who we are. So I'm a lawyer by trade. I was a federal prosecutor. My job right before this prosecuted health care fraud, and I represented doctors and medical malpractice for the justice department. I investigated pharma companies, electronic medical records companies, [Vice Chair Jim Harrison]: the [Chair Owen Foster]: gamut. Jessica Holmes is economics professor at Middlebury College, and she recently started a health policy health economics program at Middlebury College. Member Lunge has been on the board eight years, almost ten years, I believe. Member Lunge is a health policy expert, has been involved in many, many, many of the state's efforts to improve our health care system over the last twenty years. She's departing the board on April fifth. So we don't have her much longer. We're gonna get every influence of her between now and then. Doctor Merman started the same day as I did. He's a emergency room physician at Central Vermont Medical Center. And Tom Walsh is also a health policy, professor and a physical therapist, as well. We have staggered terms with the intent of being, apolitical and that not one governor will appoint all of us. Although at this point, governor Scott has appointed all of us, some of us twice, myself twice, I think Jess Holmes two or three, no two, and member of Lund has been appointed three times now. So we are all Scott appointees at this point. I think two of them started with Shumway, if I remember correctly. So the important point here is, we're very transparent. All of our board hearings have to be in public. The public participates heavily in our processes, which is a great thing. And, we don't answer to the administration. The administration does not have influence on our decisions, either through AHS or a governor's office. It's It's important to remember what we do and what we don't do. A lot of people sometimes conflate us with Medicare or Diva or AHS. We do not control many, many, many, many facets of the health care system. We have a system wide view, and I would argue that all of our decisions are interconnected with the rest of the health care system and have downstream impacts, which we need to be very cognizant of, but we do not directly regulate a lot of the system. We do not regulate the federally qualified health care centers, independent providers, ambulatory surgical centers, other than certificates of need, out of state providers, mental health, long term care, DAs. None of that is in our, authorities. We also do not regulate or set Medicare or Medicaid rates. We don't regulate Medicare Advantage. We don't regulate self insured plans or out of state health care plans. So we have kind of a small slice, but an important slice, and the focus of it is really hospital budgets. In there, we typically review how much revenue they're bringing in, the cost structure, their expenses, how they're use using their resources, and their map, they can increase their charges to commercial insurance. On insurance, we only regulate the qualified health care plans, and they're only as to the amount of rate increase they can charge. So we don't regulate other insurance providers, and there's a lot of aspects of their work that might be covered by DFR other regulatory bodies, not us. And then accountable care organizations, we regulate their budgets. I'll talk a little bit about what we what we've done there to give you a a flavor. [Chair Robin Scheu]: What's TCOC? [Chair Owen Foster]: Yeah. Good question. I Okay. The total cost of care. Oh, okay. I'm in the states. Yeah. [Chair Robin Scheu]: I haven't gotten to this one yet. Thank you. [Member Tom Stevens]: Go to the next one. [Chair Robin Scheu]: Oh, sorry. [Chair Owen Foster]: So I'll walk through some of the big if you do other work data and reporting and policy works, we have a number of annual reports that you'll likely receive that our team does. We also have prescription drug advisory board analyzing how we can the state can begin to regulate potentially pharmaceutical prices. So that's where it's it's not regulatory in nature, but other things we do. So hospital budget review, we have three staff that work essentially full time on hospital budgets. These are a huge part of the state's health care spend. State's health care spend is between seven and eight billion dollars. Hospital budgets are about three point seven billion dollars that money right now. And hospital prices and expenses associated with covering hospital bills is increasing dramatically in the state and isn't impacting the affordability crisis we have now here. And to give you a sense of some of the decisions, in fiscal year twenty three, the care board approved the total amount of revenue the hospitals requested. But a couple hospitals went above that amount. There are very large increases. In this last year, we enforced the budgets, which I don't wanna get too complicated, but it saved about ninety million dollars ish for commercial insurance. Hospitals went over by too much, and because of that, we reduced the prices that commercial insured Vermonters have to pay. Does that make sense? So if they go over the budget, we review it, and we consider whether or not it was appropriate. If not, it will result in a reduction in the amount for monitors have to pay for commercial insurance. In fiscal year twenty four, we reduced hospital budgets by around fifty million dollars. And in fiscal year twenty five, we reduced hospital budgets by about a hundred and forty five million dollars. And I'll give you a little bit of context as to why those decisions were made when I get to what I'll call the state of the state health care. [Chair Robin Scheu]: Yeah. Lynn? Just to clarify, [Member Eileen Dickinson]: when you say that you have sim seventy million dollars that you reduced commercial insurance, kids, is that paid for premiums by policyholders? [Chair Owen Foster]: It's the level of rate increase that the hospitals would charge to insurance companies. So if a charge costs a hundred dollars and they want a ten percent increase, it will now cost a hundred and ten in the next year. If we reduce the rate one percent, that amount will now cost ninety nine. So it'd be the charges that they charge insurance companies. [Member Eileen Dickinson]: So it's what they charge the insurance. So Correct. Save it because they've got [Chair Owen Foster]: Correct. [Member Eileen Dickinson]: A lower reimbursement. [Chair Owen Foster]: Exactly. And that can have two benefits. One, it can promote insurer solvency. Some of our insurers have serious insolvency risks, or at least one has very acute solvency risks, and they need to have adequate reserves to pay the claims. And so if you reduce the amount they have to pay, it gives them some room to put that money back in the bank, pay claims, or they can pass it along to their customers by not increasing their charges to customers as much. So I think that makes sense to everyone. It looks like I'm getting head nods. Can I go through this a little bit briefly because the ACO, the accountable care organization, the state for the last eight years has been in a health care reform effort called the all payer model? And there's a lot of complication to it, but at bottom, it's an effort to improve health care by paying for health care in a different way. And we have a structure called an accountable care organization. It's called OneCare Vermont. It's a subsidiary of the UVM Health Network, and they they run their key feature in the all pair model agreement. There's a cost to having that infrastructure. Annually, it's typically twelve to fifteen million dollars in operating expenses, and we hope that that investment in their operating expenses will result in lower health care and improved access and quality. The ACL model is ending at the end of this year, December thirty first is over. The care board did a return on investment analysis to assess whether or not it worked or saved money, and it is depends on how you look at it and who you're saving money for. If there's one thing I think everyone should understand is when we talk about saving money, we wanna make sure we're you know, who we're saving money, Medicare, Medicaid, or commercial. Those are the three big payers in health care. And Medicare is obviously federal, and we take part of that. But that's the one that we we don't really care if we save Medicare that much money. We'd rather get more money from the feds and pay less elsewhere. Medicaid is for, people with financial difficulty paying for health care, and the state pays about half of those costs through taxes, and then the feds pay the other half. And then commercial, our people and our businesses pay. Right now, we wanna really focus on saving commercial as much money as possible because of our health care affordability crisis that we have. So in our ACO review, we have two point five FTs that work on this. There's the big ACO, One Care, and then there's three others at this point, maybe more coming. We review their budgets. We review them for compliance with their criteria to to work in this state. And we've made some decisions last three years that have reduced their budgets. We found that their administrative costs for them to operate were too high, and we felt that the money should be reallocated to care. I have a personal view that we spend too much money on health care bureaucracy and not enough money on health care. As a state, I think that's my view is that's true. I say that as a health care bureaucrat. I don't know. On [Vice Chair Jim Harrison]: that particular issue, I'm not we'll get into the weeds of your Peruvian and so, but there's a new group, you know, for my health care nine one one or something. And they have talked in some of their newsletters or emails about that same issue that suggests that some of the Vermont hospitals are quite a bit higher than their peers. Do you measure that, and do you know where we where we fall? [Chair Owen Foster]: Yes. We do measure it. And that's one of the drivers of some of those budget reductions in the prior slides. When we make those decisions about how much money to give a hospital in particular, we review what their commercial prices are. We review their clinical productivity. We review their administrative costs. We review their expense growth. We review aspects of their quality, and all of those things go into making our decisions. So if a hospital has a ton of money in the bank and has extremely high commercial prices and we have a health care affordability crisis, the likelihood that they're gonna get a large rate increase is pretty low. Now if a hospital is geographically very important and isolated with a bad payer mix, meaning so let me back up. Payer mix refers to what percentage of your money comes from commercial, Medicare, or Medicaid. The government payers don't pay as well as much for services commercial. So if you go to, like, North Country, that hospital has what we call a a weaker payer mix, meaning more government payer. So we might allow because of their geographical importance and their their payer mix, frankly, a higher amount of commercial charge than perhaps a different hospital with a larger percentage of commercial money and and high expenses. Does that make sense? So we consider all of that, and I think that we are [Vice Chair Jim Harrison]: afraid ability to adjust your budgets by area? In other words, you need to cut one million dollars and it needs to all [Chair Owen Foster]: come from administration? We have not done that. It's an open question. What we do do is we in our decisions, when we reduce the budget from what's requested and when I say reduced, they've never gone down actually in total amount. Right. It's from what is requested. We will point to areas in the budget where we think there's opportunity. One simple example is you have high utilization in your ED and low utilization in your primary care. You can move care from your ED to a more appropriate setting and more affordable setting for people, which is primary care. So we look at things like that, and we'll highlight them in our budget orders to suggest here's where you need to go. [Chair Robin Scheu]: And and in fact, it's called the budget directive in order or whatever you call it. And you can find it on your website, and I actually pulled down one, earlier this year for the largest hospital just see what it says. And it's very interest I mean, you guys do a lot of work to put those things out. I can see why you're quasi judicial. It's it's technical, but you learn a lot about how our hospitals are being run and and where there's opportunities for improvement and where they're doing well, and it's very interesting. [Chair Owen Foster]: Yeah. So I appreciate you saying that. Those budget orders are written out the door for fourteen hospitals in fourteen days. Yeah. That's Oh. [Chair Robin Scheu]: A lot of work. Our staff is Yeah. [Chair Owen Foster]: Really cranking, and that's at the height of summer for three point seven billion dollars of decisions. Yeah. So they really work hard. [Chair Robin Scheu]: Yes. And so I appreciate it even more now having read one of those. No. [Chair Owen Foster]: Thank you. They they really they do do they do great work. So on the ACO, I just wanna flag a couple things. In fiscal year twenty three, we reduced their budget by three hundred thousand dollars, and we capped their executive compensation. This ended up going to the Supreme Court. The Supreme Court agreed that that was something within our authorities, and we did it properly. And when Blue Cross Blue Cross departed the One Care program, we ordered One Care to make sure they paid primary care the same amount of money as they were planning to before Blue Cross left. There's gonna be a shortfall of money when blue and we said, no. No. You've gotta comply with this and pay the full amount. That might seem like a small thing, but it's actually a huge value add to the state that we did that. Primary care is in a difficult spot, and that amount of money really helped maintain primary care for a number of those practices. It was I forget the amount. It was a couple million dollars, but a couple million dollars for struggling primary care is a big deal. That was a really important decision. I don't think people really recognized other than than than we did. Fiscal twenty four reduced the budget from one care five million dollars. And again, we ordered reallocation of those funds to population health and primary care programs. Again, reallocating money to support primary care and others. And just this last year, we did the same thing again. We said this budget is too high. We're reducing it by one point five million dollars and, again, reallocating those dollars to improving primary care, mental health, and long term care, areas that are struggling in our state to survive financially. [Vice Chair Jim Harrison]: Insurance [Chair Owen Foster]: rate review. This is for about sixty five, seventy thousand Vermonters on what's called qualified health care plans. We have, three FTEs that work on that. Insurers request approximately a hundred and fifty million dollars in premium increases the amount Vermonters will pay and and more premium dollars. This last year, we reduced that hundred and fifty million by eleven million, and some of it was based on actuarial analysis. And some of things were a little high here, some things were a little high there, but we we approved the lion's share of what was requested. And I think that's a really important decision to make. It's a lot of money, but Blue Cross is facing insolvency. And had we reduced that more, I am not sure how long they would be able to survive. And so, yes, we approved a lot of money, but I think sometimes that's the right thing to do, and this is an example of that. Previously, we had reduced Blue Cross's budgets fairly consistently trying to promote affordability for Vermonters. That did lead to an administratively efficient operation. Blue Cross has run administratively rather leanly and and pretty well. And I think that some of our decisions maybe had an impact on that, maybe it's their own great work, but it also reduced their reserves, and that's part of where we are now. We're having a spike in utilization and health care costs, and the reserves have been brought down to a place that is not sustainable. [Executive Director Susan Barrett]: Question. You're a bad call on me. I kinda forget. Alright. What? I'm just curious. We we're hearing about utilization rates that have affected, you know, our global commitment here in many of the departmental budgets. And I'm just wondering, how do you understand the utilization rate increase. [Chair Owen Foster]: It's a really complex thing to understand, and it depends on the hospital, and it also depends on the service. So it can change kind of across the state who's having greater increases. There's also acuity. Acuity matters because it impacts how much money you get paid, how sick is the patient. And that can be a billing thing or patients being sick or whatever it might be. So those things both tie in to increase insurance premiums. Right? So the driver of it, hardest pinpoint a driver of increased utilization acuity. But if anything, it tells us what we're doing as a state is wrong, and we're not doing it properly because we want improved population health. And if where we're spending our money and how we're doing it, it's not resulting in lower utilization and lower acuity, we've gotta really reconsider what we're doing. [Chair Robin Scheu]: And then Rebecca, can I? [Member Tom Stevens]: On the same well, same on our line of thinking. Must be to look at and see, you know, what categories of care or problems that people have that are contributing to the greater utilization? Where is it where is it coming in? Does it tie into anything else that we know what's going on in the state in terms of anything from drug use to, you know, whatever that's going on in the state. And how does that compare on a nationwide basis to other other hospitals across the country that aren't in the same kind of problems that we have? Maybe you're looking at those kinds of things to find [Chair Owen Foster]: Largely largely not. So, I mean, our hospital staff is three people and reviewing fourteen budgets that are this big with data. We we don't get into in three months, we don't get into that kind of granularity. We do look at the increases, but we don't do some sort of breakdown versus national of this hospital for I mean, that's a lot of work to get into. So I don't think we really have a finger on the pulse of what service lines at which hospital versus national. [Member Tom Stevens]: No other organization does? [Chair Owen Foster]: I don't believe so. [Member Tom Stevens]: We've got shooting blind. We do [Chair Owen Foster]: it at a high level. Right? So we really look at we will look at utilization if that's a driver that might impact whether or not we say yes or no. But a lot of it really goes back to expense control, expense growth, and provider productivity, those kinds of things. [Member Tom Stevens]: If we look if we have a trend in in the state that's different than other states that is causing the the care or what you have to with either the volume of care or the elevation of care change within the hospital, that's driving us in a certain direction. Understanding that so you could take some outside click actions might also help. [Chair Owen Foster]: Agreed. So the payers, we're not a payer, would probably have that data and information. So Medicaid would know where their claims are coming in and what they're paying for. Medicare would have that information, and the commercial would have that information. I think Blue Cross has testified as to some of the drivers they're seeing. There's particular hospitals that I've reviewed their budget more closely last summer where we did see an increase in, you know, CT and MRI and x rays, but there had been a backlog. So some of this could be trying to improve access. We have delays in getting care. So is it that we're doing a better job of increasing access and that's driving utilization? I mean, they're really nuanced questions that our team of three in two months is not gonna get into. [Member Eileen Dickinson]: Wouldn't the hospitals, when they present their budgets and their CLNs and their different things, would be able to pinpoint two things that they trends that they see within their hospitals as you're interviewing them as part [Chair Owen Foster]: of your review? Yeah. There are. There will be things, but, I mean, anecdotally, it might be, well, we're seeing more Xylazine loads. Okay. Well well, there's a whole lot else you do. Right? Are we seeing more knee replacements? We know for I I know that UBM is seeing more patients for x-ray and imaging because of something that they presented, but there's a hundred other things that are going on and that they're doing. So, yes, we do get that information at sort of what I'd call a a high level. [Vice Chair Jim Harrison]: But k. [Chair Owen Foster]: To kinda drilling down an analysis across service lines, across hospitals, across the country is not in our bandwidth. [Member Eileen Dickinson]: Has there been any discussion about the demographic effects? I mean, the older you get, the more likely you are to need care, the more For sure. Intensity, that's part of the For sure. [Chair Owen Foster]: That that that is definitely relevant. Right? I mean, we are an aging state. That is true. And the older you are on the older side will lead to more care and greater acuity. Is is that the driver? I mean, these are really hard questions to answer. This is it. It doesn't really exist as an answer. [Speaker 7 ]: From where you sit, you indicated you have a system wide view, though you don't regulate all of health care, you still look at the whole system. Correct? Correct. If you were sitting in one of our seats and you were hearing from your constituents that to the degree that it felt like they were imploding Long term care and struggling, home health closes, hospitals thinking they're cutting back services, not enough primary care, insurance company. If you heard all of that, but you were sitting in this seat and you wanted to do something, what would you focus on? [Chair Owen Foster]: It's a great question, and I would say what your constituents is are telling you is accurate. It's true. What I would say is that the state does need a statewide plan for how we're gonna allocate our money and how we're gonna use our money. Right now, it is very siloed. We look at hospital budgets and part of an insurance company. What's happening with the DAs and everyone else is not in our regulatory process. We've taken a lot of effort to bring that information in [Vice Chair Jim Harrison]: in the [Chair Owen Foster]: last few years so that we are being better informed. Because if we give a hospital ten, twenty percent rate increase, that will help that hospital for sure. But it will hurt the insurer. It'll hurt demographics. It'll hurt affordability. It'll hurt the small business and economic growth. It'll hurt long term care and everyone else you mentioned. [Speaker 7 ]: Given given so much seems to be hemorrhaging, would I be wrong we'd be wrong to focus on primary care? [Chair Owen Foster]: You would not be wrong to focus on primary care. I think right now, my view is you're in a state. We are in a state where we need to identify what's really at risk and then make priorities as to what we need to maintain and ensure we have. So local emergency care, urgent care, we need we need we need primary care in every community, mental health, and long term care. We're also aging, so we have the memory care that we need. We have the services we need. We need to prioritize the care that we have. You're going to be losing services. There's no sugarcoating it. [Member Michael Mrowicki]: Sorry. I came in a little bit late, John, because that's good to work earlier. And just to follow-up to what you just said there, do you have a sense of of the types of services that may end up being lost in some periods of mistake? I'm not trying to pin you down with the Oh, no. Hospital here at all, but we talk about that often. [Chair Owen Foster]: Yeah. Good question. So, I think that there are at least three hospitals at risk in the next two to four years. So Oliver Wyman did a study, part of act one sixty seven. That's what they concluded. Becker's put out a report totally unconnected to our state, and we were one of the states with the most hospital at risk of immediate closure. So there are hospitals that are at financial risk. They they simply are. How many? How long? So much depends. What are the federal changes that are coming down the pipe? Right? Those can make that problem happen real quick. In terms of I think if you're gonna maintain our hospitals, we're going to need to make some system wide changes on the services that are delivered. Where they're delivered and how they're delivered. And you also need to make sure that the systems around the hospitals are protected. When things back up in hospitals, it hurts hospital finances. So the primary care example, mental health example. So you need those. Frankly, I think nearly everything is at risk right now. I think mental health, long term care, hospital care, primary care, FQHCs, insurance, they're all in deep trouble. I think that you do need to to remedy the acaponics question. You need to prioritize and protect what you gotta protect. [Chair Robin Scheu]: It's a separate ticket, and then that's, [Member Eileen Dickinson]: serious. But how did we get here? I mean, I look back, when David and I were on the POC together twenty years ago. We were told we had the lowest health care costs in countries or very close to [Member Tom Stevens]: the lowest, if not the lowest. [Member Eileen Dickinson]: And everybody still thought it was very expensive, and everybody churned. You know? And since then, we got a this Medicaid one hundred and one, beginning of this session, and our Medicaid has increased by about fifty percent and our as as has Medicare because of the government program. And we're obviously getting older, so more people are using it. But we went from commercial insurance of sixty percent in two thousand eight to forty nine percent of twenty twenty one. Now I don't see that as an indicator of a healthy economy because the more people you put on Medicaid, the more pressure it puts on your commercial insurance. Because it doesn't pay the full amount, someone's gonna make up the difference. So your premium costs go up, the hospitals many times can't recoup everything. So it just has a and and we've put a ton of money since then into all kinds of reforms, including what you guys do. Although we used to get paid fifty dollars a day with a free lunch at the Capitol Plaza. But [Chair Owen Foster]: anyway Different times. Yeah. [Member Eileen Dickinson]: Well, we were not we were an appointed board that didn't do anything. We just came up to them. The point was is that we did a lot of maybe we didn't do it all. We didn't make a decision. But we were the oversight commission, and we heard all the same kinds of stuff you talk about now. But, you know, I look at it and the way the insurance has changed as an employer, we've gone to where we have we went from a you know, three ACA, a thousand dollars or five hundred dollars deductible to two thousand dollars to three thousand dollars to five thousand dollars And it just it balloons. And I'm just wondering, you know, people complain because they have to pay so much out of pocket, which is true. And I'm just wondering if maybe we should be just looking at a major medical insurance. There wouldn't be any different in cost to what people pay out of pocket. Or we we should look at maybe we've we've what we've done is we've increased eligibility for Medicaid, but we've reduced what we pay the providers instead of putting more money in. And, you know, the nursing homes are in they've always had a problem with us because they can't cost shift to anybody, but we're very little people. So how do we get out of this? What do we do next? [Chair Robin Scheu]: So Right now. Right now. You know, she We only have till four. [Chair Owen Foster]: That is right now. So, how do we get here? So let me take a couple of things. So your your point about decreasing number of commercial payers is really important because so I'll give you example. Medicare is supposed to pay about a hundred percent of what the costs are to deliver care. That's their goal. Medicaid probably covers around sixty ish percent of the cost of care, and then commercial makes up that gap. So the national average for a percentage of Medicare is about two hundred and fifty percent for hospitals. We have some hospitals that are more like three twenty, three fifteen higher higher than that. So very, very high prices. And I think that's what represent Harrison was, alluding to earlier. Meanwhile, we have all these other systems that rely just on Medicaid. Right? Like like the nursing homes or, mental health. Right? And they can't do that. So we need to fix who we're paying and how. So we wanna move, primary care out of the hospitals to the extent that we can't because it's more affordable, and they don't send our referrals to most expensive place, whatever it is. But we pay the most and you make the most at the hospitals. Right. So we want we're doing it wrong. We don't put our money where our values are. We don't put our money on mental health and long term care. We rely on Medicaid, and Medicaid doesn't pay well enough. We're not we're not doing what we say. That's the problem. So I think that right now, you you also can't disrupt the hospital system. That would be chaotic and terrible. You need to maintain what you have outside of the hospital and within the hospital as well as you can for a little bit of time. Like, that's step one. You can't have everything get consolidated into based health care system. That's kind of what we have. We have an overwhelmingly hospital based care delivery system. That's not fair to hospitals. They can't do that. That's not their job. It's way too expensive. So you need to maintain the things around it as well as you possibly can. And that's why some of these decisions I'm citing, that's why we did that, why we put the money towards mental health rather than the ACO. Right? So that's what we were trying to do. When we've been reducing hospital commercial increases, the goal was to ensure that Blue Cross could have some money to remain solvent, but also to pay those other providers more fairly so that we don't lose them. That's what we're doing. [Chair Robin Scheu]: Go ahead, Reverend Shun's gonna interrupt Stevens. [Member Michael Mrowicki]: So just real quick. So so if things moved in a direction with primary care and child hospitals, what happens? How does the hospital continue their service to the community? [Vice Chair Jim Harrison]: What what [Chair Owen Foster]: would that look like? And I don't turn it down to a number or anything here [Member Michael Mrowicki]: at all. It's just [Chair Owen Foster]: So so some we're talking about this. Yeah. Some I mean, some people some providers won't want to not be associated with the hospital, and some communities can't have that. Some communities are gonna have to have the hospital to provide primary care, but you wanna maintain it outside of the hospital to the extent you can. The impact to a hospital would be that they a lot of them lose money on primary care. So it actually might be financially beneficial, but for the referrals they get from their own primary care for surgeries, it might be a higher dollar value. But if you shift how you pay and you end up paying more for primary care, that calculation might shift a little bit. So, I mean, hospitals will be fine. There are many hospitals that don't provide any primary care that won't necessarily, like, break the bank. Might even be beneficial in some instances. [Member Michael Mrowicki]: So I guess just just to follow just a quick example. I mean, you know, the St. Johnsbury hospital there. We have our hospital. We have a couple of clinics that come under the umbrella of all of that. Right. So they're not, like, act actually in the hospital here per se every day. They're at their other location here, where they that's where the patients come to see them for checkups and all kinds of, you know, vaccine kinds of things and all kinds of things. And then if for some reason they become ill and need to be admitted to the hospital, that's the connection right there. So do do you see and there's other communities where that's probably the case as well. I'm not versed on all of the specifics specifics of every hospital area here in the state. But, how would that so so would an area be able to maintain what they currently have to some degree? We know change is coming here naive to that. But yeah, I [Chair Owen Foster]: mean, the goal would certainly to be maintained primary care as well as you can in every single community. You're not gonna flick a light switch and all of a sudden primary care moves out of a hospital. Of course not. But if there are places like in Chittenden County, it's an easier example because there's much bigger population. There are a number of independent primary care providers and FQHCs around. You don't want to lose those. So what I'm really suggesting is in the short term, we wanna make sure that those remain solvent and available. If those go away, if community health centers in Burlington, which is having financial trouble goes away, a huge number of patients all of a sudden back up in UVM's ED, and that really hurts UVM's financials and the state's financials. So I think that's really what I'm saying is trying to maintain what we have outside of hospitals because it supports hospitals. That's helpful [Member Michael Mrowicki]: if we understand that. [Chair Owen Foster]: Yeah. It's really it really is an interconnected system. One domino falls, and you have major impacts across the The [Member Michael Mrowicki]: rural across the state are just very different. Entirely different. Geography and population. Yeah. [Chair Robin Scheu]: Impacts. In essence. Yeah. [Chair Owen Foster]: The ability for an independent provider to open up shop at St. Johnsbury. Yeah. It's different. Right? Or up in Newport, it's different. Rutland is a different scene than Newport. Burlington is itself as well. Thank you. Yeah. No. Good question. Let's continue. Yeah. I like these committees. We get a lot of questions. These are really good. This committee has always had a lot of questions. [Chair Robin Scheu]: Yes. Well, we hold the first three because you really do. Hoping with a change in chair. You know, I you know, attention, we started the day with public education, and now we're ending with health care. So we're having quite a good day. [Chair Owen Foster]: Yeah. Can we skip this one? I can probably skip that. This is a little bit of the state of the state. Would you like just share this so people know? I mean, I kind of get that it's doom and gloom, I think, but [Member Eileen Dickinson]: but here's the visual. The slides [Chair Owen Foster]: will show you. So National News is paying more and more attention to our problems in Vermont and our health care, and a big piece of it is our health care costs are some of the highest in the country, if not the highest, and they're increasing the most rapidly. So the rest of the country is going up five, six percent. We're seeing ten, twelve, twenty percent in Vermont, and that just will not continue to work. We talk about property taxes, but the health care taxes. And and that health insurance premiums are a tax. They're a tax on your businesses and your people. They just are. They're the same thing even though we think about them a little different. So our costs are going up the most, and they are already some of the highest. Go ahead. This gives you a sense of what that looks financially to a family. On the left is the premiums for Blue Cross plan for a family of four and then the out of pocket. And, you can see it's close to fifty thousand dollars a year for a platinum plan for a family of four, on Blue Cross. Or even for a silver plan, it's nearly nearly as much. And then you have the out of pocket on the other side, another fifteen thousand dollars. So you're talking enormous health care costs. On the individual plan, you do have subsidies right now, which for a large swath of these people help, minimize the cost that hits the family's pocketbook. Those are set to sunset at the end of this year, and it's to be determined if they'll be extended. They're not extended. These costs become instantly very, very, very real, and a lot of people will just go off of insurance entirely. [Chair Robin Scheu]: And that's that's the general level. [Member Eileen Dickinson]: Do do all of the subsidies [Chair Owen Foster]: disappear? All of the federal subsidies are set to sunset. Okay. But they they could continue part of them or some of them, or we don't know what they're going to do yet. [Vice Chair Jim Harrison]: The ACD, the underlying ACD one's there. [Chair Owen Foster]: Yeah. They the the ones the the Expansion. COVID expansion can go away. [Vice Chair Jim Harrison]: Okay. [Member Tom Stevens]: The magnitude of the difference between Vermont and Boston seems so vague. I would think that anybody any competent analyst would be able to stumble over the region of West Highlands. [Chair Owen Foster]: Yeah. And and you that's easy. It's pharmaceutical prices, it's hospital prices, and it's increased utilization. I mean, we know what's driving it. What do you do about it? Do you tell people you can't take the pharmaceuticals that you need? Do you lower pharmaceutical prices? Do Do you lower hospital prices? The drivers are not the mental health care. It's not the long term care. I mean, that's going up, but it's really concentrated at pharmaceuticals and hospital [Member Tom Stevens]: expenses. Choices. Somebody's making choices. [Chair Owen Foster]: Sir, what do you mean by that? [Member Tom Stevens]: Well, if if if they're not going up because of some fixed cost kind of thing, then somebody has to be choosing to do something that is different than the rest of the country in order to drive the costs. [Chair Owen Foster]: So there are a lot of fixed costs that are associated with our increases, and there's probably some level of our fixed costs being greater than elsewhere because of geography, volume, all those things. I would accept that we probably are fixed cost a little bit higher because we're rural. Rural is different just across the country. And then Shouldn't go like that. No. It shouldn't. [Chair Robin Scheu]: I'm risking I just [Vice Chair Jim Harrison]: wanna put my two cents in here because I I think you you recognize what are the drivers here. When you [Member Michael Mrowicki]: look at pharmaceuticals, what they cost in this country, and then what they cost just above [Vice Chair Jim Harrison]: the border or in Europe, I mean, that's how can they do us? There's no other way to look at it. [Member Eileen Dickinson]: Can I speak [Chair Robin Scheu]: to the things are cost wait? I I think you're also putting that individuals, but we have chronic there are certain chronic things that are much more expensive, diabetes and, you know, things like that that are different than and then we've got gym and job. We could spend [Member Michael Mrowicki]: a lot [Vice Chair Jim Harrison]: of time on this. Yeah. Yes. Probably none of us here. Yeah. This side of the table have the answers, so we appreciate the opportunity to to ask questions to you. If you were to look at these last couple of charts and you we see how Vermont's significantly higher than national average. How do we compare with a and I get it. We're rural. We're small. We're always gonna be on the higher side. How do we compare with Maine, which is even older than Vermont? Or how do we compare with the New Hampshire, which I suspect is also in the top tier with average age and also rural? That's that's the things that I think we need to be comparing ourselves with, you know, as opposed to the US average, which may be, you know, really not pertinent. [Chair Owen Foster]: The answer is poorly. We compare poorly to other agencies. [Vice Chair Jim Harrison]: And and that, I can't I can't accept being higher than Maine. Maine is probably more rural than Vermont because they're they're they're twice the population, but they're significantly larger geographically. And they're old, and and that's the excuse that you keep hearing, you know, whether it was the consultant study, well, we, you know, the agent demographics are are cause of our problem because old folks like me need more health care. You know, I I refuse to accept that if other states are doing better in terms of affordability. [Chair Owen Foster]: I agree with you. And we do have a I didn't put it in this deck. We do have slides comparing us to New Hampshire and Maine. New Hampshire and Maine are, I think, the first and the third oldest. Maybe we're somewhere around there. And, yeah, no. We compare very poorly compared to that. Yeah. We need to change our system of care. That is why the state did the Oliver Wyman report, and now we need to make some changes. We can't sustain so look. Here's what happens. If we say no to a hospital budget so let me back up. What can you control? We can't control pharmaceutical prices today. We're looking at it. We're gonna try. The state allocate some money to look at it. That will be three or four years before it happens, and then we'll get sued to high water, and we'll see what happens from there. So we're not gonna control pharmaceuticals. You're not gonna control the price of me. You're not gonna control what they take. Right? People are gonna take them. So forget that. That's just gonna be what it is. Then second, you have hospital utilization. What are you gonna do? You can't go to the hospital? You can't you can't do this? You you you can't really control when people need to go to the doctor. Third, acuity. You can't really make people get healthier, tell hospitals don't bill for the level of acuity. Fourth, you have hospital price. That's the one you can control. Right? And that's not all of the problem here, but that is a problem in the state. Our hospital prices are too high. Then you have the non hospitals. And as we said, mental health, a lot of them are on Medicaid, and that's not your problem on this graph either. So the only thing you can you can control really in all these is hospital price. When we reduce hospital price, there is an uproar about what it will do to hospital solvency, and it's true. I bet every representative with a hospital in their community does not wanna see their hospital have financial problems. But you can't have it both ways. [Member Eileen Dickinson]: Looking at the insurance side. [Executive Director Susan Barrett]: Oh, you're on a different side. [Member Eileen Dickinson]: Well, I'm looking at this. I'm a little ahead of you. Okay. Well, two things. Go ahead. Two things. I'm looking at the dates of cash on it. An important criteria that hospitals look at because it's a bonding issue. I mean, schools look at it. [Chair Robin Scheu]: A lot [Member Eileen Dickinson]: of people look at it. It's going down precipitously. [Vice Chair Jim Harrison]: This is [Member Eileen Dickinson]: part of the reason the hospitals are having the solvency. This is a symptom of the insolvency. Correct. Can you talk about what that is, what that means? [Chair Owen Foster]: Yeah. Do go one first, Jean. I think this is also relevant. So so the the insolvency, as I said before, is not just the hospitals. There are insolvency risks there, but also Blue Cross. So Blue Cross, the Department of Financial Regulation range is I think it's six hundred to seven five ninety to seven hundred and fifty RBC. That's the measure of their reserves, and they're supposed to have five ninety to seven hundred, which is in this chart. And we Percent. Percent. It's a percent, but it correlates to dollars. Yeah. And then you can see from twenty twenty one to twenty twenty three, the steep decline in their reserves because they're paying out claims. They have to pay for the claims and the people go to get the care or the drugs or whatever it is. And that three hundred and thirty seven in twenty twenty three, that has dropped enormously in the last year. That would be a steeper line down. Right. Blue Cross is not able to pay claims. The entire system falls apart. People can't pay for it. The hospital won't get paid. No one will get paid. It'll be a real problem. So that's important for everyone to know. And if you go to the next one, representative Dickinson's question on a hospital days cash on end, representative is correct. It's one of the main things that we look at for financial health of hospitals, and you can see also that that's been declining. So we're paying more and more and more, hoping for solvency and access and to not lose a hospital, and it's not working because Blue Cross is going broke, and the hospitals are declining significantly on on this. There's some noise in here and that some hospitals are really good, some have, like, two hundred plus, which is probably too much, frankly, in this time. And then there are others with forty, fifty, thirty days cash on hand. Real acute financial trouble. Then you go to the community providers, the DAs, like Howard Center, I think has five or six days cash on hand. Little Rivers, you have QHC might be five or six. Lamoille might be less. So it's everywhere. It's everywhere. You can't pay your way out of this problem. So you need to make changes, and we need to accept that that's gonna be where we're at. [Vice Chair Jim Harrison]: If I already So what what level of cash do [Chair Owen Foster]: I have to be like? And, [Member Michael Mrowicki]: you know Yeah. You know, just thinking about, you know, some have for a few days, some may have two hundred, which isn't necessarily a bad thing here, but it's just [Chair Robin Scheu]: No. [Member Eileen Dickinson]: So for a hospital, we kinda like [Chair Owen Foster]: to see kinda like to sorry. [Member Michael Mrowicki]: No. So I just I [Chair Owen Foster]: those that have more cash on it, [Member Michael Mrowicki]: you know, see that year to year [Chair Owen Foster]: to year. Right. It can move depending on how the year goes. Right. In too much movement, some things happen [Member Michael Mrowicki]: when they gotta pay for things. So [Chair Owen Foster]: Yeah. So a a healthy range, we kinda like one twenty five to one seventy five. Mhmm. One fifty is pretty good. One forty is not bad. One twenty five is not, like, alarm bell. Fifty is really concerning because that can go real quick. Like, when Springfield went bankrupt Yeah. Goes fast. Yeah. [Vice Chair Jim Harrison]: It does go fast. Thank you. [Chair Owen Foster]: Yeah. So what do you do about this? We can't raise commercial insurance costs, and we can't raise medic I don't think you're gonna raise Medicaid. I don't see the feds pouring money on us. So you have to deal with that reality and make the changes you need to make to protect the care that you have to have. [Chair Robin Scheu]: Okay. Let's keep track. [Chair Owen Foster]: So I did wanna connect this just so everyone understands that so these health care costs, it's not just insurance premiums, all state of Vermont and the teachers. So a lot of talk in this building about property taxes and taxes in general, appropriately so. This is a graph of the state of Vermont health care costs. State of Vermont has a fund that it pays for claims out of reserves. And here you can see the rate increases for premiums for the state of Vermont in seven percent, eleven percent, fourteen point four, fifteen percent. When the state has to pay more in premiums, the state has to take money from somewhere, whether it be taxes or another part of the state's budget. Despite paying more and more and more in state health care costs, the state health care plan, last year lost forty million dollars [Chair Robin Scheu]: This is not teachers. This is state employee State employees. [Chair Owen Foster]: A forty million dollar loss after, what, thirty percent rate increase in two years. [Chair Robin Scheu]: And so this is why we did the eighteen and a half million in the budget adjustment Sure. Capitalizing the medical expenses so it would not be such a dramatic hit to see [Member Eileen Dickinson]: And that's a self insured plan. Yes. [Chair Robin Scheu]: It's self insured. Premiums to anybody. But, again, they've also had acuity use utilization. You know? And you have a couple of serious cases of illness, and, you know, we've all heard those stories of how much that can cost. [Chair Owen Foster]: Yeah. The next slide, briefly touch on the the teachers. This is the Vermont Education Health Initiative. This is the teachers union and their premium increases. Again, you can see other than twenty two, it's about double digits every single year. Double digits every single year is simply not sustainable. And they are also losing money on their fund. They're self insured as well, and they're also down millions and millions of dollars despite increasing their premiums pretty significantly. [Chair Robin Scheu]: And this shows up in our property taxes. Yes. Because this is in the education fund. So when you talk about health care being a tax [Chair Owen Foster]: This is in property taxes. So school budgets are strained that they pay ten ten ten ten percent more every year. So they either provide less of the services that we want them to provide for our students. It this eats into their budget or they raise property taxes. Health care costs are one of the biggest drivers of increased education costs and increased property taxes. So you need to abate this problem if you're gonna address those. [Member Eileen Dickinson]: Okay. Years ago, the teachers always had a very generous policy, and the Cadillac penalty went into effect. I don't know if you were around in those days, but I mean, good night care was around. They saw increases. I'm not sure so much the teachers, but I think the parent educators, the support staff. So are they do you know what year that was in relationship to this? Or I [Chair Owen Foster]: I don't. I'm sure we could find that out. It was [Member Eileen Dickinson]: a Cadillac that was being penalized by the ACA. [Chair Owen Foster]: I don't know what year that would have been in this chart. [Executive Director Susan Barrett]: I think it was before this chart. Yeah. But [Member Eileen Dickinson]: since then, of course I think it [Chair Owen Foster]: would be before. Yeah. Yeah. [Chair Robin Scheu]: So we're kind of running out of time. Yeah. Yeah. I'm gonna make it happen here all day. Because this is another one of those passionate subjects, subjects, so we need to make them go first. We still have your budget. So if we mean it. [Executive Director Susan Barrett]: Actually, that's an opportunity for a segue because chair Shai reference Commissioner Festucci coming in to testify for the BAA about backstopping the fund. You'd see this every single day in our budgets all across state government. You see you see the increased cost, you know, that that every single department that comes to is bringing forward. And one of the thing going back to what chair Foster was saying is one of the coolest of ironies is this, is one of the and correct me if I'm wrong because I'm not a policy person, but one of the things that is really driving the acute financial crisis for the FUHs and all these providers is their increased health care costs. So For their employees. Please. For their employees. So sorry. Let me know if I misstated Sorry. That. I'm gonna jump. Chair, I wanted to make sure I I heard you'd like us to jump ahead to our ups and downs. [Chair Robin Scheu]: We have to really I need to be done by four, which is, like, a two minute I feel like hearing, and we need to get set up for that. [Executive Director Susan Barrett]: That's why. Public. Yeah. [Chair Robin Scheu]: Oh, so public hearing. I didn't mean to say [Executive Director Susan Barrett]: this so loud. So And [Chair Robin Scheu]: it's our fault because we have lots of questions, and you're so good at answering them. [Executive Director Susan Barrett]: So thank you. I will be very succinct. So, this summary, what this does is this shows for, just the base Green Mountain Care Board, without the governor's base initiative, we are up a total of five percent. And again I hope [Vice Chair Jim Harrison]: you're not blaming that on health insurance costs. [Executive Director Susan Barrett]: Well, I was gonna say that salary fringe is up the highest amount. So, you know, but that means we have to find it from somewhere. You know? Our our increase doesn't cover all the things. I broke out act one six one thirty four separately. This was enacted last year, which is a separate funding stream, through the, advertising evidence based advertising fund, for two employees to investigate and look at what Chair Foster referenced, which is, the potential for regulating prescription drug. That's work that the legislature gave the board. That wasn't a part of the big bill last year. So it's broken out separately. The, the governor based initiative. So the, the governor and the administration, they granted us, dollars seven hundred and fifty thousand of mixed funds. So that's three hundred dollars general fund plus, the ability to match with our bill back, three full positions and, you know, potentially some contracts, which was part of a request for more staffing. I wanna quickly move right here to, before I go there, I just wanna say, in general, the the Green Mountain Care Board is funded, forty percent general fund, sixty percent bill back, which is a what that means is we charge those entities. We regulate for the pleasure of being regulated. Okay. So, the change the change this year is the addition of the very focused prescription drug work. I should say these two employees aren't available to the rest of the board. You know, they're just focused on their thing. There's been a lot of talk about the AHEAD model. The board voted to approve AHEAD going forward with some conditions. One of the conditions is that we need five positions by, like, five new positions by the beginning of September. And then we also need additional positions after that. So if the budget just goes through with the three positions that we have in the gov space, then we will the board won't meet the conditions for the ahead model, and that will trigger a no. That's a whole separate kind of conversation. Yes. But I'm going to keep moving through this if that's okay. [Chair Robin Scheu]: Yes. And I but I just wanna say, I thought I heard that, staff at the AHEAD program at the federal government, are they still even there? [Executive Director Susan Barrett]: That that goes to we have that categorized here as unknowns, which of which there are many. I think there there were three staff who were let go, but there's still staff. [Chair Owen Foster]: There are still some [Chair Robin Scheu]: staff. Okay. So [Executive Director Susan Barrett]: one thing that I am going to very quickly buzz through this. One thing that we would like, but it's not part of the gov rec is looking at just very short term limited service positions, more like right out of college data people, to do some automation. We do a lot of we do a lot of reports, and we have these great people that we hire. They see so much opportunity for getting rid of rote. You know, you kind of you're reinventing you're doing the same thing. That was a pitch I just wanted to say. We do have a language change. This is related to One Care Vermont, ending its service. I wanna be clear. The language change here is changing how our main bill back statute, the forty sixty, is allocated. So this is the sixty percent right now [Chair Robin Scheu]: With the go the ACO going away, you're changing it, but can we put that in a budget adjustment? No. [Executive Director Susan Barrett]: It's right here. It No. I know that. [Chair Robin Scheu]: No. We've seen it in the budget then. [Chair Owen Foster]: Correct. We've seen it. [Executive Director Susan Barrett]: In the budget, not in the budget adjustment. So this is just talking about the sixty percent that's allocated. So there right now, it's hospitals, insurers, and the ACO. Since the one big ACO is going away, we are requesting a change. Now there's separate work being developed, S sixty three, which, has fees for ACOs, some changes because there's Medicare only ACOs. But for the sixty percent allocated, so if you have OneCare Vermont going away and an unknown number of Medicare only ACOs, it does not make sense to have a set fixed percentage in statute for what the ACOs need to pay. So we propose, reallocating those costs, which last year would have been a little under five hundred and seventy thousand dollars between the hospitals and the insurers. Now you'll see in the language, we've heavily weighted it towards the hospitals because the hospitals are currently paying fees to One Care Vermont. So so that's why we did it there, and we did a small percentage to the insurers for some fairness. Now if s sixty three passes and we have fees there for, you know, x number of dollars for a review of Medicare only, x number of dollars for for a budget review, x number of dollars for, like, an annual recheck. If that goes through, those fees that the ACO Medicare only ACOs pay will reduce the amount of sixty percent. So we're not we're not double dipping, if that makes sense. So [Chair Robin Scheu]: So S sixty three. S sixty three. Yeah. [Executive Director Susan Barrett]: And the last thing is is the unknowns, which is system solvency, systems transformation, new federal policies and changes. And, I realize that that seems very big. But as we were trying to construct a budget that responded to all these different variables, it it just became kind of an unpenable to explain all the different scenarios that are popping around, and they're popping around so quickly. So so yeah. That's it. Great. [Chair Robin Scheu]: So we have we have your ups and downs. Okay. And in addition to that, what you're saying is, you have language change, we'll see how it compares to what's already in the budget. Oh, it's the same thing. It's the same thing. Okay. So that's the same thing. So but you would like more ahead people. [Executive Director Susan Barrett]: If you if you could we'll send it to you. Right? [Chair Robin Scheu]: We send you something in writing so [Executive Director Susan Barrett]: we Yeah. We we have like, send you something. [Chair Robin Scheu]: Tasks are related to yeah, anything else. And so John and then and then we clearly have to stop because we have the [Vice Chair Jim Harrison]: public hearing taken care of. I'll I'll I'll come back. You're gonna I'm gonna have to [Member Eileen Dickinson]: say that, we didn't get into a head at all in this conversation. I would ask that we have them come back and see what this transformation what this transition some more transition. What OneCare I mean, I don't know. [Executive Director Susan Barrett]: I don't think a lot [Member Eileen Dickinson]: of people understand what OneCare did. Yeah. I think most of us don't understand what AHEAD's gonna do, And how does that impact all of the, you know, the stuff? [Chair Robin Scheu]: And I so the health care committee is gonna take up a lot of this, and I'm imagining that they've discussed had your you've all discussed ahead in health care. I don't know if we can get them back. These guys are we're fully booked next week, and then it's not till after town meetings break. So whether we're gonna be able to get them in to talk about it before the budget or whether we have to rely on the health care committee, I don't know yet. But I understand what you're saying. [Member Eileen Dickinson]: So we have to figure out if you're gonna have it all. [Member Michael Mrowicki]: They wouldn't ask me to come back for, like, two hours, but I think a long period of time. [Vice Chair Jim Harrison]: So I'll understand what ahead is. Yeah. [Chair Robin Scheu]: But it's not gonna be till after I we [Chair Owen Foster]: I've been that's fine with the exam. [Chair Robin Scheu]: We may try to get you back in March Mhmm. For one specific topic. And try not to stray. That's the problem. Thank you all very much. Committee, we are gonna be high as in the Yeah. Nice to meet you. Four forty five in room eleven. So I'll get there at four forty, please, so we can be set.

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