Public Health, Welfare and Labor Committee- House

Yourself and who you represent the record. Dennis Smith senior advisor Department of Human Services thank you thank you. All right. A representative Gonzalez is not here yet. The representative Boyd you're recognized for a question. Thank you Mr chair I just wanted to start with discussion on the market place on the insurance market place that was originally when we pass not weak because I wasn't in the legislature but when the legislature passed the private option then we when I was there became Arkansas Works there is a lot of discussion about stabilizing the market place keeping insurance costs down now as I understand it we really only have two carriers in the market place so that doesn't you know show a lot of competition and rates are rising so why should we support this if if that's the case help help me understand what's going on in the market place from your your view thank you. Thank you representative Boyd of we've now had the marketplace places for us seven years now so our market is very stable other states that tried to do a premium assistance previously New Hampshire and Iowa had tried that they were failures from the beginning because they didn't have sufficient volume in their market places versus what we have here in Arkansas so we actually have one of the lower of premiums in the country we are well below where I well I was now over eight hundred dollars of premiums New Hampshire is slightly above this we are lower our premiums are lower than our surrounding states so again the economics of what makes market works is sufficient volume and stability and I think we've achieved that. So I've got a. Kind of a follow up kind of a separate question so is is we discuss this you know. Why again we have traditional Medicaid which is still in place. Where were not paying and in essence profit to the carriers. Why do we not just figure I mean because we have a lot of purchasing power we should be able to create a lot of efficiencies as a government why do we need to involve the carriers when we could just expand into traditional Medicaid how to answer that. I think our traditional Medicaid one of the again the one of the original reasons for going to private health insurance plans was to provide a more timely access especially to our specialty providers in traditional Medicaid You have to raise the rates for all of the providers you cannot just pick and choose in fee for service between what you're going to pay a doctor we do pay higher the U. H. bees do pay higher rates twenty five to sixty five percent of more than Medicaid fee for service does if we were to return every one to a fee for service and to have the same timely access as we do now the rates would have to be written raise not just in our Arkansas works but for the entire Medicaid program and that would be extremely costly the carriers themselves also provide part of the match rate they prefer pay a premium tax that is worth about a hundred and sixty million dollars that we can use of force state match rather than the general funds and overall when you look at not just the spending of what comes out of from the Medicaid budget but also when you look at what revenue is brought back into this state that again there's what's called a multiplier effect so as dollars gets spread out through the system we actually then collect a higher amount of revenue not just at the state level but the local level as well so on balance of our proposal we are home proposal is a hundred and thirty million dollars better then the fee for service option. All. Yeah you have fallen. So I'm I'm a little slow right now it's been a long day so you just told me if I understood that by going with a qualified health plans your math shows a hundred thirty million dollars less than if we went whole hog traditional Medicaid. A hundred thirty million better than compared so that when when you look at the spending and the revenue that comes in we would spend less in fee for service but we generate more revenue through the Q. H. P. model. So on balance we are a hundred and thirty million dollars better than fee for service. When you're counting spending and revenue. Ma'am one applies I get other people on the bottom. A representative Dotson you're recognized for a question. Thank you Mr chair. Trying to wrap my brain around that math I didn't follow that at all So. me go through. So how much more will this cost in total then the fee for service. Both federal and state. So we're looking at a five year waiver so these are five year numbers. Our assumption is we negotiate with the federal government a trend rate that grows every year the current trend rate rose four point seven percent per year. on a per member per month basis the our home proposal brings that more to four percent so we total spending will go slower than under the current waiver. We're not talking about the current waiver that we're talking about moving forward so yes Sir so moving forward this state share I'm sorry the the the the revenue from the federal government is nine point eight billion dollars. For our home. Under fee for service the Federal. Money coming into the state would be for three billion dollars less six point eight billion dollars. That's what the the firm on the federal side on the state side. Our home would spend. Nine hundred and thirty one million dollars. Fee for service we would spend seven hundred fifty one million dollars so that is less spending. However when you look at the multiplier effect of the dollars as dollars churn through the economy. We would bring in I'm sorry the fee for service would bring in three hundred and ten billion dollars less in revenue. Compared to the our home proposal. Social spending is lower. But there's also three hundred ten million dollars less in revenue. So on balance when you look at spending and revenue together. The difference is a hundred and thirty million dollars in favor of the our home proposal. Okay follow up. Yeah uniformed so if my math is correct in this from what you were saying. Total taxpayers spend is going to be about three point two billion dollars more under our home in fee for service. however you said there's three hundred million dollars that we will be saving or putting correct what your putting so it's really two point nine billion dollars more for for for our home in fee for service so. Total taxpayers spend federal and state two point nine billion dollar additional would when you are looking at the the the total cost yes the total cost is more in qualified health plans okay they are more because commercial rate the the Q. H. P.'s are paying their providers commercial rates which are twenty five to sixty five percent. More than what we would pay in Medicaid fee for service so those providers if you go back the other way. Then you are asking the providers to forfeit that the additional funding. Okay got more but I'll call in queue for us I'd like danger that to just a little bit today it so we've had fifty seven hospital closures in all the states surrounding us that did not expand Medicaid in this way and we've had one closure in the State of Arkansas in the last ten years I think a lot of that has to do with expanding the population the Medicaid population in the way that we did I was opposed to this and I think you know that I was opposed to this early on I got on the the healthcare task force I figured out exactly how the money was coming into the state the feds cut us they cut because I work my work for hospital the feds cut our reimbursement rates they can they call to sequester Asian fees right so we got cut and all these different areas and they simply say and they say we're taking the money from here you want back you participate this way and that's what the state of Arkansas did was participate that way to get that money back we also lost uncompensated care in the hospital system there's no other way to get that that through a model like this so what I'm afraid of is I live in rural Arkansas which I know a lot of a state we don't pass something like this or we end up straight fee for service with much much lower rates I know I I can promise you a hospital it is our county it is on the brink of closing any how will close. Due to how it will happen there on the break any help and so for me that's one of the biggest things with this is making sure that our rural hospitals stay open as in it's it's in the handout that was given out to you guys too that you can see how the hospitals. It's on page eight which you can see all the hospitals all around us that have closed in the last nineteen years and just one in South Arkansas so anyways that's my. It is more federal dollars it's it is I agree. Yeah committee you should have the handout that was put on your desk while we're gone so. Hi representative cloud you're recognized for a question thank you Mr chairman. The. When when we got interrupted we had a couple words that I really like to hear accountability. So if you guys would help me understand. Arkansas works we've had no work requirement for the last two years and then also and and I don't know the numbers but I'm sure you'll probably do there was supposed to be the governor talked used the term a little skin in the game where of those recipients were supposed to pay a small amount back in. Ten twelve dollars if I remember right something like that but there was just a pitiful percentage of that that was actually collected so. Now we're going to the. That negotiate I believe you said with the federal government so so help me have some reassurance that this process is going to be so much better than Arkansas Works. Thank you. So. Under the Arkoma proposal we will have more people with skin in the game than we do in the current model. Currently people below a hundred percent of poverty pay nothing what so ever. Only those above a hundred percent of poverty have been charged a modest thirteen dollars a month and if the carriers do not collect that themselves then the state has the ability to do a tax intercept to collect if somebody is paying taxes but the vast majority of the population is below a hundred percent and they pay nothing so we pay the carrier's the premium and we pay cost sharing reductions so in because people are not required to pay anything when they go to the doctor when they go to the pharmacy they pay nothing whatsoever so the neighbor is paying for them on their behalf when they go there. Under this proposal everybody everybody will have cost sharing a applicables to them so there are specific dollar amounts and this is why we think even the by demonstration will approve it because these are amounts that are allowable under federal law for Medicaid. There's specific dollar amounts and there's an overall five percent of household income cap so somebody will who hits that cap then doesn't pay the rent anything more cost sharing anymore copayment for the rest of that quarter. But then that quarter starts all over again so there is much more serious skin in the game in this proposal and in the past. And if I could add we're changing the way it's collected we will not make the carriers hole if they don't collect it so we're not going to be going after the fact through attacks intercept it is on the insurance companies to collected. Representative Gonzalez you're recognized for a question. That is not a question but thanks I do now. the the tax intercept how many times as has that been used and what is a percentage of of people who actually participate without that do we have good participation in that without using tax intercept and and if not do we use tax centers up. Yes please. Yes we do use the tax intercept we send a notice the carriers send a monthly bill basically to everyone to pay their premium and at the end of the year those who have not paid all the premiums they send that to us we send them a letter that basically says if you don't pay by X. date we are going to turn it over to T. FNA to collect through your taxes and then DFA does and I'm not sure if don has exact percentages. You are right I mean in general. It is not a large percentage that pay all of it but there is a significant percentage that do or pay most of it we get with that last we're about to collect and turn you over to the FNA we do get people who then pay us and then the FNA has been collecting thank you over a million dollars annually through that process. So as a whole what percentage of what's owed to the state we actually recover. I'm looking to see if. Don knows this issue behind this pillar. Okay so She's to my left. The president is already. Okay maybe the numbers that we can do the percentage so. For You need to come to the table and this yourself or give information. Please introduce yourself in the represent. Dawn Staley DHS you're recognized thank you. So for for the because it as secretary Glaspie said we have to we have to wait for the year to and send the letters and then collect it so we're always in the arrears in terms of being able to collect against prior years payments but we had four point eight million dollars that was due from the twenty seventeen plan year which resulted in a total of three point nine million dollars in unpaid premiums and then of that and we collected thus far of one point six million dollars. So again. This is what's different going forward than in the past if someone didn't pay their premium that was up to the state to collect it that's not going to be the case in our home of an the end of the queue HP's now are going to have a greater interest in making certain their members pay the premium to them because if they don't collect the premium that's out of their pocket not the taxpayer any longer if someone doesn't pay their cost sharing. That's not out of the taxpayer pocket anymore so those men so this is a fundamental change to make certain that these in fact are personal obligations no longer the obligation of the taxpayer to make the Q. H. people. So if they don't collect the premium then they are out of the of that is there. Can I follow up Mr. One follow up thank you So we've done all these things to it to expand access to care in Arkansas suppose we spend this to expand access to care with the Arkansas Works private option we've given people health insurance we're still next to last and and healthcare outcomes in the state how can we be assured that this program is going to improve healthcare outcomes and not just continue paying health insurance. Please We agree with you and that's why we one of the elements we worked into this is. Allen the accountability line is that every year as part of our purchasing agreement with the Q. H. P.'s it will included it will include health improvement targets that they have to meet in the next year we are of included in the law the ability for us to assess penalties including financial penalties against you a recognized that they do not and then to ensure that there is very public transparency around all of that we've we are proposing in there to create a and this was actually suggested to us by some legislators during our meetings to create and accountability and oversight panel that is part legislators part legislative part executive branch and then some individuals from the from the general public that will review quarterly what is going on in terms of both health performance economic independence performance in life three sixty home performance so throughout the course of this five years. We intend to be measuring all of this but also not have it we're just DHS is looking at it to where we have a broader group looking at it and it if this happens it would start this summer with the setting of the targets for next year and that panel will be part of the review of what those target should be. Just real quick I will put you at the bottom of the list so that once it's directly related to this all right S. the correct so this is a part of this legislation or is that some of the part of the rules that no it's part of the legislation it is and also want to say to you what one of the things that I added after meeting with Senator Flippo Was is on page nine but see here Page two line twenty seven on page nine if the Department of Human Services determines that the individual Q. H. fees have not met the quality of health performance target for two years the Department of Human Services shall develop additional reforms to achieve the quality and health performance targets so that was one of the things and then also DHS may take the action to Legislative Council are executive subcommittee for immediate action and I'll tell you to you senator I don't remember who filed the was Senator Solomon and maybe however this representive Miller can be rooted in the House but they've also got a bill that will bring it was I think monthly reports to a L. C. or public health or something like that so that we can measure this from a legislator I'm fine with that I think that's a great idea to do so we can track the outcomes because I agree with you that we need to track that. Representa Miller you're recognized for a question. Thank you Mr chair We've had. Several meetings and talked about this and and appreciate Bills good temperament But this is. Go time for lack of a better word and. What I can I mean I've heard. A lot of things said. I mean basically I don't understand why we're not just spend and. Eight billion trillion dollars a year of. And Q. H. pays because they're so great for the economy. I mean listening to. Listing to this logic why are my first question is why are we still the only state that does this. I think we're the only state there's still does it because it's working here in Arkansas the two states that tried premium assistance previously one was I will the other was New Hampshire I'll work of. Included only those above a hundred percent of poverty. Instead of their entire expansion population they didn't have enough bodies to make it economically they also their largest insurer Blue Cross did not participate there are other plan was a coop plan that came out of the ACA of legislation itself that Cooper had no experience in running a health insurance company. They collapsed almost immediately they ended up they ended premium assistance they put everybody into managed care plans. In New Hampshire they tried premium assistance also their churn rate was over fifty percent because in New Hampshire people were getting out of poverty and getting out of a hundred thirty eight percent poverty level so quickly again their market was unstable this isn't a matter of this it's a matter of economics right economically neither one of those states could make it work because of the choices that they made instead we put this effect we have sufficient volume we had the experience carriers of who know how to make health insurance work I think the other thing about premium assistance premium assistance is something that when you look at different groups when they talk about Medicaid reform if you look at the heritage foundation if you look at the Galen institute you look at all of these of of a policy think tanks. They were saying put people in premium assistance put them in private coverage not fee for service Medicaid. Again and and I appreciate the response you. You told us one of our New Hampshire failed. There's forty seven other states. I don't know of anybody else that's even tried it and I know there may be some thank thanks probably those that are funded by the insurance companies who are making a healthy profit. On this program that obviously or promoting it but I'm just saying we've been dealing with Medicaid expansion as a country for. Ten years now yes Sir so and and we're the only one doing it and I'm just I'm I'm still like why why aren't other states looking around and saying boy Arkansas this is working fabulous the other like them I'm sorry. The other states are not putting their population into fee for service either they're putting them into managed care plans so when you look at the other states that did Medicaid expansions they had their history in Medicaid for ten twenty years is Medicaid managed care so many insurance companies that offers. Products in Medicaid managed care and in private insurance they don't want to mix their business so the Medicaid managed care side of the house when you look at these large national companies the Medicaid managed care side of the house got the business instead of going over to the commercial side but those other states are not they don't have their adults in fee for service they have it in managed care and those managed care plans what the Medicaid managed care plans. Want to keep them in there instead of in the on the commercial insurance all I just wanna make sure I'm clear on what you're saying all other states that have expanded Medicaid. Do not have their. Populations and fee for service they have and managed care every single one of our. I will go back and check to be absolutely certain but not a single state comes to mind that is that is in fee for service. Okay and I can tell you to a representative Miller that I know when I was on the healthcare task force that Arkansas we only covered at the time of to seventeen percent of federal poverty level before we did this and they were other states that were up to the hundred that were over a hundred or a hundred thirty so there was nothing to expand for them right so we had a lot of expansion today where they had nothing to expand. So short though that out there as well. Thank you Mr. The representative Boyd you're recognized. Thank you Mr chair. So. M. that number on I'm I'm gonna. Represent Dotson you're recognized for a question. Thank you Mr chair So I think it would cover a couple of my questions The. I guess the question is under the your new proposed our homes plan how many more people will be covered under than what it is currently covered today. So the the adult population nineteen to sixty four we are currently around three hundred thousand individuals so how many more become an eligible eight is really dependent on the economy the stronger the again Medicaid is means tested it's measured by federal poverty level so in a strong economy if people are so a lot of people are working even below a hundred percent but they are what we would consider under employed they are not working full time full year full time for a year is two thousand eighty hours a year if with a minimum wage increase that went up to eleven dollars an hour if you work full time full year you will not be eligible for this program because you make too much money to anticipate there being a reduction in the number of people who qualify it did it will depend in large part on the economy right now we cannot discern role people because of the federal law on the and a COVID legislation so we have to keep people in the program but that will end at some point in time so when that does happen the enrollment will likely go down. We. To be very clear we are not changing eligibility the eligibility is set and it was set when private option was establish it stayed the same through Arkansas works and it stays the same with this so the same age group and income groups are eligible our goal with this is to get more people educated skills moving up the ladder and off the program but that would happen naturally because they would not be eligible anymore. As follows yes as I understand it you're expanding the. The carrots to enroll no Sir no Sir not at all and We had no it is it is the same program with the same healthcare coverage right that exists today that people sign up with notice for services no additional services the Q. H. P.'s and in fact when you think about it putting cost sharing on on it is actually it right now we have cost sharing on Children and medicate we don't have cost sharing on these adults below a hundred percent right so they will have copays and cost sharing that they don't have today but the Q. H. P.'s one of the things that we're trying to do with the Q. H. pieces to get more value out of using Q. H. P.'s and so we're bringing the Q. H. P.'s and. Both through accountability measures and through allowing them to do incentives so that they have to drive health improvement target meet health improvement targets and drive health improvement every year right and then in addition to that they have to be partners with us in trying to promote economic independence among the population so those for that reason yes there would be more value to being in it but it's not like by being in this plan it's going to a pay for your housing or something like that right you're still getting your your doctor is still getting paid through the plan is what's happening does that make sense thank you. Representive Eubanks you're recognized. Thank you Mr. I'm just I'm curious have how of this the three hundred thousand people that are on private insurance how that affects the overall insurance market. For the state to all the other citizens of the State. I'm. We can obviously let others know insurance better discuss this but what I would say is this they influence the market there in not the entire insurance market so there's somewhere between fifty and sixty thousand people who are not in Arkansas Works but our purchasing plans through the market place and so what happens is by putting all of these additional lives in there and purchasing plans in that market place it makes the risk pool much larger in their and so for the fifty to sixty thousand what they were talking about is that helped provided more stability than in other states and help to keep our premiums at this point lower than surrounding states. Thank you. representative mentally you're recognized. Thank you chairman First off how much of the nine point seven six billion that we're paying to the crease piece how much are they able to keep for profit. So again that figures over five year period of time each year we are about. Roughly one point eight billion two two hundred two two billion but the premium is what they get right they get to keep their when they pay out cost sharing to provider that goes out and gets paid to a provider we pay about three hundred million dollars in the fee for service we pay about three hundred and thirty some million dollars on cost sharing so the premium amount they have to meet a medical loss ratio of eighty percent that's what is it in the affordable Care Act so we follow that eighty percent of medical loss ratio out of that yes and the so the eighty percent is on the medical benefits. The other twenty percent is the cost of running the business the cost so the Part of that is the provider tax that comes back to us that comes out of the the twenty percent it cetera so would you do the cost of the operations of the premium taxes it's cetera the the margins of what they keep as profit I don't know that of amount. But if I could just to add on to it the M. L. ours that are reported in terms of what they had to spend as he said on the medical side what we have seen is that uh year after year one of the carriers is up in the ninety percent every year over ninety percent up to ninety five percent so that doesn't leave a lot for the administrative cost on the other side or the two and a half percent that is paid back as premium tax so No and that we do not pay the nine billion to the Q. H. fees I mean part of what he was saying is that out of the one point eight billion every year about one point one to one point two is actually what is flowing through the Q. H. P.'s and it is off of that one point two that you look at the medical loss ratio so it. It It is not as large as it appears follow on that what what percentage of the people that are receiving these. The healthcare benefits that are not using them at all do we have an amount of you know we work we're paying for their health insurance every month and they're they're not utilizing it all be a percentage of them I mean those are not being utilized yes it it varies again by age by all the number of different very just very Abel's remember it is insurance so you expect to have people who don't have claims of and the and then the the number of number of people with zero claims the number between zero and five claims fifteen or more claims by any year so when you're looking at the the when you look at employer sponsored health insurance as an example and we have not gone back into the queue HP's so again I just by reference there are studies out there that generally thirty to forty percent of people don't have claims in any year but again it's those people who are not using it that offset the cost of the people who are use a lot of medical services so the percentage that are low users and the percentage that are high users is generally about the same. World press and I let you go on to someone else but give me some real quick details on this maternal homes I know should busy but just give me a real brief. Roof over your quick or how we're going to how we can improve our maternal mortality will be rates through this. Right so. Maternal our home at the concept is that hospitals in the state birthing hospitals in the state basically become an anchor and what we will do is for women in medic in Arkansas our home right to have high risk pregnancies which statistics what we've seen in previous years it runs about five thousand women a year would be eligible for that hospital to provide for them through either the hospital or local partner in that county intensive home visiting services and those intensive home visiting services would start while she is pregnant to help focus on getting through a good pregnancy right and hopefully a healthier birth and then continue for up to two years after to help ensure that both the mom and the baby are healthy through that period so it it it is a it is taking some models some of which already in Arkansas and some which are nationally approved and basically finding a way to put those or we have somebody literally going into the home and working with the mom to be or the new mom. Thank you. The representative Payton you're recognized for a question. Thank you Mr so earlier before the break we were discussed in the incentives or penalties depending which side you're on for healthy living a healthy lifestyle doing the things we think would reprove your health and lower the risk which is lowering the risk for the insurance companies that were purchased in the insurance from but in that discussion you mentioned that people not following. The prescription. Might be moved to fee for service and I know we already have medically frail population. That we protect insurance companies from covering them. So it seems like we're underwriting the insurance companies to make sure they don't have the losses which I know when we started this a private option there was a trigger that if they hit five hundred and fifty dollars a month per member per month it would kill the whole program so there's a lot of incentive to. Our we had people that didn't exist on there to drive the per member per month down and we so can you tell me today. How many people who are part of the expansion are currently own fee for service because they're medically frail or or because we're trying to keep those losses off the insurance company. Twenty two thousand medically frail and that stays pretty constant of over over time there are people who are temporarily in fee for service they've just been found to be newly eligible they wait a short period of time in fee for service before they moved to the qualified health plan that's about twenty six to twenty eight thousand people. So I need to follow up yes you can follow so the twenty two thousand the the medically frail and then with the guidelines we were talking about earlier of others that we may move for other reasons. Have you done a projection on how many we're talking about that we would be. Following and and is that am I misinterpreting the fact that I mean these are the high loss high risk you know more expensive healthcare field or what let me let me make sure I correct something with you first and then we can get the second part of that. In in fact what we're talking about in terms of people who don't. use their plan right would would be people who. Over a over a significant period of time are not using their plan in any way and are not showing that they're moving towards economic independence so from your your question you're asking those would be people there for who aren't showing any claims right so it wouldn't be the high cost people it would be it would be the people who don't cost the carriers anything that the carriers would be at risk of losing into fee for service so there incentive would be to get those individuals. Doing something right actually it moving up that income ladder getting across certain thresholds are taking advantage of things versus just being on the Q. H. P. so I did I did want to correct that part. If you wanna answer as a part of his well know what we're on the correction so you're saying that if somebody's not following the prescribed Safety measures or or the incentives is gonna help them have a live a healthier lifestyle if they're not following that and they have losses. And claims that we would not move in date they would stay in the queue H. B. if you're having medical claims and you are using your insurance you stay with your insurance even if you're not far even if you're failing to meet the incentives the incentives are about creating opportunities for healthier improvement and if so the Q. H. fees will be required to provide incentives both on health improvement and on economic independence if someone doesn't avail themselves of either of those then they miss out on the incentive but they have medical claims they still stay in the queue H. P. thank you thank you Mr president Miller you're recognized for a question. Thank you thank you Mr chair. Mister Smith. Earlier you were talking about we were talk about the comparison between if we went fee for service as opposed to using the the Q. H. fees are in the insurance companies and you you brought up the word revenue. Quite a bit and that the We we save money as a state and as a but government we say taxpayer money if we if we go. The route of fee for service but we lose revenue. By not going the route of the insurance companies Who is getting the revenue what whose whose revenue is this that you're talking about so it would generate less revenue it still generates revenue but it's a lesser amount and the FNA bill this off of a business development model on how to model what the revenues are the revenues go to local government and to the state government part of the city income tax part of the sales tax so there other kinds of taxes on who so the local government may be getting a good will get part of this tax revenue and the it so then it shows up on the state revenue side as well. So that the you're talking about you're talking about it the the distant day still tax revenue that we see coming back and as to the timing of a hundred and I think you told me one time a hundred and thirty million over five years more it it's a hundred and eighty million better than fee for service I'm sorry it's three hundred billion dollars better than fee for service. But since this state spending when when you are netting it out on the spending side because we spend less on fee for service but fee for service also brings in less revenue so when you count the spending and the revenue this state is better off. With the Q. H. P. model because we generate more revenue under that model. To that state and local budgets. Khalfallah Mr one more follow up thank you. So with that being the case. Why do we not do. All of Medicaid under the same model because the state still has to come up with its share federal government will send money to us only if we come up with our share and we're competing in our home has to compete against everything other budget priority in the state budget right so again that's why we are saying it is we think the better model. But even that has some constraints we can't just take every time they put it into our home right exactly thank you Mr. Representative when you're recognized for a question. Thank you Mr chair so we've heard a lot of questions getting into some some of the specifics of this bill and it's a very complex issue sometimes it helps us refine argument if we step up and take an overhead view again so I'd like to ask a question of. When when I got under this committee. I wanted to increase access to health care and I wanted to lower the cost of health care how does this bill help accomplish both of those goals. Kind of an elevator pitch opportunity here sure and if you give me an elevator pitch I will take it. so what this bill does is it increases access in that. Those who are in our home. The evaluations that have been done by a chi and others show that those who are in our home have faster access to health care services right so they are more quickly able to see a specialist there more quickly able to get a doctor's appointment than someone intricate traditional fee for service Medicaid it also helps with access because of the point representative gray was made other states around us have wound up with their rural hospitals closing. And I I know we have some hospital CEOs who are here today that will talk to you about the impact if they lose this if they lose the additional rates money that they received by work by the for the Q. H. P.'s so that keeps our access in place helps them to continue to grow and improve what's in this state there's significant difference between where we were seven years ago where we are today and it does provide faster access our goal around cost is two fold. One we are slowing the growth in cost we will negotiate with CMS a trend line for how much this can grow that will be below the current trend line that creates that cap that every year we can't go above if we go above that is a state that we go to a hundred percent state spending and That you'll kill us I mean that that it is a cap and so we have also said in the legislation that the Q. H. P.'s must also abide by that cap every year if for some reason they're above that amount we will not reimburse them we will not pay them so we are putting some measures in place to hold ourselves at that slower growth cap and then the third point on that is at the end of the day the way you reduce health care costs. Ultimately is to get a healthier population and that's why we put in a real plan for true not just. Requiring health improvement on the population but real time tracking it with you all so that we can keep moving towards it and penalties if they are not. if they're not improving health. Thank you. Representative Wardlaw you're recognized for motion. Motion to call the question. You mean do pass. Meg motion do pass I make a motion to I have a second motion meeting. Immediate consideration. Thank I can't do that because not proper I would make a motion to call the question okay. I have a motion the call the question. not debatable. All in favor signify by saying aye. All opposed nay. I'm set eyes have been. Okay. Local. This way this way. Representative Wardlaw yes. Representative Eubanks. Representative McGee yeah. Representive Johnson. Representative Dotson. Representive Miller. Representative Payton. The representative Bentley. No no. Representative gray. The representative Gonzalez. Representative Boyd. Representive Allen. Representive Coleman yeah. Representative Pilkington. Representative Pilkington. Yes. Representative weighing. Yes. Representative Penzo though no. Representative Perry. Yes. Representative Marsha Davis. Representive marsh Davis. Representive cloud. No. Vice chair Ferguson. Sure Ladyman yes yes. Six. Whether you nine nineteen is here Thirteen. Motion for me questions fails. All right. We have no further questions on the list. Representative Gonzalez have a question you're recognized thank you Mr so managed care's been brought up a few times now and if I know insurance companies use a managed care model basically and that we all have to do prior Austin seven and they have to do this through the Arkansas Works program as well I'm sure So how are we better off paying insurance companies to do that versus just flat out hiring managed care company to come in and and manage our cost. So of. Managed care is a culture. In Arkansas does not have that culture here. Of in states that have expanded managed care they started back in the seventies they did it in the eighties they didn't do it statewide in those that did try to straight to it try to do it statewide basically failed you start small and then you expand from there but managed care to me is again is a culture Medicaid cannot bring that culture by itself it has to do with the doctors the hospitals the beneficiaries themselves all have to be comfortable with that model to actually work. And I don't think that is here in Arkansas. I've been in states in which I did have managed care companies. I did it in Virginia I started small and grew it it took twenty years to get as big as it is today. You don't do it all at once if you do try to do it all at once it fails miserably and your constituents will be calling you three times a day every day of the week your doctors will everybody managed care is managing to a contract if you look at a Medicaid managed care contract those are four hundred two with twelve hundred pages long. And that managed care company is managing to that contract if you didn't say all you have to report this every month they're gonna say what in the contract US and do something else say it's not in the contract managed care is a culture. And I don't think Arkansas is ready to do that state wide four three hundred thousand people and the doctors and the hospitals and everybody else. Follow up yes recognize the face I'm not real sure that that answered my question so in I don't know what you're what you're saying that's that's fine it Arkansas may not be ready for managed care but just on pure cost basis what we were looking at our off of an insurance company is not in the thank you again the managed care companies are looking to where you overpaid on the fee for service site they are looking to get if to get any efficiencies out. They are just and they're managing a tighter utilization and lower of provider rates quite frankly that he's asking is what my school missing what's the cost to the state per member per month or something like that for managed care versus this was asking we we did not model of a managed care proposal the I. it would be I don't wanna just gas. Right any other questions from committee. Seeing representative Pilkington you're recognized thank you I know this debate going back and forth about fee for service my next as nothing to do with what we've been talking about it it's clear on the A. R. homes program can you kind of explain to me it's very hospital based which is great but can you explain to me how our local providers in clinic groups work with the A. R. homes model because I'm not. I'm confused and where they can ACT scan can you explain that to me. remember that the bulk of this is continuing what is right now all right so just like right now day. At work with the Q. H. P.'s they have agreements they get paid that still going on right still those rates still that when you look at the life three sixty homes which is I think we're we're we're we're you're focused. Part of what will be will be working our way through it is with the hospitals and with the providers it is simple question. Maternal our home. How do we get those who are seeing a high risk mom to refer that mom and for these additional services so over the next couple if if our home comes into being part of what we would be working with everyone is how does that referral take place and if she's in an area. Let's say that that referral isn't naturally happening we can work with the Q. a recognized for the committee recognized to go through the claims and identify that mall and perhaps reach out into her purse to her providers right and try to get them to refer her for the services so part of that will be how those connections take place between the anchor hospital which is where you can get referred for the service but it's not disconnecting in any way shape or form the mom to be from her provider her provider is still her doctor her provider is still the one getting everything and our goal would be that for example her OBGYN would be getting the information back and forth with with the person who is doing the home visiting with one doctor we talked about this around the success life home who sees of substance use disorder patients right I mean she was very excited but she said when things I want to you know think through is how do I make sure that I get the information I have about this person to the one who's going to be working with her every day in our house. And you know not things that shouldn't go but just some things that she wants to make sure they know and then how does that person get word back to me so I am aware that there are problems arising so that connectivity will have to happen but that part of that is the role of the hospital in the middle to ensure that connection on the medical side. It. All right any other questions. How. What. That's how we want the communication to happen and that's why this is we keep stressing this is a five year plan because part of this is is now to move to the design and work through how would that work and the life three sixty homes we know they're not going to start all over the state simultaneously that's actually not even a good idea we need to have a few starting trying out these different areas and working through how a lot of this works and then from there other hospitals and populations take it up and keep going so. All right any other questions from committee. Seeing none we have to people's signed up to speak for the bill and to to sign signed up to speak against the bill. So the first one will call is nik Hatton to speak against the bill. Please introduce yourself and who you represent. Sure in accordance with the foundation for government accountability. You're recognized sorry my handwriting is poor Mr chairman. Would like in a to me even if you're recognized. Thank you Sir. Thank you Mr chairman and members of the committee for the opportunity to testify today. My name is Nick cordon and I'm the research director for the foundation for government accountability. FGA is a nonprofit think tank that works in thirty plus states on health care welfare and workforce reform. But I'm also native our cans and I have worked on public policy in this state for the better part of a decade now I live just outside of Conway with my wife and two kids and to be honest there huge reason why I'm here today and I felt like I had to speak on this bill. Members quite simply the private option model has failed. And not just by a little bit by a long shot. And just to be clear when I say the private option I'm referring to the specific way as you're all familiar. In which we administer obamacare expansion. We give able bodied adults free private insurance plans. Purchased on the obamacare exchange with obamacare dollars at more than twice the cost of Commissioner Medicaid. And every major promise the private option proponents made in twenty thirteen has failed to come to fruition. We were promised lower premiums. But premiums have more than doubled. We were promised more insurers in competition in the insurance market. But we lost insurers. We were promised a smaller Medicaid program that enrollment would go down but enrollment has skyrocketed the higher levels than we've ever seen. We were promised cost savings. But DHS's own numbers show very clearly that this model is cost more than twice as much as regular Medicaid expansion. We were promised a thousand hospital jobs. Instead we've seen hospitals close in just a couple years ago right here in Little Rock UAMS closed six hundred positions. And we were promised that this model would make as a national leader in Medicaid reform. Yet the only other two states that even tried it has scrapped it very quickly. Leaving us as the last date standing. In fact you'd be hard pressed to find a single promise of the private option that's come true. At the time before many of you were here. This concept was sold as a conservative way to expand a bomb a care. Because we were told by funneling billions of dollars to insurance companies. It was a free market solution. In reality. It was a political shell game. And taxpayers got left holding the bag. We added more than three hundred thousand able bodied our Kansans to welfare. Helped prop up obamacare as one of the of the only southern states to expand Medicaid. And we made the program even more enticing an expensive. We now spend more than seven and a half billion dollars on Medicaid in Arkansas. Before expansion. We spent just four and a half billion. So we're well on our way to doubling the amount that we spend on Medicaid in the state in less than a decade. Nearly thirty percent of every dollar that we spend goes to Medicaid. And what we gain to return. But as you all know this hearing is not just about re litigating the past it's about the future. It's about what kind of Medicaid program do we want to have and what type of culture do we want to create for future generations in our state. After failed promise upon failed promise upon fill promise you're now being sold many of the same hopes and aspirations and being asked to double down. By not just re authorizing the private option model but I believe. Making it even worse. Specifically this proposal would expand Medicaid expansion to even more able bodied adults who have employer sponsored insurance. It would put state taxpayers on the hook for paying part of able bodied adults obamacare subsidies after they leave Medicaid. It doesn't include any real meaningful cost controls. It doesn't provide any real cost sharing your skin in the game. Most of these able bodied adults will pay nothing. It will initiate a large in wasteful outreach campaign that will almost certainly increase dependency. It does not include work requirement. And based on my reading of the bill it does not include a real trigger for if and when Congress reduces the federal match rate for expansion costs. And much more. In addition to be just blunt about it I believe the bill is poorly drafted. It mentions in independence initiative as has been discussed here today but it doesn't clearly articulated define who will be subject to it. Perhaps because as noted in the bill dissipation will be optional. It says enrollees will receive incentives to participate but it doesn't specify what those incentives will be or who will pay for them. Although I think it's safe to assume it will be the taxpayer's. The bill also gives the false impression that the department will assess medical debt to enrollees who fail to meet the work suggestion. But the bill also specifically says enrollees will not lose coverage if they fail to pay. And again. Most enrollees will pay nothing. So this is really a red herring. The bill also suggests DHS may limit enrollment in private insurance plans but it doesn't require it. It creates yet another task force to offer advice but it doesn't give the panel any actual authority over anything. Overall this bill places a lot of trust and hope in the best intentions of state government and big insurance companies. It gives the appearance of meaningful reform without actually accomplishing it. And I get it I understand we don't have the same willing federal partners is CMS that we've had for the last four years so this bill has been largely constructed in a way that the bite administration will approve it. The probably even like it. As in many ways it will increase dependency I keep I can't instructed Medicaid. As conservatives I think this should obviously concern us. It's frustrating that we don't have real flexibility. But rather than playing within the Obama Biden rules and catering to them. We should ask act in the best interest of Arkansas which I strongly believe would mean rejecting this bill in transitioning conventional Medicaid expansion. Our estimates show based on numbers from DHS that this shift would save nearly a hundred million dollars and state funds every year. And think about what we could do with that money. By saying no to continue to line the pockets of big insurance companies. We can say yes to our teachers. I give everyone of that everyone of them the two thousand dollar raise. And have money left over. We can say yes to expanding broadband access. For yes to paving an untold number of miles of Arkansas roads. We could even increase reimbursement rates. And reduce the waiting list for traditional Medicaid populations in Arkansas so that truly needy for Kansans can get better access to doctors. Frankly I think all of these things would be better uses of these tax dollars thank you ten Ewing down the failed path of the private option. Ultimately I think this bill cuts against the grain of who we are as our Kansans. People who are committed to hard work and independence. And it's not the future that I want for my home state or for my kids. And with that be happy to take any questions. Representive Allen you're recognized for a question. Thank you what's the term of the very very brief at the given a speech you said that we have hospitals the coals in the State of Arkansas so would you please give me the names of the hospitals that actually close in the state of Arkansas. Besides you M. S. sure absolutely we had six positions because it messes I mention women we had a that's not that's not hospital closer I'm sure you're you're miss did not close sure that's correct okay again I would I would point out we were promised over a thousand new hospital jobs when the private option was passed no we're talking a hospital closer sure okay so I would hospitals schools so there was a hospital in Jacksonville the clothes I don't remember the exact name of it there was a hospital in Crittenden county that closed there was a hospital to queen that closed as you all well aware UAMS as I mentioned is laid off six hundred positions we had That does help reported back to back losses of twenty million dollars we we thirty million dollars so that we might talk about losing money we talk about hospitals that closed. Yes Sir I'm I mentioned several of those as well okay thank you yes Sir. Represent Ferguson you're recognized for a question I mean there's so much misinformation in your presentation I don't even know where to go first we're have a ninety ten match now the thirty but my hospital close before Medicaid expansion in creating County the main reason we closed is because we were almost a full Medicaid hospital and they couldn't afford to stay open we now have a new hospital that is doing very well because of Medicaid expansion and the improved provider reimbursement so I mean there's just so much and wine you've given bad information but I won't go any further. Any other questions. Seeing none thank you for your call thank you Sir. Okay to speak for the bill Joe Hannah. Joanna is here. I don't see him here's. What. Is in the waiting room. Okay thank you. I'm. Nothing. Come. Okay John show month did you want to speak on the bill. You're good okay. Okay Gregory foster to speak against the bill. Did I pronounce your name correctly. Close okay if you introduce yourself in the represent. All right thank you Mr chairman members of the committee Good evening my name is Greg Pfister and I'm a senior fellow with the opportunity solutions project and I'm here today to speak against S. before ten. A couple weeks ago I was in Jefferson city Missouri to share the story of Marcus login with the Senate public health committee I first learned about Marcus when I read an article in the St Louis post dispatch with the headline in Missouri people who can't speak and see wait in line for help. Marcus is from north St Louis and at the time the articles written he was twenty two years old he has a severe autism and epilepsy nonverbal yes to wear diaper and a helmet in case of seizures and he's on a waiting list for additional Medicaid coverage that would get him into a care facility it was real support. It's a sad story and it's what happens when a state does not prioritize is most vulnerable citizens they end up waiting in line for funds become available. It's also a story that's not limited to Missouri unfortunately here in Arkansas there are thousands of vulnerable people that are on a similar wait list waiting for Arkansas to find the money to help them by providing services that they desperately need in the state acknowledges that they qualify for but can't have yet. People like Skyler over men from saline county. Skyler has a rare neurological disease called skits and stuff away and requires constant care. She could not eat on our own walk go to the bathroom for talk. If anyone were to perfectly fit into the description of a vulnerable citizen. It would be Skyler and yet she was on a waiting list here in Arkansas for the first ten years of her life before finally being approved. The sad thing is that will thousands of severely disabled citizens people like Skyler. We did at the back of the line Arkansas found the money to enroll over three hundred thousand able bodied adults. Into the expensive Medicaid expansion private option program. Arkansas as was mentioned earlier is a last state in the nation that uses an excessively expensive plan like the private option every other state figured out quickly that it did not financially work in fact according to an intracellular should done by the Arkansas center for health improvement the private option is ninety eight percent more expensive than conventional Medicaid expansion would be that's what twice as much money. The private option has also set up a perverse system. Able bodied adults are given an expensive private insurance plan. With taxpayer dollars while the disabled poor children pregnant women and the elderly are placed into Medicaid. And severely disabled people are put onto a waiting list for additional support for things like home and community based services voting down as before ten will not kick anyone off of Medicaid. It's not going to remove a single able bodied adult. What it will do is and the private option in shift able bodied adults into the same Medicaid program as Arkansans traditional Medicaid population the same Medicaid program that every other state that has expanded Medicaid uses at a much lower cost. Based on our estimates it'll be about half as much money. This will end of the tiered Medicaid system that Arkansas currently house in which able bodied adults are treated better than disabled people by saying no to the private or option. Arkansas can say yes to many other things that will actually help vulnerable citizens with that extra money you could pay down the Medicaid waiting list. For citizens that are the most vulnerable in society but with that extra money you could also provide things like the only community based services for people that are developmentally and physically disabled people like Skyler and Marcus you could better fun nursing home facilities you could expand home health services for seniors and this is just to name a few there are a lot better ways that this money could be health spent to help vulnerable citizens been pouring it into private insurance programs for able bodied adults and with that I'm happy to answer any questions of the committee may have. Represent Ferguson you're recognized. You do realize that seven hundred people on our waiver plan are off the Waverly is because of a two percent insurance premium tax because of the insurance premium taxes what's affording those people to come off the list do you realize that I mean insurance is facilitating packed well I would say that if this program or allowed to expire all of the people could be removed off the waiting list. Not if we lost a hundred thirty million in in tax revenue from the increased employment and the trickle down economics that this produces. Well to that I would say that if economic development is based on welfare then I think we're heading down the wrong the wrong path as a as a state as a nation I think the the California model has shown us that that's not the best way to approach it. Say it's based on providing health care to. Anyway. Representative Miller you're recognized for a question. All other questions I just want a different view. All right. I think we're all their representative Miller And any other questions. Seeing none thank you for your comments thank you Mr chairman. All right see no one else signed up to speak for or against the bill represented were you to close for the bill. I am Mister chair that thank you so so much and also want to say same land with I think it's a Baptist in Jonesborough did come down today CEO but due to time he's he's let me close and let us get out of here one way or the other so I do want to I appreciate him driving down today I am so what I'm gonna do enclosure I there's been a lot of good questions head trying to figure out I was writing as fast as I could rights when Mr net court was at the table there were so many inaccuracies with what he said like I'm not even sure where to start he started out by saying that the private option has failed out but he didn't give like any actual reasons as to why it failed to mount still going we're able to physically sustain it has to do a lot of things for the state is out you know what to do with that and. I wasn't here in two thousand thirteen I know maybe a couple of you where you were at the dentist during one of those votes I think I remember the hat but a few of the war I can't say what those promises were and what they wired all I can tell you is what my district needs as far as my hospitals my doctors all my providers what my constituents need and also in this Handout this is one of the things that I want to point out it shows percentage of qualified people who have this state thank you H. P. of your adults that are not all medical not on Medicare my counties are some of the highest in the state so Stone County I think was at about twenty seven percent of the total population is in this is in a Q. H. P. so I had some of the highest in the in the state and he or he was saying that hospitals closed only one hospital close that was into queen nothing in Jacksonville closed into the six hundred employees at UAMS laid off or or fired posted COVID at a hundred fifty my hospital that we ended up having to let go due to code had absolutely nothing to do with The Medicaid expansion that does not expand insurance to any groups it's the same qualifications that we've had the entire time in order to get into the program. And. A talking about cost sharing it with that there's no cost sharing yes there is cost sharing we can include that the talk but no work requirement I can't include the work requirement we just got a letter from CMS last week this is your work requirement is stricken we will not allow it I can't put a true work requirement in this waiver it will not be approved one hundred percent by administration will not approve it. T. talked about this bill increases dependency nothing in this bill increases dependency I know he's talking about it would save a hundred we'd save a hundred million a year not sure what testimony he's listening to you are what we're looking at but that's not the testimony that was given today by DHS the testimony given today by DHS was yes we save a certain amount by going to straight fee for service but we also lose a lot more than that the hundred thirty million they're not but we lose a lot more than that in revenue but not having this program in place And then he said there is no mechanism in the bill if if the feds change the model from ninety ten to something lower yeah it's on page eleven starts online one that the DHS has what is it a five hundred twenty days they separate into the CMS plan within thirty days of the reduction and I have a hundred twenty days to essentially do something to terminate the program so that's in the bill as well so I just close by saying I've heard a lot of inaccuracies in it inaccuracies with that And I hope that. The presentation today I hope that with this right here you can see that what we're doing is the best thing to keep our hospitals open to keep access to health care for our constituents especially the high population in my district spree shooting good vote. I guess I make a motion to pass. I committee most on floors do pass any discussion on the motion. Representative Miller you're recognized. Thank you. Insure chair of folks I'll try to be as brief as possible and and. For for the record I want to thank the representative Grady she knows that I'm not supportive of this bill was out sick last week she could've ran it and so it was very classy of you and I appreciate that a lot We have a two the gentleman up here Manigault saw spoke on this. We have a two tiered system in our Medicaid program right now. And it's just going to get worse. If we keep this. Private option private insurance model in place as the token. Disabled legislator I get calls from all over the state somebody has found themselves in a situation similar to mine. And they can't go to their PCP. Five miles up the road in their home town because they're no longer taking traditional Medicaid patients. That young man that young woman. Only has traditional Medicaid. They do not qualify for any of these insurance plans. Period that happened. They have to wait two years at a minimum before they can get on Medicare. And that's happening more and more across our state. The longer that we stay in this. The worse it's going to be. We are in this is not represent grace faults not Senator Irvin fault it's not miss Gillespie fall. It's just the way it is. You say well how do we fix it. Well I think we could at least level the playing field. As far as what we do we as a legislator legislature do not have the ability to force. Private entities doctors offices hospitals anything else to to do anything. I mean within reason yourselves say. But. We can. We can quit giving them. A of. A two platform. System. We can quit saying Hey the able bodied folks. Many of whom are not working I'll say it again many of whom are not working. Our push to the front of the line they have the best interests have better insurance than your school teachers at home. That that we're paying for. And yet you take someone in a very vulnerable situation. Recent spinal cord injury recent diagnosis was something else. And they may have to drive an hour just to go to a regular primary care doctor. Depending on where they live. That sucks. We shouldn't do that here. And. You know I'm not I don't wanna I I've been opposed to the program since two thousand thirteen. I've been posted since two thousand twelve. And I willing to say at this point I give up I'm done fighting it let's just do it fairly. And let's do it the most affordable way possible. There were the word revenue was used a lot today and I can tell you who's getting a lot of revenue. S. couple insurance companies and some big hospitals which I'm fine with the hospitals and doctors offices making money. But it's not my responsibility as a legislator. To help their books. It's my responsibility to do what's fair what's judged. What makes financial sense for the state of Arkansas and for that I would ask that we not vote this out. And we consider our other options thank you. Representative Johnson you're recognized. Thank you Mr chair I'm is no surprise probably where I'm going to be on this bill I I haven't been. Lobbied I don't think a thing been asked one time to vote for by someone You know I've I've been here since twenty thirteen when the private options past when we debated that went back and forth You know this this really isn't about expansion any longer that ship has sailed We have it that bill can't be un rung but we're talking about this particular program moving forward and as a fiscal conservative it's not something I can support when we're going to spend two point nine billion dollars more than an alternative that is available so. This is above and beyond what is required by the ACA. obamacare and is is a lot more expensive program and so I'll be in a thank you. Representative first you're recognized. Yeah and and really this is for representative Miller I I completely agree with you I think we ought to pay more in Medicaid fee for service but you have to realize for a hospital or even a practice to sustain themselves they can only have so many they for service Medicaid patients on their panel and if you don't pass this and you go to strike the for service in X. Medicaid expansion you're actually gonna make your access to health care much worse because then all these people will be in Medicaid fee for service and you will see it immediately but you'll start to see doctors closer panels and a particularly specialist who are already hard to say. They will it will it will be impossible to get in to see a specialist if you close down this program from insurance reimbursement and get put all these people in fee for service it will it will make it you think it's hard to see somebody now the only way you have hospital close but you'll have you won't be able to get in the doctor's office. Representative Bentley recognized. Thank you chairman I think your best time to an hour long and tiring appreciated parties work on this but I think I heard twice senator trickle espys mail that the people that are on the private option on the Arkansas homes get to see specialist for those that aren't traditional Medicaid and over over again I hear is as representative militants from my constituents they cannot get in to see a position. Hurting those that need it the most and I'm I know raised anyway I will again I'm saying I want fee for service for everyone to work on it to make it possible but. To take three hundred thousand able bodied people and put them ahead of those that really need it it hurts me and I have always been I'll continue to be and I want to work for those that need it the most thank you. All right seeing no more discussion no more comments motion is do pass all in favor signify by saying aye. All opposed nay so. Is haven't. Overall call the roll. Representative Wardlaw hi. Representive Eubanks yes. Representive McGee. Representive Dotson. No. Representative Miller. No. Representative Payton. Representative Bentley. No no. Representive great. Representative Gonzalez. No. But not. Representative Boyd. Representive Allen yeah. Representive Coleman. Yes. Yes. Representative Pilkington. Representative Pilkington. Representive wing yes. Represents the representative Penzo. Representive Perry. Representative Davis. Representive Davis. Vice chair Ferguson. Sure Ladyman. The plan. Over. Well. What you missed representative clout I'm sorry representive cloud. I'm sorry without no. Motion passes. Resolution your bill is passed. The Committee. Looks like we're done committee I want to thank you all for coming back with nineteen people come back I really really