2025-04-07 00:00:00 - Joint Committee on Ways and Means
2025-04-07 00:00:00 - Joint Committee on Ways and Means
(Part 1 of 2)
SPEAKER1 - Welcome everybody. Welcome to our, joint committee on ways and means governors h 1 budget proposal for fiscal year 20 26 6 HHS 1 hearing. This is the18 seventh public hearing on the h 1 budget, by the joint committee on ways and means. The eighth and final hearing on the h 1 budget proposal will take place tomorrow, April eighth at 11AM at the State House, and we'll feature testimony from the public. My name is Paul Feeney. I'm the state senator from the Bristol And Norfolk District, Assistant Vice Chair of the joint committee on ways and means the senate committee on ways and means. It is my pleasure to welcome you to Attleboro High School, to the city of Attleboro. To I wanna just say thank you so much to all my colleagues, not only for coming here today to the Jewel City, but also for traveling across the Commonwealth over the last month plus for all these hearings. It's, it's been evident that this is the way the government should work going out to every community, that we possibly can across the Commonwealth, and I'm thrilled to have you here in Attleboro this morning. Today, this hearing will73 be co chaired by myself and my good friend and partner in government state representative David Beal. We will hear from the executive office of Health and Human Services, EOHHS, MassHealth, Office of Medicaid, Department of Public Health, DPH, Department of Mental Health, EMH, Health Policy Commission, Center for Health Information and Analysis, also known as CHIA, Executive Office of Aging and Independence, Massachusetts Commission on LGBTQ Youth, Commonwealth of Massachusetts Asian American and Pacific Islanders Commission, and the Betsy Lehman Center for Patient Safety. HHS is the largest secretary in the Commonwealth with 11 agencies and over 23,000 employees and directly deliver services and programming117 to nearly 1 in every 3 residents of the Commonwealth. We will try and move as expeditiously as possible through the testimony and provide legislators with an opportunity to ask questions and make comments on the proposal before us. But before132 we move into the testimony and and and and the subject matter of the day, I'd like to take a few brief138 minutes to officially welcome you to the brand new Attleboro High School. I'm gonna hear more about this school in a moment from our principal, but I just wanna highlight that this $260,000,000 building project for the new Attleboro High School was almost 20 years in the making and finally opened its doors to students in August of 20 22. The largest municipal undertaking in the city's159 history, the project featured $126,500,000161 reimbursement for the Massachusetts School165 Building Authority after city voters approved the property tax override in April 2018 to pay for the building171 with 66%172 of the vote. We'll hear more about the school in a moment from our principal, Kate Campbell, but I wanna underscore how proud we are of180 this wonderful school, especially the CTE programs offered here. Attleboro High School is very unique in that it's 1 of 14 comprehensive high schools offering both traditional general education curriculum and chapter 74 approved career and technical education programs. Hopefully, you'll get the chance during the day to hear all about the the many shops that are offered here at Attleboro High School and how the students have taken Evangeline. I'd like to take this opportunity right now to turn it over, to our co chair, representative David Beal, for opening remarks.
SPEAKER2 - Thank you, Chair Feeney. Good morning, everyone. For those of you who I haven't met, my name is David218 Beal. I am the state representative for the Fourth Suffolk District, which includes the South Boston neighborhood in the city of Boston. I'm grateful for the opportunity to be226 here. This is a wonderful school, and look forward to, hearing from testimony. As we know, we live in uncertain times, and with all the, activity that we're seeing going on in DC, looking forward to hearing testimony on how that will impact specifically, health and human services and working together with my colleagues in the house and senate in the administration, put forward a budget as we craft, our budget for the upcoming fiscal year. So thank you, Chair Feeney and your team for, putting us together, for hosting us, and look forward to a productive day of testimony. Thank you.
SPEAKER1 - Thank you, mister chairman. It's great to have you down at God's Country coming from the city down to Attleboro this morning. As I said, members have been traveling to this committee. Members have been traveling all across the Commonwealth to many, many hearings over the last month, and I would like to give them a chance to introduce273 themselves, where they come from,275 their district, and the communities that they represent.277 So why don't we start on my right down at the end of the table here, rep, Kearns.
Grab any of those mics. Talk directly into the mic if we could. And if, I think there's a switch on the top to make sure you turn it on so that everybody on the live stream can hear us as we make our296 comments.
SPEAKER3 - I got you. Thank you, mister chairman. Good morning. Sally Kearns, thirteenth Essex District, Danvers, Middleton, Peabody, Wenham, Topsfield. Great to be here. Thank you.
SPEAKER4 - Good morning, everyone. State representative Marcus Vaughn from Wrentham, but originally hail from your, rival North Attleboro, but I
SPEAKER5 - represent Wrentham, Plainville, and Norfolk, Walpole, Millis, and Metfield. Thank you. Good morning. State representative Kelly Pease. I come from the Fourth Hampton District, which is pretty far out west. Westfield and Southampton is who I represent.
SPEAKER6 - Good morning, everyone. I'm John Moran. I'm state representative from the Ninth Suffolk District, which is, part of the South End Roxbury, Dorchester, and the city of Boston.
SPEAKER7 - Good morning. Thank you, chair. My name is Steven Exaros. I'm a Massachusetts state representative from the fighting Fifth Barnstable District on Cape Cod, representing the towns of Barnstable, Sandwich, and Bourne.
SPEAKER2 - Good morning, everybody. Representative Michael Chasen from the First Bristol District representing Foxborough, Mansfield, and Norton.
SPEAKER1 - Good morning, Joe McKenna, eighteenth Worcester district in the house representing Webster Douglas Sutton on the border of both Connecticut and Rhode Island.
SPEAKER8 - Good morning. State representative Todd Smola. I'm the ranking member of the committee. I'm from the First Hamden District in Western Massachusetts.
SPEAKER9 - I'm Jim Hawkins, and I'm the state representative from Attleboro and a proud retiree of Attleboro High School. And and everybody else had to drive all over the state. I could have walked here this morning. Sorry.
SPEAKER10 - Good morning, Tip Digs, second Barnstable District, Petuit, Austell, Cynival, Hyannis, Barnstable Village, and West Jammoth. Proud to be here. Thank
SPEAKER11 - you. Good morning everyone. Jo Comerford. I represent the Hampshire Franklin Worcester District. That's 25 cities and towns in the Connecticut River Valley and over up until North Worcester County.
SPEAKER12 - Good morning everyone. Great to be in God's country. I hail from the heart of the commonwealth was serving the first Worcester District State Senator Robin Kennedy. Thank you.
SPEAKER13 - Good morning, everyone. Judith Garcia. I proudly represent Chelsea and Everett. Thank you so much for having me.
SPEAKER14 - Good morning. State representative Margaret Scarsdale. I represent the First Middlesex District, which is Ashby, Dunstable, Groton, Precincts 2 And 3, Pepperell, Lunenburg, Precincts A C And D, and Townsend.
SPEAKER13 - Good morning, everyone. My name is Lindsay Sabadosa. I'm the state representative for the First Hampshire District, which is the city of Northampton and 8 other communities in Western Hampshire County. Good morning, everyone. I'm Priscilla Souza. I represent the Sixth Middlesex District. That's about 60% of Framingham, Southside, Westside.
SPEAKER4 - Good morning. My name
SPEAKER15 - is Rodney Elliott. I represent, the City of Lowell and North Charleston.
SPEAKER4 - Good morning. Russell Holmes. I represent the 6 Suffolk District, which is parts of Boston. So Mattapan, Dorchester, High Park, Rosendale, and JP.
SPEAKER13 - Good morning, all. My name is State Representative Shirley Arriaga. I come from Western Massachusetts. I represent the great city of Chicopee.
SPEAKER16 - Good morning, Vana Howard. I'm a State Representative representing the 17 Middlesex District. That's Lowell in Tewkesbury. Welcome.
I'm Representative518 Kristin Kasner. I represent the Second Essex District which is North Shore, Hamilton Ipswich, Raleigh, Newbury, Georgetown, and, part of Topsail. Thank you.
SPEAKER1 - Great. Thank you so much. And there may be other members. I'm getting a couple of text messages, members joining us later on in the morning, and we will recognize them as they, as they come up to the stage. Right now without further ado, again, Attleboro, as I mentioned earlier, has been known historically as the jewelry capital of the world. Odds are if you had a school ring at some point in your life, it was manufactured right here in Attleboro. We have a long, manufacturing tradition and history here in the city, but we are ably led now, during these times by mayor Kathleen DeSimone, and we're thrilled to have you here, mayor, and we wanna welcome mayor DeSimone, for some remarks this morning.
SPEAKER15 - Thank you, principal Campbell. First of all, good morning. Thank you all, for coming here. It is awesome to see581 all of your beautiful smile smiling faces583 on this great Monday morning. I am pleased to be here to,587 welcome you on behalf of the City of Attleboro. We are proud to host today's meeting, and we are grateful for the good work that you do for the residents of Attleboro and the Commonwealth. I'm also particularly proud of the beautiful, amazing, top notch, number 1 high school in the Commonwealth, and to be joined by, principal Campbell. Attleboro is indeed a city on the move evolving from, as Senator Feeney mentioned, our manufacturing roots. We are a great a gateway city rapidly becoming a community that supports and welcomes and embraces our educational system and our community health care systems that include Manet Community Health and Sturdy Health. We're on the move folks and I'm glad that you're here to see that. As you all well know, former Speaker of the House Chip O'Neill famously said that all politics is local. As much as that statement is true, it is also true that politics is not government nor governing. Good government is hard, as you all well know. It requires discussion, debate, compromise, getting things done even when we fundamentally disagree. Good government serves all of the people regardless of political party. Good government is open, fair, transparent, accountable, and efficient. Equally important, good government is also accessible. And holding your legislative663 committee meetings at locations like665 this across the commonwealth and allowing folks to access them via video are great ways to671 demonstrate good government to all of our residents. I am grateful for your service to the Commonwealth and your commitment to good government, and I look forward to a long well, not long. Strike that. To a productive and rewarding day for all of you. Thank you very much for being685 in the city.
SPEAKER1 - Thank you, Mayor. At this time, I wanna turn it over to, my partner in the delegation and member of this committee, also a former teacher at this school. So please welcome State Representative Jim Hawkins.
SPEAKER9 - Thank you, senator. I actually wasn't a teacher at this school. The school that I taught at is probably where you're parked. This was built a couple feet away from the school where I taught, but I'm I'm proud to be retired. I'm proud to 1 of my proudest713 things is my association with Attleboro High School as a teacher. As a district, it's forward thinking, does many things that I know don't happen in other communities. And this building amazing thought went into this, that it would be functional, that it will be good for generations to come. As a teacher. I can appreciate all the good work that went into this. I'd also like to since I see so many of the people that I used to work with here, I'd like to give thanks to the staff at Adelberg high school who are welcoming welcoming us in so many ways And the double ACS who's who's, making this technology top notch.745 We're, we're very747 lucky to be in Attleboro. It's my job to introduce principal Kate Kate Campbell, who has led this to teach this school. She would have been my boss if I was still here. So I'll introduce her very respectfully. Thank you.
SPEAKER17 - Thank you, Jim. On behalf of Attleboro High School, I'd like to welcome you all to our spectacular school. We're grateful for768 this opportunity to host this important session of the joint committee on ways and means led by Senator Feeney. Thank you to everyone sitting here sitting here today for your passion for public service. Less than 3 years780 ago, we opened the doors to this glorious building, But in time, we have created more than a school. Together, we have designed a place where dreams take root and where ideas come to life. We have a learning environment where each and every student has the opportunity to grow and shine in areas of interest, skill, and content. I'd like to thank Dave Sawyer, our superintendent of schools, who's led this journey. His hard work and determination have built a solid foundation on respect, engagement, creativity and collaboration for our district. Along with the Attleboro High School team, superintendent Sawyer had a vision for how a true comprehensive high school should be. Currently, our 19 CTE programs are embedded into life at Attleboro High School. And for many, it's the connection to the world beyond high school. As I've been known to say, I wish all high school students could do school like we do at Attleboro High School. At Attleboro High School, while exploring new subjects, discovering hidden talents, or challenging themselves, our students continue to create pathways that will lead them far beyond our walls. What they acquire here will lead them to opportunities showing the valuable contributing members that they are. Our students of Attleboro High School will make the world a better place. Thank you again for joining us at Attleboro High today. We hope you enjoy your time here as much as we do.
SPEAKER1 - Thank you so much, madam mayor, madam principal. We appreciate your hospitality today. And I believe before we, get into our testimony in just a moment, we're gonna highlight some of the students, this morning. Madam principal, do we wanna bring out our select choir?
SPEAKER17 - Caroline and the select choir with missus McCarthy, if you could join us.
SPEAKER1 - And I would ask all members, if you're able to, and everybody in the audience, please just rise for our pledge of allegiance and sing every national anthem.
SPEAKER16 - Just be the flag of The United States Of America and to the republic for which it stands, 1 nation under God, indivisible, with liberty and justice for933 all.
SPEAKER17 - Thank you, missus McCarthy, and the select choir.
SPEAKER1 - We needed that this morning. Thank you so much. Once again, thank you to the Slack Wire.
Beautifully done. So now we're gonna move into our testimony. Just as we bring up the secretary and her team, feel free to come on up to the to the stage. Just a couple of logistics issues. If anybody needs the restrooms, they're located, to my stage right, house left. Those signs there, you can follow those out into the hallway. There's also a little break room over there for members, with some coffee and snacks to help get us through the day, if you need to go over there for the public as well. There are restrooms located out in the hallway. If anybody needs anything there, we have staff, both up here on the stage and down in the audience as well. So with that, we are going to move into our testimony. We wanna welcome secretary Kate Walsh and Daniel Schock, assistant secretary for A and F at EOHHS. And with that, that is time to change classes. So I don't know if that's You
SPEAKER16 - don't wanna be late for math.
SPEAKER1 - Right. Right. Right. Representative Hawkins, a former teacher, will yell at us if we're not in class in time. So, yeah. So with that, welcome, madam secretary, and1098 the floor is yours.
SPEAKER16 - Well, good morning, Chair Feeney, Chair Beal, and members of the, joint commission committee on ways and means. I'm really honored to be here with you today to discuss Governor Healy's FY26 budget for the Executive Office of Health and Human Services. I'm here with Dan Scharke, who's our Assistant Secretary of Administration and Finance. So I would urge you to, direct all hard questions in his direction. I know I'm first up in a very long day ahead of all of us, so I won't read my entire written testimony, but they're just a few comments upfront that I think are really important in setting the context for today, before we move on to your questions. First, as you've already heard from Governor Healy, A and F and some of my colleagues, the administration's House 1 proposal reflects our commitment to fiscal responsibility, to being thoughtful stewards of taxpayer dollars, and to ensure that our state is on a sustainable pathway for years to come. This budget proposal represents funding EOHHS at $33.3 billion including the MassHealth program. This is a 9% increase over FY '25 GAA. This increase is driven largely by non discretion cost saving increases including Chapter 2 57 provider rate increases and the requirement of the State's collective bargaining agreements. Our caseload continues to grow. The people we serve have more acute and chronic needs. The cost of everything has increased and our facilities are aging. These rising costs have far outpaced overall revenue growth and we're left with hard choices. Our objectives in House 1 were to maximize essential services, maximize available resources, mobilize services efficiently and effectively and ensure that our clients are served in the safest, least restrictive environments for their care. This budget proposal supports our continued work to address health disparities in our communities and address workforce shortages in the health and human services industries. House 1 right sizes agency funding to address growing caseloads, especially for those families and older residents who rely on us for basic services like food, transportation, and economic support. Guided by Governor Healy's pillars of affordability, equity and competitiveness, these investments drive EOHHS,
our mission to live up to, to enable that all Massachusetts residents live the lives they were meant to live. This budget is shaped by some underlying1265 demographic and economic realities. The rising cost of living including housing and healthcare costs translates into increased caseload for our programs that address economic insecurity. We have an aging population in our state with more residents 60 than 20, which has heightened the demand for services for older adults. Our health focused agencies, the Department of Mental Health, the Department of Public Health and MassHealth are impacted by higher acuity of illnesses, including behavioral health issues. Our agencies that serve people with disabilities are also experiencing caseload growth with rising clinical need for services for neurodiverse individuals, including those with autism spectrum disorder and intellectual disabilities. This caseload is also aging as well, bringing additional acuity challenges and pressures on aging critical infrastructure. These demographic and economic realities are known challenges that we can plan for and manage here in Massachusetts. What we cannot control and what is not included in our FY 26 budget proposal is the impact of potentially drastic federal funding cuts. Many programs across EOHHS rely heavily on federal funding particularly MassHealth programs and programs administered by the Department of Transitional Assistance DTA, including SNAP and the programmatic support that DPH receives from the Centers of Disease Control. MassHealth provides coverage for over 2,000,000 members, more than 1 out of every 4 people, friends, neighbors, relatives in our state. In Massachusetts, 48 percent of the children, 50 percent of people with disabilities, and more than 70 percent of residents living in nursing facilities rely on Medicaid to get the services they need.
Total revenue claimed through MassHealth amounts to about $15,000,000,000 Congress is actively considering several Medicaid reform proposals that would likely translate into billions of dollars of cuts for MassHealth for next year. DTA programs bring in more than 2,500,000,000 in federal dollars annually to offset the expenses of the 1,100,000 Commonwealth residents who utilize DTA programs. Federal budget reductions could include hundreds of millions of dollars and require savings from USDA which are most likely to come from SNAP and additional reductions, I should have read that, Supplemental Nutrition Program, sorry, and additional, reductions from federal HHS that would come from Temporary Assistance to Needy Families or TANF Block Grants. Cuts that are being proposed would restrict program eligibility, reduce benefits, reduce federal matching, and I think increase hunger in our state. Meanwhile, we've seen the Federal Department of Health and Human Services abruptly terminate grants worth more than $100,000,000 to our Departments of Public Health and Mental Health. That happened just last week. These grants went towards a wide range of urgent public health needs, like addressing infectious disease, emergency preparedness, behavioral health services, and critical public health infrastructure.
We're grateful to Attorney General Campbell for filing a lawsuit last week to fight this funding while we work to address the immediate disruption and chaos. These actions by the federal government have ripple effects well beyond the programs in question. Oh, sorry.
I don't have to start again, do I? No. Okay. Thank you,
sir. Everyone on this committee knows healthcare is a major economic driver in our state and our hospitals are our largest employers. And they're faced with these challenges plus our large academic medical centers are facing draconian cuts in NIH funding that will ultimately deprive patients and families of life saving innovation. If these federal cuts come through, facilities in our state will be faced with extremely difficult choices including layoffs, reduction in services, and possibly closure. This goes well beyond the health and human services industries. SNAP and TFDC dollars not only combat hunger but they're a direct investment in retailers, particularly small retailers and family farms. In short, we expect even more pressure on an overburdened Health and Human Services system across our State. We'll do, we'll work to do everything we can to support our communities, but as this Committee knows, we simply do not have the resources at the state level to fill in federal funding gaps through these critical programs.
These federal cuts will force some very, very difficult choices. With all this in mind, I really appreciate the opportunity to testify today. I'm happy to answer any questions you might have about the budget proposal even in the face of the uncertainty that I just described. Now more than ever, our team will need to rely on your ongoing partnership, commitment, and wisdom as we work to best serve the Commonwealth. Thank you.
SPEAKER1 - Thank you, madam secretary. With that, I just wanna ask if there are any, questions or comments from members of the committee. There is a blue sheet in front of you with my cell phone number as well as, co chair representative David Beal's cell phone number. If you do have questions and you can't flag us, just send us a text and we'll add you to the queue. With that, we're gonna open this up to questions, and I wanna turn to my colleague, senator Robin Kennedy, for a question.
SPEAKER12 - Thank you. Thank you, secretary Walsh, for your testimony today and for your ongoing partnership and your agencies on the Committee on Children, Families, and Persons with Disabilities. I do want to ask you a question, speak a little bit about the personal care attendant program. Certainly it goes without saying we all know of the uncertainty and the potential devastation we face with the federal cuts. And as you know, as you mentioned, certainly, difficult decisions. That said, we know the personal care attendant program has the ability to not only provide better care for individuals to help them stay in their homes, in their community, but keep them from having to go into long term care facilities, which are often more costly. That said, over the last couple years in different, opportunities, the governor has proposed restricting access to the personal care attendant program and making pretty significant cuts, to the program, including in her proposed budget, which puts a permanent cap. Now we know that the program is growing because of the number of seniors that are choosing to stay at home and continue to to live safely there, as well as our ongoing efforts to help our PCA's move towards a more livable wage. So a couple questions in that program. 1, can you talk about any work that HHS is doing to actually provide an assessment? So as we're looking at a comprehensive budget of the cost benefit of PCA services compared to long term care facilities and and the balance between those 2 programs at large. And also, to get a to talk about difficult decisions, certainly, any further cuts are gonna mean that families are not or individuals are not gonna be able to access going forward, that there's going to be cuts to current services and individuals that we're currently our constituents are accessing, or that there's a likelihood that we're not going to be able to continue to support our PCAs to get towards a more livable wage. So, can you talk a little bit about what are those avenues you're considering and, a little bit more about the program?
SPEAKER16 - Thank you. Thank you, Chair Kennedy. Very important question. And I I wanna highlight the most important point that I think you made, which is that, you know, our commitment is to make sure that people can age with dignity and independence in their own homes. What we have proposed in House 1 is not a cut of people getting existing services. We are, we are by virtue of the fact that we simply are, do not have unlimited resources, is we are being very careful and making sure that the people who, that we have resources for people who absolutely need this program on a prioritized basis get this. The second thing I would say, there is a difference between PCA programs, between the PCAs broadly and homemaker services and that the prioritization is for homemaker services, not for personal care attendants. That's driven off of a medical challenge. The third is, I would not characterize the PCA program as being capped. I would characterize it as being challenged by all of us need to make sure that it doesn't grow faster than the rate of health care inflation. So what's proposed in the budget is that the PCA program would live within the health care benchmark. And I think healthcare costs both the benchmark, sorry. And if I lapse into jargon, just wave me down. But the idea is that like any part of the healthcare delivery system, pharmaceutical costs, long term care costs, hospital costs, the PCA program should also live within the same constraints that we're all operating under because there are not infinite resources. Finally, I would flag that while people in their heads think about PCA and homemaker services as things that are paid for and something that you require when you get old and might be covered by Medicare. In fact, it's paid 100% by the Medicaid program, which we have just identified is in for enormous cuts. So this isn't a very good example of 1 of the very hard choices that we're facing. But I think the,
the cap is really much more of a of a of a guidepost to make sure that people who need the services get the services they need. And so that somebody coming out of a hospital, for example, you know, in in is faced with going to a nursing home or being in their own home and needs some help with homemaker and shopping, gets those services as opposed to somebody who may have chronically, you know, it might be nice for them to have, but isn't essential. So, we're really trying to focus these services where they belong and there, and we, but there's no question there are hard choices in every 1 of those sentences that I just said.
SPEAKER12 - Thank you. I appreciate that. I just wanna to, encourage and and look to partner with you on the assessment piece of it because often things like the 10 hour cut that was proposed previously, those 10 hours are what peep is what actually keeps you on. So I appreciate it a little bit of a nuance between cap going forward and cut, in
SPEAKER16 - the And I no. And the cut was that was proposed, I mean, a lot of states have looked at other ways
SPEAKER8 - The cap secretary, I'm sorry.
SPEAKER1 - Well, I mean, could you just pull them, like, a little bit closer and speak directly into it? Some some of our older members are having trouble hearing that.
SPEAKER16 - I'm I'm really sorry.
SPEAKER1 - I I joke. It's me. I
SPEAKER4 - I I
SPEAKER16 - kind of have this bad combination of I talk a lot, but I have a soft voice, so it's
SPEAKER12 - not good.
SPEAKER1 - Good. Good.
SPEAKER4 - Thank you.
SPEAKER16 - I'll talk even louder. So I would say that the PCA cut that was proposed last year, which this body rejected, was an example of us trying to get cost under control. It was focused on people who needed fewer services. Other States have taken different approaches to the cap. They have capped the amount of PCA hours you can have on the top end at 65, for example, which would be devastating and would would would would keep very disabled people much more homebound than they already are. So we we thought that was a more humane and effective cut. You this body and their wisdom rejected it, but these are the kinds of cuts that we will not be able to look away from in the future.
SPEAKER1 - K. Turn it over to co chair representative Beal for a question.
SPEAKER2 - Thank you, chair Feeney. I also wanna acknowledge rep Megan Kilcoyne of Clinton who's joined us. Thank you for for joining us this morning. Good morning, secretary. With rising costs throughout the economy, especially in the healthcare industry, how are you working to mitigate the effects of these rising costs on both programs you administer and the residents you serve?
SPEAKER16 - So I think there's there's, 3 parts to the cost challenge in our state and, you know, as of 1 is in on the commercial insurance rates and we're working with our colleagues in the Division of Insurance at the Health Policy Commission at CHIA to make sure that we understand why we're seeing such staggering increases in healthcare costs across the State. The second, and that phenomenon has flowed into the program that we administer. We're
we're the health insurance company2086 for low income residents of the State2088 through the Medicaid program, low income and seniors in the State. And so those cost pressures that are driving up the cost of your Blue Cross premiums or your GIC premiums affect us in Medicaid as well. And then the third issue, which is healthcare as an industry is under enormous pressure in our state. Aging infrastructure, higher labor costs, generational inflation in labor costs in our state that has made it harder for them to bring down their costs. And we, as you know, there are many hospitals in the state that are struggling with negative balance sheets. So we're trying to pull the leverage that we can from a policy standpoint without trampling on an ecosystem that is, you know, represents the largest employers in states we have in our state. We have many hospitals in our state that are, you know,
quite concerned about their ability to continue their operations under the current scope of services, to say nothing of our nursing home industry, which is in deep distress. So we can't just go kind of go trampling in cutting costs. We have to make sure that we do it in a way that makes sense. And I think there are people around this table who think some of the cuts we've taken don't make sense, but it's just our best judgment. There are no easy answers here. And I think in our state, more than others I talk to, we kind of have a group therapy with a group of people who do my job across the country every Friday. It's much more acute here. 1 out of 4 jobs in the Commonwealth are either healthcare, education, or life sciences and biotech. And so the cuts that are coming in Washington are really very fundamental to what makes Massachusetts the great place it is to live, work, worship, raise a family. And, and that's what has us very concerned. So we're trying to be very measured and thoughtful and acknowledging that these resources are not infinite.
SPEAKER18 - Thank you.
SPEAKER1 - Next up for question is the, senate vice chair of the committee, senator Joe Pemfren.
SPEAKER11 - Thanks, mister chair. Secretary, thank you for your service at this time, especially, Of course, it was, painstaking and herculean before this time, and now just through your testimony, and from all we can see it is. Brutal for you, and HHS. I just wanted to go back to what Senator Kennedy said about a conversation with the legislature about looking at the, cost benefit of PCA services over time. I have a constituent. I had a constituent. He's since passed, Joe Tringale. And Joe taught me about the benefits for him personally of PCA services and all a very few hours unlocked for him in terms of his ability to work and have a fulfilling life. And I do think we we have a lot to learn, about the cost of potentially cutting, or capping PCA services, because of what they unlock for our constituents. I I know you know this, but I do think a bigger conversation, the 1 that Senator Kennedy's talking about, would be, good to have. I wanted to talk though today about the proposed cuts to the DMH workforce. And so, as you might imagine, right, we did some preparation for this hearing. I I talked with both DMH workers in Western Massachusetts, also the service providers in Western Massachusetts. As you say, the, the caseload of HHS is increasing. DMH is increasing. My understanding is that the DMH workers are already maxed and now they could potentially get doubled in terms of their casework and the service providers, would have increased pressures as well right with fewer case managers managing the individuals the well-being of the individuals. So I I just I would love you to help us understand your thinking with regard to this. How how is DMH going to guarantee service provision to the individuals we serve? How what is the relationship with the let's call them vendors with which the state contracts? Are they going to do more2365 in this model? And how2367 are we going to help the DMH workforce essentially double its work, in this proposal? So just more of your thinking there.
SPEAKER9 - Yeah.
SPEAKER16 - I let me I I won't kind of go point by point, but let me describe how we got to that cut and where we are across the board. First of all, I I am, a poor substitute for, Commissioner Brook Doyle, who will be testifying momentarily. But let me just say that the DMH budget is about $1,200,000,000 and it was increased by 7%. So people who say that this is a cut to DMH spending, that is flat out wrong. The second thing I would say is this budget, particularly with the Chapter 2 57 rates, includes a substantial increase in stabilization for the DMH contracted workforce. We had a, particularly coming out of COVID, huge short, about a 30% vacancy rate across health and human services, particularly at entry level, particularly at DMH, people working with patients struggling with substance use disorder, people working with people struggling who have developmental disabilities. So we really work to increase the, the base wage for those for those workers and have, I think, done a good job at at making it easier to be a DMH contractor. The last thing I'll say2451 is that, case management has become a of an often a pretty overused term and often is used as What we're trying to right size in the DMH cuts is making sure that it's possible for That first of all, the people who need case management have it and they could have it through DMH, or they often have it, I think 40 percent of the people affected by the DMH caseworker cuts, were actually case managed by another program, most notably the MassHealth Accountable Care Organization. So, we weren't leaving patients uncovered. The second thing I would say is that the pressure that we feel is for new patients, people who are newly identified as part of the system. And the caseworker model that we had within DMH didn't allow those workers to see new patients. There was no you know, they had their caseload, which is important and very is and and very important, but there was no way for us to absorb all of the people who call your offices saying, help. I need to get my uncle into treatment. And so we were trying to create additional capacity by opening up, emergency capability. And then finally, this is a budget challenge. And the biggest challenge that our, well, a big challenge that our Mental Health Commissioner faces, and she'll talk about it during her testimony, is the very substantial increase in people who are being placed by the courts in psychiatric facilities. And those are the sickest, the people who are in most need of services amongst us, and we were there languishing in jails when they should get treatment. And so, we put our dollars there. It's again, this is another example of hard choices, but that's the thinking behind it. It was really trying to understand where the $1,200,000,000 plus 7%, could do the most good for the people in most need. Nobody, nobody but the state takes care of the seriously and persistent mentally ill people who are involved with the criminal justice system. And that's where we put our dollars.
SPEAKER2 - Next up, we have a question from, ranking minority member, Representative Todd Smollett.
SPEAKER8 - Secretary, thank you very much for your testimony here today. I think we all acknowledge you have a big job. And no doubt when we look at this budget, HHS and everything that falls2613 under that umbrella is is the big 1. Right? That's the 1 where we we spend the most resources on. But, I don't wanna beat a dead horse, but I've got to come back to this PCA issue that, a few of my colleagues had, preceded me at the to discuss. And I I'm worried about the, the spending growth model that's proposed in house 1 simply because if we look at the numbers, and the cost of the increase of the program from 2020, which is about 1,200,000,000.0, and the estimation in by 2027 is2644 gonna be $2,000,000,000. That's a big jump in 7 years. It's it's we're talking about a 67 percent increase in such a short window of time. And some folks are predicting that, Massachusetts is gonna be the highest, per capita cost for home care services in the entire country right here in the Commonwealth Of Massachusetts. You know, I those numbers don't tell me as a member of this committee that, we're we're moving in the direction of people living within constraints of the the structure of PCA or the changes that you you may be talking about here today. I see exactly the opposite. That in a very short period of time, we're gonna be looking at a greater need, more dependence on a program that more and more individuals across the Commonwealth, really believe in and stand by. So I just again, I I acknowledge the fact that you have a very, very tough job before you, and I know the administration is well intentioned when it comes to all the things that fall under the your secretariat. But I am worried about the the the proposal that is specifically for PCAs in this budget. Is there anything else that we should be doing outside of a dollar amount that we're talking about here and what's being proposed in house 1? Is there anything else that we should be doing or we should be focused on relative to the dramatic growth that we've seen2725 in this program in such a short period2727 of time particularly when it looks like the Commonwealth of Massachusetts is gonna be sitting at the top of the heap2733 in the entire country on this expenditure.
SPEAKER16 - Yeah, I agree. I think that if you look, if you step back and look at cost drivers in our state, I think everyone agrees that health care premiums are too expensive. I think there's unanimity that farmer prices are driving and the growth in pharmaceutical costs2757 have been, have been a big driver. What you've identified and what we identified and what we proposed last year and tried to do this year was say, this is 1 part of the program. In Medicaid speak, it's called Long Term Support and Services. It's growing too fast and we have to be more selective about who gets it. We cannot be a nation of patients and caregivers that's economically non productive. And so we were proposing to cut the program. We were proposing to slow the rate of growth to be consistent with healthcare inflation. And many people believe that that's, you've heard from fellow people on the committee, that that's not a good cut. I actually think it's, you have to look at where the growth has outstripped, far outstripped any other economic indicator in the home care programs 1 of them.
SPEAKER8 - And I and I think, you know, our common sense tells us that that's really a smart model to pursue, and I and I think most of us see that. But I'm worried that in the time period that we're2819 talking about to make these 2 things, parallel with 1 another so that there's kind of more of an evening of the of the playing field that the limited increase that we're talking about here in this budget is gonna be just too dramatic in such a short period of time. Again, I I know I'm preaching to the choir because I I I know you understand this, and I know that this is discussion that we've had.
SPEAKER16 - I I actually don't think it should be too limited. I think that we we have to make sure that we get services to the right people. And and and we we know how who those folks are. What I'm much more worried about is that we won't have the federal resources or the federal the so called federal match to do this. So this, you know, this like minded people can disagree about whether or not the program's been cut too much, slowed too fast, growing too fast. I think we're in a situation where these will be the good old days and the cuts were contemplated will be, wow, wish we could have done that. Thank you, secretary.
SPEAKER2 - Thank you, secretary. I do wanna acknowledge state representative Steve Owens from Watertown has joined us. Thank you, representative. Next up in our queue, we have a question from rep Kelly Peace.
SPEAKER5 - There we go. Good2903 morning. Thank you, Chair. Thank you, Madam Secretary, Assistant Secretary. Appreciate your time here today. Now I'm gonna look at another approach that's that's being cut. Alright. All the cuts. And, it's it's but it's for the adolescent programs, the mental health adolescence program. I mean, it and I don't know if we look at that, if that's the smart place to cut because, obviously, if we're not attending to the the younger generation who has mental health, then you're just gonna get a pipeline into further problems in prison and and more cost to the to the commonwealth over time. So I guess I just like to know what maybe your thoughts are on why
SPEAKER16 - those
SPEAKER5 - cuts were put in there.
SPEAKER16 - Oh, thank you for that question. There are in House 1, 2, and Commissioner Doyle will talk more about this, but there are 2 programs that, in the face of growing a lot of other programs that experienced a reduction back to basically the levels
of demand that we're seeing for those. They're 2 very specific programs that were overbuilt relative to the demand. And I think 1 of the things that we're wrestling with is that we've added lots of behavioral health services in response to this crisis, and it is a crisis. And I think the work that we need to do is to figure out what programs are the most effective. I would point to the community based mental health centers that have 20 fourseven access, treat families, can begin, induction therapy for medication, administrative treatment for substance use disorder that can, that have mobile crisis units, that can go out into the community and address things immediately versus the bricks and mortar inpatient residential stays, which are the 2 programs that we're reducing back to their they were 50% occupied. And so, we were spending money in 1 place and people weren't accessing services and under resourcing in another place. So, we're trying to right size our behavioral health infrastructure. The other thing I would say, and and you know this, but we're in a school, so it so that we we know that the most important work that we can do is3041 meet adolescents, particularly kids where they are and kids are in school. And so our partnership with DESE to make sure that school districts3049 have the mental health services that they need so that kids can again live the life they were meant to live and not be kind of locked away is really what we're trying to accomplish with this budget.
SPEAKER5 - Well, thank you. But I I did you wanna concentrate on that, the residential programs. Right?3067 Because you got the the the folks over 12 years old. You're cutting 50% of that, and you say because they were only at 50%. But my understanding is because of the antiquated process to get a referral
SPEAKER13 - You're right.
SPEAKER5 - For so long that the hospital's gonna keep them.
SPEAKER16 - You you're right. We have to. So we've reduced, the number of of children and adolescents and young adults waiting in emergency rooms by more than 50%. We have built a lot of capacity. I think the question for the legislature is do you want to pay for standby capacity in 2 or 3 programs across the state that may or may not be used. In the meantime, you should challenge us to significantly improve our antiquated or very complicated processes to get people into these systems. Some of which I will remind us were were the result of court decisions. So we have we have patient referral
pathways for people with, for children with behavioral health challenges that were built by lawyers with due respect. And I think that part of the challenge is we need a much more streamlined clinically focused process that has lots of different doors for families and kids to go into for the right treatment that they need. And it's really, again, a question of the highest and best use of the state dollar to treat the most people.
SPEAKER5 - Okay. And I guess the last thing I'll say is that for adolescents or for children 6 to 12, there was only 1 home that was available. And with these budget cuts, that home will not be available. So I don't know what's gonna happen to the those serious mental health problem children in that age group, which I'll throw into the adolescent.
SPEAKER16 - I'm gonna have to defer that to Bert because I don't know if that's true. But if if I could ask commissioner Doyle to answer that question. Sure. Okay. Thanks. I just don't wanna misspeak.
SPEAKER2 - Thank you, representative. And I believe we have a question from, my co chair, senator.
SPEAKER1 - Thank you, mister chairman. And, I do wanna acknowledge we've also been joined by senator Pavel Pallano, Representative Rita Mendez, thank you for being here, this morning as well for this hearing. Madam secretary, I wanna take us away from the line items for a moment to an outside section. We've heard from many pharmacists and and pharmacy consumers throughout all of our districts, but certainly here in in in my district, about the implications of, outside section number 78, which would implement the $2 dispensing fee, quote, unquote, dispensing fee on prescriptions filled at pharmacies across the Commonwealth, presumably to unlock federal funds. But, you know, with the kind of uncertainty of any federal dollars being released, how can we ensure that this proposal does not create an increased burden on our pharmacies, particularly our independent pharmacies that are struggling to keep their doors open as it is.
SPEAKER17 - Yeah.
SPEAKER16 - So I think I think I'm a little bit confused because there are 3 different pharmacy proposals, in in the budget and some outside section. Are you talking about the outside section language in the stuff that was just filed?
SPEAKER1 - I I believe there's a dispensing fee in in this proposal. Correct? In h 1?
SPEAKER16 - Yes. There is. That was that's but that's that was designed to use our Medicaid purchasing dollars to try to keep pharmacies open in low income communities where we're seeing pharmacy deserts. So we were saying, okay, if we're the MassHealth program and we support low income people, we wanna make sure that if you're a pharmacy in an area that where you might have to close, that it won't be because of the dispensing fee that MassHealth pays. So, it was really to try to address the problem that we see, particularly in the major cities in our state where pharmacies are closing in low income neighborhoods. And we were trying to address
SPEAKER4 - that challenge with our purchasing power, because those are where,
SPEAKER16 - remember I talked about us as an insurance
purchasing power because those are where remember I talked about us as an insurance company, those are where the people we insure live, work, and so we wanna make sure they could get their medicines. So it does hurt the independent pharmacy in Wellesley, but we try to
preserve,
funding for those independent pharmacies that do extra work for us. For example,
pill packs for, for group homes in the area. Those pharmacies that offer durable medical equipment to people in their in their region. So it was really but it is definitely a, you know, an attempt to use our purchasing power to get the services our patients need.
SPEAKER1 - Okay. And I would just mention that some of the independent pharmacies that have reached out, to me aren't, you know, just in affluent communities. They're in gateway cities like Attleboro and next door in North Attleboro. And and that's a that's a big concern as
SPEAKER16 - they I know. I know it is. I I know. People are independent pharmacies are struggling for a host of reasons,3383 that probably are less related to this budget and more related to the role that farmers playing and that that that the PBMs play, but I I hear you.
SPEAKER19 - I doctor Simon, a lot
SPEAKER1 - of common ground there with you on that on PBMs and, and some of the other external challenges.
SPEAKER15 - Mhmm.
SPEAKER1 - I just hope that we wouldn't take any steps to further, complicate, you know, them being able to serve the communities.
SPEAKER16 - I I appreciate that. Thank you for those comments. And I think there's been I I know I know there's been a lot of commentary on that, and we expect that there'll be more.
SPEAKER1 - Absolutely. Thank you, Secretary.
SPEAKER2 - Thank you, Chair. We also have a question from Representative Margaret Scartell.
SPEAKER4 - Good
SPEAKER14 - morning, madam secretary, assistant secretary. Thank you so much for your service to the Commonwealth. I did not envy you in 2024 as the Stewart Hospital debacle was happening, and I certainly don't envy you now, as you navigate this current landscape. As you know, I serve the region in North Central Mass that until August 2024 had Mesheba Valley Medical Center, which in addition to the many outpatient services and the 38 Gerry psych beds also served 16,000 emergency room visits in 2023, and those ER visits now have to go to outlying hospitals, which has put a severe strain on the 13 emergency, departments, emergency services departments that are in the region. We also lost 400 jobs, and we are currently a health care desert. And it is sobering, and it has a staggering cost for our small and very rural towns. So I'm wondering what additional tools you need to protect and preserve essential services so we don't lose services like Leominsters Birthing Center and Neshoba Valley and Kearney.
SPEAKER16 - Thank you for the question. I I, you know, I've obviously and our team has spent a lot of time working to prevent what you just described. I think the, I think we all have to think differently about what hospitals are and what they'll be in the future. And, I think that the, you know, hospitals are such iconic parts of communities. People are born there, They die there. They get better there. It creates a lot of jobs. It's a center. It supports the deli guy across the street because people forget to bring their lunch. I mean, you know, it it is They are really and I I grew up working in hospitals. I love hospitals. I hate to see them closed. The sad fact is across our country, there are 1,300 critical access hospitals. There's 1 in Massachusetts in Athol, and a third of those hospitals were projected to close. The small community hospital is just really threatened. It's threatened by changes in how people live their lives. It's threatened by changes in how health care is delivered. And so what I think we need to do here in Massachusetts is a little bit of what's happened as a result of the closures at Kearney and Neshoba.
You know, we will have in your district a satellite emergency facility so that people won't be in the back of ambulances, you know, very worried that they're taking their last breath. We will have, hopefully, when that facility opens, the ability to add additional services there. Think about what people need. Like, think about cancer treatment now. Everybody thinks, Oh, I have cancer. I have to go to the hospital. Most cancer treatment is done in outpatient infusion areas. That's what we need to create. We need to make sure that people have access to the services they need in the most effective way to deliver them. So I think about infusion. I think about ambulatory surgery, which also allows for for screening. I think about imaging to make sure that people can get routine imaging and screening. And I, you know, I think that that we have the beginnings in the Neshoba Valley of a of a of a more durable and sustainable health care delivery system. And I and I hope that that, because what we had was an empty community hospital that people just weren't using. Because if somebody was using it, it would have been more economically viable. I mean, person after person went through that facility, buyer after buyer went through that facility and said, we just can't make it work. And we were, you know, we were really encouraging them to purchase. And, and the other thing that we saw there was a structure on the capital side that was just economic, which was the other rock that was weighing down that facility. You know, I think at Kearney we'll see a combination of health care delivery, a school and housing. That's great for that neighborhood. I think that we just have to think differently about what success looks like.
And I say that acknowledging that it's very hard for communities to give up their hospitals, but this is not the last conversation like this we'll have in the next couple of years.
SPEAKER14 - Thank you for that response. I will say that Mesoba Valley was not served by Stewart, really running into the ground and reducing services and not providing equipment so that it created a self fulfilling prophecy. Yeah. And I I am allowed to ask a second question. You talked about trying to determine, which programs were the most effective and to right size services. And I I understand that with all the constraints on us and the uncertainty from the federal government and increasing cost of everything and reducing, you know, having a a reduced
workforce. But I have received many heartfelt emails from constituents, including 1 last night about the $83,000,000 in budget cuts from direct services to DMH clients, including 14,200,000.0 from the jail diversion program. And I'm wondering how HHS hopes to manage the consequences of these cuts, which not only affect families, they affect mental health professionals, they affect our court systems, and our law enforcement, and our hospitals. So if you could speak to that.
SPEAKER16 - I'm gonna I'm gonna defer that question to commissioner Doyle because, I I I I would characterize it differently, and I think3827 it's a mess. I let let me just refer that question to to Burke, if that's okay.3831 I don't want him to speak.
SPEAKER2 - Next up, we have a question from representative John Moran.
SPEAKER6 - Take it off. Good morning, Madam Secretary. Thanks very much for all you do, for the Commonwealth. Had a quick question. Last year, my my district concludes, of course, Mass and Cass.3858 I know you're a neighbor as well. And we had a little couple shocks to the system, the closing of the Shadow Cottages, the closing of Envision. Although, thanks to your good department, we were able to, re reestablish the Envision Hotel. And this provides these these services provide somewhat of a relief, to mass and cast. But also we have a substance use disorder, crisis across across the state, including with my colleagues here from The Cape and elsewhere. I'm learning of a $20,000,000 cut to BSAS this year. And I guess I was just wondering if you can give me some flavor around, what those cuts are and and how how they're justified.
SPEAKER16 - Yeah. Yeah. The you know, I think that, we continue to make progress against substance use disorders. And, you know, and I always when I work to Boston Medical Center and, you know, as you point out, I live in the neighborhood, I always have to remind myself that when you see somebody on the streets who's struggling with substance use disorder, this is just somebody we haven't figured out the best way to treat yet. These are very hard diseases to treat, but we have treatments and they are effective and people do recover. And as frustrating as treating this disease is we have to remember that. And I think it's really important for lawmakers to remember3939 that this is a3941 disease that carries an enormous amount of stigma, an enormous burden on families, and we are really working hard to treat it. And we have to, despite what you hear from the federal government, look at differences in the population. Look at race and ethnicity to figure out who we aren't. We have 11 percent drop in fatal overdoses, but if you look under the covers, there's some, we're leaving some communities behind, notably Black men. So, how can we fix those challenges? That's the work that our Public Health Department does through BSAS, but it's also the work that's being done by the Opioid Relief and Remediation Fund. And so many of the BSAS cuts were in fact rescissions. They were money that we weren't going to be able to spend this year and we knew it. So we gave it back and we're trying to replace it with this other source of funding. So this is more of a funding swap than a reduction in services. These were much like the behavioral health beds. This was money we weren't going to be able to spend. The cottages were, very expensive, not all that effective, and they were gonna have to move anyway. So some of this was an expediency around a budget cut, and I think Commissioner Goldstein can talk more about this, but a lot of it really was to say, again, we're facing a time where what we did before, we have to be really nimble and say, okay, if this isn't working as well as we hoped, what can we do differently? And that's really hard to do because you guys fight to get programs for your districts and then we're changing them. But really, I think we need to partner on how we can create a better solution in the face of these cuts that we're seeing because you know, a version of these cuts are coming.4050 And so the kinds of things that4052 we're trying to preserve, we just won't be able to save everyone. So we have to be we have to we have to be really focused on the outcomes of the programs that we4062 that we've built, Be ruthless about the ones that are working and not working and apply the, the fewer sources we have left for the, for the, to, to do the most good with them.
SPEAKER6 - Yeah. Thank, thank you very much. I just would say that that 20, you know, that that mon those monies, the ORF money could have been used for recovery because I think we're in a situation where Long Island is closed. We asked ORF for money for recovery, but then they're saying that the money's been committed for the next 6 years. So until we get into a situation where where we have monies for recovery in the state, we're just gonna be moving people from point a to point b, from city to city. And so it's unfortunate that there wasn't some discussion around
SPEAKER18 - how that money could have been used.
SPEAKER16 - It's a difference between Long Island and or funding for recovery. I I I I would actually argue with that, but due respect to Mayor Wu. But
SPEAKER2 - Thank you, madam secretary. Next up, a question from the assistant vice chair of this committee, representative Kip Diggs.
SPEAKER10 - Thank you, mister chair. Question, so I live on The Cape, and I have an independent pharmacy, and they're struggling. And what would you recommend I say to them? How can we make them stronger and better so that, you know, we have a lot of big pharmacies around them, but they're just, 1 mom and pop that, you know, we treasure. And we respect all their hard work that they're trying to do everything they can to exist. And and I do believe in the what you were saying just a minute ago, being proactive and working together. And we do need to trust the people that are actually doing the jobs so that we could hear them and not micromanage and saying, oh, they're not doing this. But when they are doing something, we need to really pay attention to what you're saying and what what the experts are really saying. Thank you. Yeah.
SPEAKER16 - I I think it's a very, very hard job to be an independent pharmacist. I mean, there's some data to suggest that every single American lives within a 20 minute drive of a CVS. And if you think about our rural,4192 the rural parts of our4194 country, you can imagine that just just how many places like CVS and Walgreens there are just on Cape Cod alone. I mean, it's I don't know how independent pharmacists are doing it. I think they it's because they are in a pharmacy desert and that means CVS and Walgreens have decided it's not lucrative for them to be there or they provide other services that4219 the community needs like durable medical equipment, or4223 they're incredibly tenacious. And I don't but when you look at what drives the cost increase that this, I think was the first question, pharmaceutical costs were a huge part of that. And that's not the fault of the independent pharmacy, but they are swept up in that challenge. We have to look at every aspect of the system and figure out ways to do it better. I don't know what to say to an independent pharmacist. I really would think about diversifying what they do, because and trying to meet the needs of their community like they've done for some people for centuries.
SPEAKER2 - Thank you. Next up, question from my good friend from Boston, State Representative Russell Holmes.
SPEAKER4 - Good day, Madam Secretary. Couple questions. My first question is about PBMs. About PBMs? Okay. Yes. My my big question there start with something easier?
What did you say?
SPEAKER16 - I said, could you start with something a little easier now?
SPEAKER2 - Okay. Okay.
SPEAKER4 - Let's go to something easier then.
SPEAKER3 - No. It's fine.
SPEAKER4 - No. No. Okay. I'll go to something easier. CCA is, you know, obviously looking at it's closing down. And my concern with, the fact that they're closing down is obviously 50,000 or so folks of what you've been talking about all morning, are at risk. My question here is, with what we pay, is it even a profitable or a business model that can continue because of the fact that I know you said we're raising some of our rates, but you have 50,000 people. I think Fallon and other people you're thinking about handing or taking over some of these 50,000. Is is what we're paying enough for them to be successful even after other people take over?
SPEAKER16 - I'm ready for this 1. Good.
SPEAKER4 - Okay.
SPEAKER16 - Easier than PBMs. Thank you, Robert Holmes. So Commonwealth Care Alliance is a program that insures about 46,000, disabled and low income people across the state and they have, and they they do that through 2 programs. 1 called 1 Care, which is a program that that allows people who have Medicare, Medicaid who are because they're low income to also get, Medicare and Social Security because they are disabled. And something called SCOE, which is senior care option, which is a dual eligible or Medicare and Medicaid plan for people who are over the4392 age of 65. And, and CCA has had a long and storied history across our state and they have people virtually in every region. It is a, it has been a wonderful program and in many ways a national model. There are 2 payment sources though, Medicaid which CCA has done very well on and Medicare which they have not done as well on. The second challenge with CCA is that the because because ironically they were doing well, they took their model on the road and expanded to 4 other states where they lost their shirt. And so they are, in their current corporate form, really struggling from a financial standpoint. We have spent, and the MassHealth team has spent enormous amounts of time, working to try to stabilize that insurance plan. And, as you know, there are many flavors of people who do this work across the country, from UnitedHealth, which is a Fortune 50 company, to a small local plan like Fallon, and everything in between. And, we encouraged everybody we could find to look at that program. And, most people were quite dismayed about what they saw about their financial management. We, have been working with, with a potential, solute working very hard to get a potential solution to that problem, and I think we'll have very good news this week on that. So that, the 46,000 people who have relied on that insurance plan will go into a different plan that will have many of the same characteristics. It will be non for pro not for profit. It will, be very experienced in caring for people with with these kinds of challenges. Their references from other states are excellent, so fingers crossed.
SPEAKER4 - And they will be Massachusetts based, it sounds like, or Massachusetts focused it needs to be?
SPEAKER16 - They will4515 expand into Massachusetts.
SPEAKER4 - Okay. Alright. I'll ask the PBM question in a soft a softer way then. How about this? Are there things that we can do with PBMs so that we can at least get more transparency so that the cost savings that's or the cost of the drug when it starts is really passed to, these low cost providers? Is there something we can do so that we know the level the levels of all these added costs that have been added on, at least trans more transparent?
SPEAKER16 - Well, I think I I think the the the bill that passed last summer has a lot of elements. I mean, we're we're just gonna begin to see the fruits of your work on that. But I think the HPC has much more authority to investigate pharma costs. I serve on that committee and, we spend a lot more time in each meeting on drug costs. So I and and Chia is, I think, tracking them as well. So I feel like we'll have better information as a Commonwealth to make decisions about how, where, what part of the healthcare cost growth conundrum that we're all struggling with is directly related to pharmaceutical costs.
The reason I kind of like blanched at the PBM question is it's it is these are these are national phenomenons. These are big companies. They operate in 50 states and around the world. They're sort of intermediaries that have exploited
SPEAKER1 - Yeah.
SPEAKER16 - The challenges that we have as as an insurance company in our state that big providers have, that, that independent pharmacies have by basically disrupting the supply chain.
SPEAKER4 - Controlling the supply chain.
SPEAKER16 - Right. Right. Right. And so disrupting both parts, both supply and demand because they're they're managing both parts of this. So or attempting to manage both parts of it. I think that we have put in place some good the this legislature put in place some good guardrails that I think we need to test. And and I'll remind you that as we test these, we're often testing the price point of cures that were developed right here in Massachusetts. And so part of the challenge really is these, some of these these, these medicines that are being created are fantastic, but they come at a price point that is almost impossible for us to sustain. So we have a lot of work to do in that space and it'll be a combination of what we can do in the state, but also what the federal government chooses to do.
SPEAKER4 - And so finally on that, now 3 40 b, same question really. Like, how do we make sure that these discounted prescription drugs are passed or I mean4693 it just needs to be transparent like what Yeah.4695 What they're paying, what the people are paying. I know there's some legislation to try to expand 3 40 b, but even before we expand it, it would are there things in place with this budget that's gonna help us to at least get more transparency on PBMs, 3 40 b's? Because it seems like this prescription cost is just running rampant for what people have to pay, particularly when we keep hearing what you pay in Canada versus what you pay in, you know, all around the world. Since I shouldn't just say Canada, sorry. What you pay all around the world for these same drugs that are developed here versus what we pay in this country? And between 3 40 b, PBMs, and all these other stuff
SPEAKER16 - But I yeah. I think what you 3 40 b is an equally, important challenging disrupter. What 3 40 b has become is less about a way for people to get medicine and more about a way for health systems that disproportionately serve low income people to profit on getting that medicine. I mean and so it's a very convoluted system, which I I come I completely exploited when I worked at Boston Medical Center, and I completely rage out in this job. So.
SPEAKER2 - Thank you, Madam Secretary. Next up, we have a question from Representative Lindsey Sabadoso.
SPEAKER13 - There we go. Thank you so much for being here today, madam secretary. It's always a pleasure to see you. I have a question that I'm just gonna say is is a heartfelt spontaneous not very prepared 1. I appreciate everything you've shared and I I hear my colleagues talking about programs that we wanna preserve and maintain and I, you know, I I feel that way too. I want I want abundance. I want to see our state fund these programs as to the best of our ability and to protect our residents. And yet in my very long drive here this morning, I listened to the news and I hear Congress talking about reconciling a budget that just feels devastating to health care. And in my head, I think, but we're Massachusetts and we always do better and we protect people here. And I I feel like we're trying to budget on quicksand at the moment. And so my my question to you today, which may be an impossible question, yet I welcome anything you have to share is, you know, what what can we do? What what plans can we lay? We we know that there there's the potential for millions of people to lose their health insurance in the4850 coming months.
SPEAKER16 - Mhmm.
SPEAKER13 - And how4852 do we as legislators, or how do you4854 think we should as legislators, look at what we know is happening and try to do the best we can for the people of the state?
SPEAKER16 - Thank you. That's a I I appreciate that. I I had had a similar ride and I have that I have that pretty much every day and I've kind of gone into, you know, trying to figure out, well, there must be a better way to do this. I think of it in 3 buckets. The first is, and the most important thing are what do we value here in this state? And even in the face of
a look at transgender care, had the opportunity to go with the governor and, Commissioner Goldstein to Boston Children's where she reassured the team they're very quiet, no cameras, that we'll still be able to take care of those kids. If there's, you know, because if we don't there we know they're at much higher risk of suicide to the mental health issue that was raised earlier. You know, so values first. I think the second thing is can we can we reduce the cost of goods sold? Like, can we deliver the services that we know people need at a lower price point? I think we have to do that. We are going into a recession. I mean, this guy's forcing us into a recession, which puts I talked about caseload pressure. That's before what's happening. And and and we I see hear this from colleagues in states like Virginia, where the people who used to administer the Medicaid program are now Medicaid eligible because they've lost their jobs. So there's gonna be enormous pressure on caseload. DTA, SNAP, hunger, how do we feed people? Like, what are the basic things that we need to do? And can we do it differently and better? And what I would urge us to do is really partner on this. So you might want to save a food pantry in your district, and I might say to you, no, we need to do this another way, because it's going to be a more efficient way to get a meal to everyone in the Commonwealth. And I think that those trade offs that you'll have to make for programs, again, you've built, sponsored, earmarked, supported, we might not be in the position to do that. So can we can we can we reduce the cost of goods sold in an accounting term? And then finally, and it goes I think it goes to rep scars my conversation with rep scarsdale. I think we need different programs and services. Like, I think what we've done in the past, going to have to do differently, whether it's community hospitals become micro hospitals or ambulatory surgery centers and satellite emergency rooms, whether nursing homes become, senior centers with enhanced medical care. I'm making that up. We have no plans to do that for those of you who are worried. I think whether we think about, home care and PCA services as more of an economic development, we're gonna have work requirements across the board, both for, I'm pretty sure for SNAP and for Medicaid. How can we use those work requirements to make sure that we're, that we're able to use those workers in the programs where we need workers. We just we're just gonna have to think more creatively and differently. It's and and I think it's gonna really challenge the
it goes going back to the values, what's made us all so proud to do this work, which is that we've built programs that people can really that have really saved people's lives or may enable them to live the best life they could possibly live. And that's easier in this state than probably any other state on the planet, except for the weather. But and so how do we get there from here? And I don't know the answer, but we really are at an inflection point. And I think it's gonna take a partnership with everyone in this room, with everyone behind me holding signs and organized labor, with my team who get very, you know, attached to the programs we build. We get just as attached as you guys do. And how do we how do we do things differently? That's why I applaud people like Commissioner Doyle who came forward and said, okay, if I have to cut, this does the least damage. And we have to trust each other because we are going to be cutting.
SPEAKER2 - Thank you, Madam Secretary. Next up, Representative Jim Hawkins.
SPEAKER9 - Secretary, thank you for all5123 your time here this morning and sharing your day with us like you had nothing else to do. I just wanna amplify
SPEAKER16 - Starting to feel a little like detention. But
SPEAKER9 - No. This isn't my teacher voice. Some several of the comments have been about local independent pharmacies, in particular in particular, the 1 that senator Feeney mentioned. They're blocked from here. Family run, just bought it, very ambitious. I personally went to a big box pharmacy just because it was easier forever. And I went in 1 day and they're yelling at each other and and behind the behind the screen. I said, oh my god. I don't need to do this. And I went down there, and I I'm standing behind somebody else. They know me, of course, but they don't know the person in front of me. They're calling them by name. They know everything about them. They're ambitious. They expanded. They have a new facility in North Attleboro. That's the kind of business that we wanna support. And I get all the challenges with PBMs and everything else that's been discussed. I don't wanna ask you another question about that. But I just wanna emphasize that these are people and we're not in a desert here. This big box one's a mile that way and a mile that way. We're not in a desert here, but this is this is the kind of service that we wanna, protect and support. So thank thank you for all your work.
SPEAKER16 - No. I I appreciate it. And, I I we we'll we'll take these comments back. And MassHealth buys a lot of services, as you know, about $20,000,000,000 worth. So we should use our purchasing power for the again, going back to what we value as a state.
SPEAKER1 - Thank you, madam secretary. Are there any further questions from members of the committee?
Seeing none, secretary assistant secretary, thank you for being here, for answering our questions, for your testimony, and for dealing, what is likely to be 1 of the most challenging times, in health care and across all sectors, really, with the volatility that we're seeing at5243 the federal level. Continue to work with us. We know, you know, that we've had cooperation in the past. Certainly, the5251 chairs of this committee, work well with the administration, and we just wanna make sure, that as we go into these next few weeks, months, years ahead, that we're all working in a concerted effort to make sure that we continue to deliver the services that the people that come off deserve and expect. So thank you, madam secretary, for all your
SPEAKER13 - work.
SPEAKER16 - And thank you all for your time and for, enduring my somewhat rambling answers and to your staffs for very, very good questions and to you for very, very good questions. Thank you. We're we're asking the right5280 questions of each other.
SPEAKER1 - Great. Thank you so much. Before we bring up, our next panel, we do have a little bit of a technical issue over the stream. I guess we need to sync the audio. So why don't we take some time to just reset that now and fix that?
Welcome back to the joint committee on ways and means public hearing. We're coming to you live from Attleboro High School.
We heard, earlier from the executive office of health and human services. We'll continue now to, receive testimony. Ask members, if you do have questions for the testifiers, once again, if you could just text myself or, chair representative Beal, and we'll make5324 sure to add you to the queue, for a question of the testifiers. And with that, we wanna welcome, MassHealth. Joining us today to testify, to answer any questions we may have is the assistant secretary for MassHealth, Michael Levine. Mister Levine, thank you for coming and the floor is yours.
Should have a switch right on the top there and just speak directly into the mouth. How's that? Perfect.
SPEAKER4 - Thank you.
SPEAKER1 - Nice and loud so we can hear you.
SPEAKER18 - Thank you, Chair Feeney. Thank you, Chair Beal and members of the committee. My name is Mike Levine. I'm privileged to be the State Medicaid Director here in Massachusetts. MassHealth covers over 2,000,000 residents of the Commonwealth. That's more than 1 in 4 people in Massachusetts. We cover half the kids and nearly 3 quarters of people in nursing homes.
My written, my written testimony includes detail on some of the progress we've made over the past year to advance our 4 key priorities as an agency. Those are Advancing Health Equity, shoring up primary care and behavioral health, improving member experience and customer service, and importantly, promoting independence for members with disabilities. I'm gonna focus my remarks this afternoon on the budget headwinds facing the MassHealth program. I've been at the agency since 2016, and I've never been through a budget cycle like this 1. And there are 4 major pressures that we are confronting in this House 1 budget. The first is our caseload. Today, MassHealth covers 250,000 more people than we did before the COVID-nineteen pandemic. There used to be more people on private insurance, but over the course of the public health emergency, we saw a transition from private health insurance onto public coverage at significant expense to taxpayers. The second key challenge is acuity and utilization. On average, our members are sicker and using more services. I'll give you a couple examples. Last year, spending on5442 pharmaceutical products per member increased by 16%. The share of MassHealth members using long term supports and services increased by 11%. We are not immune to the challenges the private insurers are facing causing their premiums to skyrocket. We're seeing that at MassHealth as well. The third major headwind facing MassHealth are what I call non discretionary increases, things that are outside of our control. So we help cover Medicare Part B and D premiums for many low income seniors. Those are going up 6 to 10% next year. There were a number of provisions in the Long Term Care Law recently enacted that required significantly increased expenditures at the MassHealth program. And these things combine to, to compound, to compound our challenges. The last challenge, the fourth headwind that I'd highlight for all of you is5501 that we have managed through the past couple of years with 1 time savings levers that are no longer available to us, and I'll be specific. During the public health emergency, when our caseload skyrocketed from $1,800,000 to $2,400,000 we were getting about a billion dollars a year from the federal government in enhanced match to help fund those costs. Well, that enhanced federal funding ended a couple years ago. And since then, we've been managing a series of, shortfalls with5532 1 time initiatives that, frankly, in FY26, are no longer available to us. It's akin to pulling rabbits out of a hat and running out5540 of rabbits. So in 'twenty 6, we're confronting high caseload, high utilization, these non discretionary cost pressures without some of the 1 time initiatives that we've had in the past to support, the General Fund. Taking all those things together, if we were to do nothing and just kinda go on autopilot from 'twenty 5 into 'twenty 6, the MassHealth program would pull $1,300,000,000 more out of the General Fund in 'twenty 6 than it will in 'twenty 5. And I'm sure members of this committee agree that that's not an increase that we can sustain. And so we did put forward a budget in House 1 that would fund the Medicaid program at $22,600,000,000 gross, and about $8,700,000,000 net. Net refers to the money coming out of the general fund. The difference between that really big $22,600,000,000 number and the pretty big $8,700,000,000 number is all of the federal match that the secretary described, and that is currently the subject of debate in DC right now. There are a number of provisions that we proposed in the budget that would help us close that gap. And I'll just address, I think, 2 that, I know are top of mind for this committee given the prior session of testimony.
So the first is the pharmacy assessment. I share your concerns about the ongoing viability of the pharmacies and frankly pharmacy access broadly in the Commonwealth. That was actually part of the thinking behind this proposal. The way the pharmacy assessment works is it levies an assessment on all scripts filled in the Commonwealth and then reinvests those dollars plus $20,000,000 into Medicaid rates for pharmacy services. So were this, proposal to be enacted, pharmacies would experience a net increase of net income of $20,000,000 over today. We do that through higher dispensing fees on the Medicaid side and requiring our managed care organizations who currently pay independent and other pharmacies a lot less than MassHealth does to match our rates. And there's a special investment in those independent pharmacies and community health centers that offer some of the excellent above and beyond service that I've heard described in this session today. It also accrues, the proposal also does accrue to the benefit of the general fund and helps support our operations on an ongoing basis. And, it's been a privilege to work with both Mass Independent Pharmacy Association, the chains, the health centers, the hospitals, to do some modeling together and actually understand the impact at the pharmacy level of this proposal. I'm happy to kind of share what we've learned, in the days and weeks ahead. The second proposal I'll touch on has already come up a few times, which is, the notion that, in the years ahead, we would, tie personal care attendant spending program personal care attendant program spending in MassHealth to the Health Policy Commission benchmark. I think about this as an invitation to a very transparent and open process about the rate at which these services should grow in the years ahead. 3.6% is the annual growth rate in the HPC benchmark today. You might not think that's the right percentage. But given the rocket ship that this program has been on from a spending standpoint, well in excess of revenues that support it, I think a transparent and common understanding of how quickly we do want the program to grow and just what impact does it have in helping Massachusetts lead the country in rebalancing spend away from institutions to the community is a conversation we need to have. Because continuing to keep our heads down and plodding along at the current rate is gonna leave us in a situation where we're actually unable to preserve the service for the people who need it the most. So we'd love to talk more about that. I guess, before I pause for questions, I just want to emphasize that even before you get to the federal uncertainty facing us, we have real significant structural challenges we need to talk about at the MassHealth program. Again, House 1 puts forward our best ideas on how to close and mitigate some of the challenges that are due to caseload, that are due to acuity, and due to these other other factors. But the federal uncertainty coming from DC is only going to make those challenges more significant. I think5814 there are 2 things that we should all expect5816 coming out of this, you know, congressional session ahead of their5820 August recess. 1, I would expect that there will be less money available to states like Massachusetts to run their Medicaid programs. That's gonna cause a budget challenge that we need to figure out together. I would also expect that there will be fewer people with health insurance as a result of some of the policies being proposed. Certainly, there's a lot of traction in DC right now around nationally mandated work requirements for Medicaid, which in the states where they have been enacted, have been proven to be very effective at keeping people from getting health insurance. And so that causes a different kind of problem. That's not a state budget problem. That's a Commonwealth health care financing problem. And how do we ensure that hospitals, whether you're a safety net or not, can afford to treat someone coming into your emergency department without an insurance card. These are things we're gonna have to solve together, and, and I look forward to doing so. I'll pause there. Welcome your questions.
SPEAKER1 - Thank you very much, assistant secretary. Appreciate that, commentary that uplifted us all.
SPEAKER18 - You're welcome. Right after lunch.
SPEAKER1 - Thank you. We're gonna open up the questions again, and if you do have questions or comments, just text, either, chair Beal or myself, and we'll add you to the queue. I would want to start with Senator Robin Kennedy with a question.
SPEAKER12 - Thank you so much. And, I echo the the concerns that that raised. And I appreciate that the challenges we're up against in, bringing back the conversation on the the PCA program. And we absolutely have to have a conversation, a comprehensive conversation. I I think some of the concern, some of the cuts we saw last time around before we knew what we were heading into in the next budget year, particularly concerning, especially when short term cuts can really offset somebody's ability to to stay in the community. So, I agree with you a %. It needs to be a a much more comprehensive, program because, again, we know that the baby boomer generation is aging, and we know that there's, gonna be more need. And I think a unified desire to keep individuals home and in their community as best as in as long as possible. I do want to ask a specific question, about the mass health move, towards having an independent assessor eligibility or entity. Excuse me.
SPEAKER16 - Mhmm.
SPEAKER12 - I've raised and had lots of conversations with Leslie Darcy. I have strong concerns around moving away from community based determinations into a single entity. Mhmm. I, you know, I I appreciate that not all providers are created equal, and some may need some help in addressing some challenges, lag times, and making determinations, etcetera. That said, I'm very concerned with having 1 entity, particularly as, someone who res represents individuals outside of Boston who typically were not served well when there's a single entity making determinations in the state. But wanna speak specifically about some of the entities that that could be potential bidders in this, those that are private equity firms, those that may be headquartered outside of Massachusetts, which cause further challenges for our residents here in the community rather than the provider that's here. So I wanna, you know, ask you not to put put you on the spot. You know, RFRs are are you know, I appreciate closed processes, but, if you can speak to if you can commit to not having more private equity firms coming into health care in the Commonwealth, and and continue to work with us on figuring out how we can maintain the community based assessments, without losing that, that ability through through this, 1 assessor. And if you can speak to what you perceive to be cost savings in this overall switch, again, at the cost of losing that community based, support and assessment? Yeah.
SPEAKER18 - Well, thank you, Senator, for the question. And let me start out by categorically stating that, we are not eliminating any community based assessors. So last year when I testified, it came right on the heels of us6061 releasing a procurement that did something pretty remarkable, which was unite an extremely fractional stakeholder community in opposition and in agreement, against what we had proposed. So we went through an extensive process of listening and hearing from stakeholders. And later in the summer, last fall, we announced a pivot in direction. So let me describe, the challenge and where we'd like to go with the benefit of several procured consumer stakeholder input groups that are helping guide our work. Look, there are about 400 organizations across the Commonwealth today that can provide you an assessment for LTSS. It is a very confusing alphabet soup of organizations who do great work, but who for whom, you know, many people find their way to us after saying that they've been thoroughly confused and have no clue where to go in terms of getting their LTSS. We also observed that even within just, individual segments of providers so if you look at, personal care management agencies or PCMs, these are the groups. They do a lot of things. 1 of the things they do is assess individuals to determine their need for for PCA services. For some PCMs, if you walk in their door, it might take you a few weeks, like 20 to 30 days, to get from that first stage to having your PCA authorized and in your home. There are others for whom it takes 150 days. They're all paid the same. They all have the same contractual requirements, and the variability in quality and performance, From my standpoint, serving these individuals and covering them is not acceptable. We also heard that there is a need for more technical assistance, for more uniform assessments, for the sorts of things that we need to do to build a really robust, high quality network of assessors throughout the Commonwealth. So what we basically did is we took the procurement, we put it on pause, we engaged a bunch of stakeholders, and we said, we're gonna break this up into 2 parts. Part 1 is the technical assistance part, where we're going to procure an organization to do quality improvement, to support organizations who need to figure out how to upload an assessment to the network and how to use the data and how to do analytics and all of that. And it's gonna be, I'm sure a great organization, probably not have too many of the concerns you just described. The second part of the procurement we'd like to go out with is a public assessor option. So not replacing other assessors, but basically saying, Look, if you're horribly confused or you've been waiting for 6 weeks but the PCM agency said, I'm sorry, I can't help you, here's an 800 number. And we'll get out to your home, we'll do the assessment and whatever the required time is, and then you just have another option. We're basically going from 400 options to 4 0 1 options. And I think this is a way to give consumers more choice. I think it is a way to connect consumers to services more quickly. And we're not gonna do it if we get bad bids. At the end of the day, if the bidders don't meet the needs of the Commonwealth, if it's not cost competitive, if it's not gonna provide a good service, you know, we're not just gonna do it for its own sake. But I think there is a meaningful gap here, and I think many consumers agree that more choice and a more streamlined path to get from here to the service whose authorization you're seeking, it's probably in the best interest of consumers. But you're right. I don't wanna prejudge a, a procurement outcome. We haven't even reposted the procurement. That's gonna be later this spring. And, and I think for us, we are going to just remain focused on making sure that people are not slipping through the cracks, and they are able to get to the service for that that is6281 appropriate for them.
SPEAKER12 - To follow-up on that, so 401,6287 so it would be a new cost to create to for this new entity that may or may not be compete I don't wanna say competing. I don't think that's the right word. But, so someone could still go to their local provider for the assessment
SPEAKER4 - Mhmm. But
SPEAKER12 - then there'll be a separate entity that we're funding that's not so 1 of my questions, what was the cost of this new IAE?
SPEAKER18 - Yeah. That's why we do competitively bid procurements. I think what I would say is, we burn a lot of costs in the months that it takes to get people services. And if you need a PCA and you're waiting 3 months to get a PCA because someone can't get a nurse assessor out to your home, high risk of falls, high risk of EDU, you know, all the stuff we're trying to prevent. So I think we're gonna have to take a hard look at bids that come in, make sure we can afford it, obviously, given the the circumstances we're in. But I think if it can be a step towards an overall higher performing network with more choices for consumers that can actually get them to the right place more quickly, there could actually be cost savings by just taking all that churn and all that noise out of the system. But I share I share your concern.
SPEAKER1 - Thank you. And I just want to mention, as well, we're being joined by Senator Jake Olivera. Thank you for being here, Senator, Representative Patrick Kearney, as well who's here, and also, for the edification of the members that are looking up. These are out of our high school students that are studying civics that are with us in their classes are coming through to see their government in action. So thank you to all the students for being here. I'll turn it over to Chairman Beal for questions from the House.
SPEAKER2 - Thank you very much, Chair. Assistant Secretary, thank you for your time. I was wondering if you could describe, any savings or investment initiatives, that you're proposing and how they will affect the populations that you serve.
SPEAKER18 - Yeah. Yeah, there's a lot6397 a lot in the House 1 budget and a lot underneath the $22,000,000,000 budget. You know, I'll, I'll describe 1 series of investments and 1 series of savings initiatives and how that might impact people. So on the investment side, you know, MassHealth has sought to be a leader in primary care and behavioral health. We're not unique. Every Medicaid agency is the primary payer for behavioral health in the state, just given the population that we serve. But there have been a series of investments we've made and that House 1 would sustain to significantly increase dollars that are available to primary care practices and dollars that are available particularly to the behavioral health crisis system. And so I'll just highlight on the primary care side, House 1 proposes to further increase our primary care investments. So that 10¢ of every dollar that we spend is on primary care. Something that most countries blow past, very few states in the in in The US have accomplished, but we know is necessary in order to preserve access to high quality, low cost care in the community where our members want to receive it. On the behavioral health side, we proposed some additional investments, but really sustaining our current investments in the community behavioral health centers that are, currently, you know, nearly 30 of them across the Commonwealth, that are providing and are being successful at diverting people from the emergency department when they're in a behavioral health crisis. So we've actually seen a remarkable shift just in the last 2 years from, nearly a thousand visits a month that used to go to the emergency department now go to an outpatient community crisis intervention spot, which is so much better for kids and adults who need it. So House 1 sustains these investments and has additional targeted investments in some of our hardest to reach populations, including, individuals with dual diagnosis, both serious mental illness and substance use disorder. Again, it's all about keeping care in the community where people, where people need it. 1 of the savings and savings initiatives, I I would point to is just generally being really tight on provider rates. So if you think about what we as an agency do, we pay for stuff. And, given the budget environment we're in, we're we basically put a budget forward that is more or less flat for every provider group, but does include some targeted reductions. I'll describe 1 because there's an outside section on it, which is for our ambulance providers. So ambulance providers are currently the only provider type in MassHealth where we are required to match Medicare for members who have MassHealth and Medicare. Our budget proposes to make that optional so that we can return to the practice that we have for every other provider type that would, basically pay MassHealth rates for services rendered to MassHealth members. Certainly, I don't think there's anyone in this building or elsewhere who thinks that EMS providers are overpaid. But in an environment where we kind of have 1 set of rules of the road for all providers, we want to extend that to to the EMS providers as well and continue the investments that we have made, which included an $18,000,000 rate increase a couple years ago and a $13,000,000 improvement from our ambulance assessment that's currently in effect to to ensure the sustainability of those providers. So that's an example of a savings proposal that we hope we can, limit the impact that it might have on providers and members. Thank you
SPEAKER2 - for that. Look forward to reviewing those proposals. We do have, several members in the queue. I'm going to turn it over to Rep. Zarrows.
SPEAKER7 - Thank you both chairs. First of all, I'd like to say thank you for doing the Pledge of Allegiance and our National Anthem. I thought that was really special. It means a6639 lot to all of us and especially me and my family. Thank you for doing that. To you, sir, I like your style, the transparency. 1 of the questions that comes up a lot is because we are a right to shelter state, that people that come from other states or other countries come to Massachusetts and they're provided a lot of services. 1 of them is MassHealth, I was told. Do you know how much money that involves?
SPEAKER18 - Well, I'll start by saying that a requirement of being on MassHealth is intent to reside in Massachusetts. So, there is active program integrity work we do around individuals who come to Massachusetts but do not intend to stay. They're not actually eligible for Medicaid in this state. So I would separate out folks who are maybe here on a temporary basis seeking medical treatment. That's something that we actively work on just in terms of running a really compliant high program integrity operation. I think your question is probably a little different, which is, well, what about folks who are coming here and plan to stay? So, a couple of things. I want to follow-up with some of the actual numbers because I don't have a specific, in, you know, number to share with you. But I think we have been really thoughtful about how we have partnered with HLC, who obviously is running the the family shelter program, to ensure that to the degree that services are being offered, it's the right services, and we're getting as much federal reimbursement as we can for them. So you might be aware, we got special approval back in April of 20 24 to help, basically recognize the fact that, you know, providing someone a roof over their head, especially in a Boston winter, that's a health care dollar, and it ought to be recognized by the federal government as a health care dollar and reimbursed accordingly. So we've actually been really successful in working, as with the last administration, around getting federal dollars to support some of the costs that you're describing because there are costs. But to the degree that, you know, everything we do, we try to get as much help from the federal government as we can. We've really laser focused on this population as well because I'm sure you'd agree at the end of the day, if someone's coming here, you know, it's a federal issue. It's not just a state issue. So we've tried to partner with with the feds on that. But to your specific question about how many people and how many dollars, that's something my office will have to follow-up with you on.
SPEAKER7 - Thank you, sir. Thank you, Chair.
SPEAKER1 - Thank you again, this is secretary. Just a real quick question for you.
SPEAKER4 - Yeah.
SPEAKER1 - CHEER reports approximately 200,000 membership, I think, that we're seeing away from employer sponsored coverage, to state funded coverage.
SPEAKER4 - Do you
SPEAKER1 - have any insight at all? Can you dig into that a little bit? And is that normal? Is it something that's sustainable? And why are we seeing such a shift from employer based coverage to MassHealth?
SPEAKER18 - Not normal, not sustainable, but understandable. So, premiums have I mean, you pay them, too. Look at how much premiums have gone up for employees and employers over the past few years. And, you know, CHIA's director, Peters, will be able to speak more accurately to this. But the share of employers, both large and small, that are offering health insurance to their employees has fallen significantly since 2021. So, you know, if I'm an employer and there are affordable options with you know, whether it's the connector or it's MassHealth, it's great health insurance. Probably makes sense to kind of connect employees with it where possible. But in terms of the impact on the MassHealth budget, I mean, it's well over a billion dollars of impact from those additional 200,000 people. You know, keep in mind, it's primarily,
children and adults, less incidence of disabilities. These are people who are generally working and, more often than not, part time, them and their families. But, but it's a real cost. And it's not 1 that, you know, there's no corresponding revenue associated with that expense. And that's part of why it's such a challenge.
SPEAKER4 - Just to clarify,
SPEAKER1 - billion dollars is the cost that we would see from that6896 shift from employer based coverage no longer provided or whatever the decision may be within those those employers, the state funded care a billion dollars.
SPEAKER18 - Yeah. If our budget proposal is $22,600,000,000 it would be at least a billion dollars less if, that shift had not occurred.
SPEAKER1 - Wow. K. Thank you, mister chairman.
SPEAKER2 - Thank you. Next up, representative Russell Holmes.
SPEAKER4 - Mike, again, I think you were here for when I was with the secretary. So, I'm going to just ask really the same 3 questions.
SPEAKER19 - Sure.
SPEAKER4 - Do we pay enough to keep places like CCA, or this new place that may be coming from out of state to have I'm just gonna tweak it a little bit. Do6952 we pay enough that they can stay afloat and, my tweak, provide quality care? Like, we want them to still have good care, and I do not think I layered that with the other question. So, quality care or good care and be able to still stay afloat, Juan. And then you have said, you know, prescription drugs were up 17%. So, anything we can do in this budget around 340B, anything we can do around all of these costs for prescriptions that we can muscle to try to get these folks to, get some of these costs down. As you may have heard the question with the Secretary, are drugs, as you know, much more expensive? I think at the federal level, there are some things, obviously, with Medicare that they're doing to get some of these drug costs down. Are we doing something similar with with Medicaid so that we can get some some of the drug costs down? So if you7010 can answer the quality care and7012 not just stay on the phone Of course. That would be helpful.
SPEAKER18 - So I'll take CC. I'll I'll take the the the integrated care question first. We call these programs integrated care7020 because it pulls Medicare and Medicaid together into 1 benefit. I7024 have good news and bad news. The good news is we pay enough. The bad news is, by some measures, we pay too much. So if you look specifically at the 1 Care program, where we have about 40,000 members enrolled, about 28,000 of them with CCA, the state overpays and Medicare underpays for their share of of the services. And if you look at the overall economic performance of our plans, most of them are doing very well. And they are delivering services that achieve health outcomes and quality that are better than most other states in the country. There's absolutely enough money in the pot. It is a7064 question of how you use it, how do you keep those7066 dollars in Massachusetts, which is critical and something that frankly did not happen the last couple of years with the organization you described, and ensure that it is the members who are benefiting from the services. So whenever we talk about CCA, whenever we talk about integrated care, we're talking about our most complex, most vulnerable members. There is adequate financing for them to continue to do a great job. We see other plans in the market doing great work.
On pharmacy,
3 40 b is a program that, as the secretary said,7101 it's an important part of the financing puzzle that safety net systems use to stay afloat. They generate enormous margin by buying drugs at a discounted rate, selling them back at a market rate, and pocketing the difference. Happier for them to do it. They've reinvested in patient care. It's great. Part of the challenge with 3 40 b is that when someone buys a drug through that program, we, the state, cannot negotiate a rebate with the manufacturer. And 9 times out of 10, our rebate is better than the discount that the manufacturer, that the provider can get. So if a health center or a safety net hospital is getting $10 of margin on every script of Humira that they're prescribing, just round numbers, not speaking to a specific drug, but we could probably get 15. And so what's actually happening here is we're actually leaving a lot of money collectively on the table because there's a better discount that we7159 could get if we went ahead7161 and paid for the drug not through 340B for our Medicaid scripts. So something we've been talking to the Mass League about and MHA about is to say, Hey, can we kind of solve this problem together? Where I get 340B, we're not gonna take that margin away. We can't. It would be really challenging for a lot of providers. But can we at least do this in a way where the state can capture some enhanced value through a supplemental rebate? And that way, that's money we can reinvest into the program and move us up better. So it's it's it's certainly complex. It's certainly something we're trying to. And to be honest, I think the federal government's I don't expect this administration to befriend them. And and that's just gonna put pressure on all of us. The only the only other thing I'll say just quickly, 1 of the drivers on the on the pharmacy side is these super super high post drugs, you know, $3,000,000 cell and gene therapy. We have entered into value based agreements with manufacturers, including a lot of local Massachusetts based manufacturers that we should take a lot of pride in because they are standing behind their drug. If it works, pay you millions of bucks. If it doesn't work, taxpayers get most of their money back. And I think that's really important for some of these super, super high cost drugs. It is amazing to live in an age where we can cure sickle cell, but having a manufacturer stand behind their drug is really encouraging. It's something we've seen a lot of manufacturers willing to do. We want to do more of that in order to ensure accountability and manage some of the cost trend we're seeing from these very, very expensive drugs.
SPEAKER4 - So I just want to make sure I hear it right. Enough money. We just need to figure out how to make sure we pay it. And this provided us out of state that we're looking at potentially for CCA. They will understand that they need to try to keep as much in Massachusetts as possible. 1. 2, we are working with Michael and the League already around trying to get some of the rebate back. That's always the conversation you're having?
SPEAKER18 - We are having conversations with Michael and the League about how we make sure that we're not collectively leaving money on the table.
SPEAKER4 - Okay. And then PBMs, that would that's just7295 we've lost that fight. Is that I
SPEAKER18 - think we've lost that fight. I think, you know, not to echo the secretary too directly, I think that the legislature took a good step forward around some PBM transparency and I'm sure that. Eric Busser, you know director Celts and his team are going to dig into the data look at mass health we out we forbid spread pricing a couple years ago. You know, we, our managed care plans do7320 have their own PBMs. It's challenging. I think there's more we need to do, but I'm hopeful that7326 if we can get a little bit more data and a little bit more transparency into what these guys are doing, that'll help. I mean, connect it back to all the concern about independent pharmacies. I mean, who do you think is getting squeezed the most? It's not the pharmacies that are vertically integrated with the PBM. And while the independent pharmacies, they do have PSAOs, they do intermediate a little bit and try to lever up some of their, group purchasing power. It's awfully tough to sit across the table from, you know, a care mark or an express script. So, I think within the confines of the Medicaid program and the 3 plus billion dollars a year we spend on drugs, I feel really good about the pharmacy products that we, MassHealth, buy directly on behalf7368 of our members, because we are our own PBM.7370 And don't worry, we're a good actor. I think it is challenging still to get several clicks of insight into how our managed care organizations, PBMs operate, but that's something that I hope in partnership with HPC we can keep making progress on. But it it defies an easy answer.
SPEAKER2 - Thank you. Next up, representative Jim Hawkins.
SPEAKER9 - Thank you, Chair. And to the students in the gallery, I was a teacher here before, and I've get to come to sometimes. I'm have the pleasure of visiting some of your classes. And you take on some important causes. It makes it I feel good about our future knowing that you're doing that, and you should know that your voice is heard and do more of this. Come to more of these things, pay more attention. You can make a difference. So thank you thank you for coming to this, auditorium. And
I I do have a technical question too. Sorry. With the looming threat of federal cuts to programs like Medicaid and MassHealth, how are you preparing to continue serving residents in the face of these threats?
SPEAKER18 - Well, we can't buy ourselves because a lot of this is gonna come back to budget and appropriations and hard choices. So, like the, there are 4 things that are gaining traction in D. C. Right now around Medicaid cuts. 1 is a bunch of rules that the Biden administration promulgated that probably get taken down. 1 is work requirements, where individuals are gonna have to prove that they're working, they're trying to work, whatever the qualifying activity is in order to keep their Medicaid. 1 is just a simple cost shift to states. It's7477 called per capita caps. But that is gaining traction. And that's the 1 that Ways and Means and the Administration are gonna have to work really closely on. And then, some modifications to provider taxes, which will be, certainly a hot topic, I'm sure, in the months ahead with many of our providers who participate in provider taxes.
I think we collectively have an obligation to protect core parts of the program. Look, we've come so far in helping people who do not want to be in nursing homes stay out of nursing homes. I think we have to just collectively identify the degree to which that continues to be a priority, and that's where we preserve our investment. I think a ton of the preventative work we do for kids, covering half the Commonwealth, getting kids vaccinated, getting kids their well child visits, access to behavioral health, it's awfully hard to imagine us stepping back from that. But I think it is, it is a matter of identifying our key populations and what we're gonna do to support them and collectively coming up with answers. Because you might have a point of view on, you know, if we're on track to spend $8,700,000,000 out of the general fund in 'twenty 6, that number can go no higher than X. That's really gonna clarify our choices and what we're able to continue to do and what we're gonna have to stop doing.
SPEAKER2 - Thank you. Next up is Rep. Sally Kearns.
SPEAKER3 - Thank you, mister chairman. Thank you, commissioner. Very sobering situation that we are all in, and I appreciate your work and your, ongoing commitment to data. I know that that that is your approach to things along those lines, on the assessments, on the long term, community, long term services care and supports. I'm hearing from people and have been great concern about, I guess, the quality, the impact on an individual. This is a population as you know. Change is hard. Disruption can unravel someone. What are the what are the ways in which you can assure that people will not be put into a very bad place with this change. I mean, it it seems to be working. I've got a great grade in the AARP magazine of '23. We're known, right, are we not, for doing a really good job on these community based assessments, is there something that you have in store that will safeguard against this kind of big anonymous faraway entity running things. And and by the way and and I don't know if this is your bailiwick too, but Mhmm. There's a outsourced assessment process, I think, for determining eligibility for emergency housing, so not your bailiwick. But it's outsourced.7673 And when you call it, it's a call center. So anyway, any light that you can shed on that? Thank you.
SPEAKER18 - Yeah. Thank you for the question. And I just wanna repeat categorically, we are not eliminating existing community based assessors. And, and the, the proposal on the table is to add an option that we would run with the support of a contractor as another option. So if you're really happy with your PCM that you've been going to for 207706 years and you know that the nurse case manager and she knows your family, like, no change.
SPEAKER9 - If you
SPEAKER18 - wanna keep if if you're new to the system, and and you're you got a referral from a friend, hey, go check out, you know, that ASAP down the street, that is going to remain an option. We're proposing 2 things. Again, we took the procurement, more or less scrapped it, and started over with 2 pieces. 1 piece is improving the quality of the network by supporting all the ASAPS, all the PCMs, ILCs, alphabet soup goes on, of great organizations that are doing this work today to help them do it better because candidly, I'm not satisfied with the quality in the network. I think a lot of people wait too long to get assessments that are different if you go down the street versus over there. I mean, there's just a lack of uniform that it we can do better as a commonwealth than we ought to. And then separately, it's it's this different option that if the other 400 options are not the right ones for you because you can't actually access them, you can't get anyone to call you back, you can you know, all the things that we hear about in our constituent services office, then there is a number you can call. And to the earlier question, if we don't get a good bid, and we don't think it's gonna be successful, we're not gonna do it. This is about connecting people to services faster so that they don't fall through the cracks.
SPEAKER3 - Thank you.
SPEAKER1 - Okay. The, chair recognizes vice chair of the committee, Senator Joe Comifred.
SPEAKER11 - Thank you, mister chair. Assistant secretary, thank you so much. I wanna start by recognizing your work on MassHealth Estate Recovery. Thank you to you and your team. You did an excellent job, both in your embrace of the policy, but in the rollout, which has been, I know, very difficult amid everything else you've been doing. I wanted to go back to something you said in your remarks where you recognized and and supported, keeping people in their homes, which I know has been another, value that you've led with at MassHealth, and thank you for that. So I understand that your team at MassHealth has been working to implement, a change in the, the program of all inclusive care for the elderly, PACE and the home and community based services, HCBS. So my understanding is that, this is another innovation, that you've leaned into. I certainly support this, and that you've made or you're going to make the following. So you're gonna raise the asset limit, up to $5,000 for individuals, $7,500 for couples to improve the ability of of individuals to maintain themselves financially while being in their community. And and that you are going to roll out this commitment to allowing people to pay just what is above the premium in terms of their assets, which, again, I think is very smart policy. Does this have a budget implication? Will it be affected by any of the federal volatility? I know you're facing such headwinds.
SPEAKER18 - Yeah.
SPEAKER11 - And can you help us understand the rollout timeline for this?
SPEAKER16 - Mhmm.
SPEAKER11 - And and how you expect it to increase, the ability of people to stay in their homes and also, any other kind of, impacts from this?
7926 SPEAKER187926 -7926 Yeah.7926 Thank you for the question. And I'll7928 separate the question into 2 parts.
SPEAKER11 - So there7930 are some Yeah. 1 is a really
SPEAKER4 - good question.
SPEAKER18 - Asset limit. Right. And 1 is, this idea that you wanna make it easier for people to stay in the community. So on the asset limit side, the asset limit for MassHealth for people over age 65 hasn't changed since 1989. It's been $2,000 the whole time. So the proposal, would be to raise it to 5,000 for an individual, dollars 7,500 for a couple. I wanna be really candid. This7957 is something we wanna do. We put it in the budget for a reason. I think if we are hearing enough concern around some of our savings initiatives, I really worry about being able to move7967 forward. Only because there's a certain level of appropriation, and if we're counting on some of these savers to help us do something like this. So it is absolutely the right thing to do. It is absolutely what we wanna do, and we believe in it. But I think if you look at a state like California, which actually eliminated their asset limit, they have a $6,000,000,0007987 shortfall and had to pull out an emergency7989 loan to fund their Medicaid program. So we're just, this is something we believe in. It's something we wanna do. We have7995 to be able to afford it. And so I think it just needs to be part of the bigger discussion, the bigger picture around, do we have adequate appropriations to do everything we wanna do? But within the confines of what we proposed with some of the investments and some of the savers, it works. So that that is 1 piece, that I think is really important. On the, Home and Community Based Services Waiver and PACE Program, the confession I would make is that if I had to apply to 1 of these programs, I would have no idea how. We have made it so complicated. And all we're doing is making it harder for people to stay out of nursing homes. And a nursing home is the most expensive place to age. It's the right place to age for some people who want to be there, but it is the most expensive place. And so if we can lower the barrier to entry in a waiver program, I know that we will keep people out of nursing homes. And the budget impact, you know, the way we've modeled it. I mean, obviously there's a sensitivity table and it could go either way, but it, it's, it, it around pays for itself in terms of nursing facility diversion. It's a complicated policy to implement, and we're not gonna implement it without clear guidance from CMS that they are not changing the authorities that they've previously put on the table. All indications so far are good on that. So I I continue to remain optimistic that the federal pieces will will continue to hold. But, a a again, I I think it is something that would happen probably towards the very end of the fiscal year, only in terms of the implementation timeline and and working it all through with the feds. But again, it's the kind of thing where it's probably the right thing to do both from, keeping people in the community and dollars and cents standpoint because it diverts people from nursing facilities.
SPEAKER2 - Thank you, Assistant Secretary. Next up, we have a question from Representative Sabadoso.
SPEAKER13 - Thank you so much. Good afternoon. I I was going to ask you a question about the 11 15 waiver, and I would still like to ask you that, but I have to start when you talked about ambulance services. Yep. So I represent 8 rural communities. They are served by 2 non public ambulance services. In fact, Island and Hilltown EMS, they are community based 50131 ambulance companies, and they are super tiny. And what that effectively means is even though they're non public, they're regionalized. They were told by the state decades ago, regionalized so that you can save money. They set themselves up as non public, non profits in order to try to create a sustainable model. What we have found is that it is not a very sustainable model. They run-in a shoestring, and I think you you might know this. And what I I I really wanna stress today, I hear you talking about your changes to how we fund EMS service. And these ambulance services texted me earlier this week and said, what does this mean? Because they have no idea what this proposal does. They have no idea how it affects their bottom line. And this seems to happen again and again and again. Now they don't have the staff to come to meetings in Boston. They don't have the staff to get on Zoom. They really don't even have the staff to run the services sometimes. I mean, we're talking about places with 1 or 2 trucks and, you know, they're serving multiple communities. If either of these services go out of businesses, people in the hill towns will have to rely on the city of Northampton or the city of Westfield to send ambulances up to an hour away, which means people are going to die rather than get to the hospital. These are elderly communities by by and large. So I I guess, my my question Mhmm. Is how can we do better to make sure that these voices are actually at the table when we're proposing programs that really $10,000 could put them out of business? A loss of 10,000 could. And they've already gone through this whole debacle with the non public ambulance service trust fund. And Yep. I know you worked really hard to make that work, and I appreciate that. But it feels like we're once again in a position of how do we just make sure that they're heard and that we aren't always playing catch up to try to make sure we don't put them out of business.
SPEAKER18 - Thank you for the question. Debacle is the right word. So a couple of years ago,
language was put into statute requiring an assessment for ambulances that was not federally compliant, and that is very unfortunate. We work as closely as we can with the Mass Ambulance Association. I don't know that everyone is at the8264 table. And so I think speaking8268 just from MassHealth's perspective, we're trying to do8270 our best with a very bad hand. When something8272 gets put into law that would8274 result in tens and tens of millions of dollars getting disallowed from the8279 federal government, it's a really unhelpful place to start. I think we've at least gotten8283 it to a place where it's federally compliant. I know that our team does an enormous amount of hand to hand work with each organization. I think Chia does too because they collect some of the data. And we absolutely continue to try to do our best. But I think, you know, when we're working through these kinds of financing schemes with other organization with with other provider groups, It doesn't go this way, you know? Like, when we worked last year with all of you and with our partners in the hospital community to change the hospital assessment, I mean, everyone was at8314 the table. There was unanimity around what we were doing. It's It's been a very different dynamic here. And so, frankly, I'd I'd welcome the opportunity to talk with you and figure that out because we are we're starting from our back, our back heels a little bit, just trying to get this thing, you know, to a place where the federal government's not gonna ding us for operating it. We're there now, which is good. But moving forward to make changes, you know, no 1 here wants to do something that threatens access to emergency medical services in rural parts of the state. So I'd welcome your partnership on that.
SPEAKER13 - I appreciate that, and you will absolutely be getting the phone call because I'm sure I will be in both of their stations soon trying to walk them through what this is gonna mean for them. If I may then, I would love to, hear any insights you might have. I worry a great deal about our 11 15 waiver. I appreciate how much MassHealth has done to be creative and nimble in those waivers, but I know that the federal government often, when there's a change of administration, challenges them. And so I just wonder if you have any insight into what we might be looking, what, what, what might see coming down the pike, right? Yeah.
SPEAKER18 - Of course. So for those who don't know, we have something called an 11 15 waiver8378 about 3 dozen other states do too. The 11 15 waiver is, a state and the and the federal government agreeing that we can break8386 some rules in the traditional Medicaid statute.8388 We get to waive those rules, spend money, cover services, cover people in a way that, you know, people weren't thinking of in 1965 when the Medicaid statute was written. Massachusetts authorizes an unusual amount of our program under our 11 158403 waiver. And that is a product of the 90s when the waiver was agreed to and it's evolved over time. But we do have a lot of money and a lot of services tied up8413 in that waiver. So the 2 things to think about are 1, when does the waiver contract term end? Only answer is it ends in December 2027, which means we will be renegotiating our next extension with this federal administration. It'll be the first time we renegotiate with, with8431 the Republican administration since 02/2006. So this will be a new process8435 for us, and we're gonna have to work really hard and closely together to understand what's the most important thing to us8441 in our waiver, what can live somewhere else, and how do we preserve services and federal dollars that come in through the waiver. I think there is a concern out there about, hey, you know, these guys, they're moving awfully fast. What if they just tear our waiver up?
The federal government does not have a good track record in rescinding 11 15 waivers. The previous administration tried with a couple of states and were largely unsuccessful. It was blocked in court. So, I'm not a lawyer, but I think there are, we have significant reliance interest on our loan 15 waiver. It is perfectly reasonable for an administration to say, you know, when it's time to renegotiate, we'll renegotiate, reflecting the priorities of that administration. But, I think we're in a position where we're continuing to implement and operate, and we're gonna keep doing that until we're told differently.
SPEAKER1 - Okay, any other questions for members of the committee? Excuse me. I exhausted everybody we had in the queue. Seeing none assistant secretary. Thank you. Thanks. Yeah. Good luck and and and let's keep in contact in the, in the months ahead. Appreciate it. Thank you. Okay. Next we have a panel from the Department of Public Health. And while we reset the stage, I do want to mention, we've been joined by Senator Kelly Duna, a member of the committee who's here with us as well. Thank you, Senator.
SPEAKER19 - Thank you for this opportunity to speak with you today on behalf of the Department8529 of Public Health. I'm here to share with you some of the challenges we face as we adjust to a shifting federal landscape and as we navigate a new, uncertain, and frankly, troubling reality. And at the same time, I hope to reinforce that amid this turbulent time, our collective resolve to preserve and advance the health and the well-being of every individual and every community in the Commonwealth is unshakable.
Our state is a leader in public health. It's driven by a history of state investment in vital services that have dramatically improved the lives of our residents. Our immunization infrastructure, our harm reduction programs for substance use disorder, our efforts to prevent chronic diseases and protect against environmental health threats. All of these make us a national model for public health. Our success is firmly rooted in this state's values and in our shared commitment to the people in Massachusetts. And we must acknowledge that the success and the health of our state and the department are not just a result of the state's commitment to public health. We've been fortunate to receive significant federal funding, close to 700,000,000 a year, that supports these public health priorities. These shared priorities that are essential for the well-being of our residents and particularly for our most vulnerable populations. So, as we enter this 2026 budget cycle, we walk carefully. We're in unfamiliar territory. The uncertainty around federal funding for public health is not only disconcerting, it's potentially devastating. The Trump administration has taken aim at crucial funding sources, threatening the stability of the programs we rely on to keep people safe and healthy to support communities to promote wellness and prevention to save lives. I want to be realistic about8655 the potential impacts of these federal actions. I also want to be perfectly clear. These are not abstract threats. These cuts are real. Our programs are at great risk. People's lives will be affected. People's jobs already are. You heard already from Secretary Walsh, from Assistant Secretary8677 Levine, about the looming risks to MassHealth, our state's Medicaid program,8681 and the assault on safety net programs like SNAP benefits and school lunch programs that support families in our state. Cuts to these essential8690 programs could push our most vulnerable residents into even greater hardship. And there's another deeper layer to these threats. Public health is the network that sits under these safety net programs. When people lose access to government funded health care and human services, they seek out the community health centers and community based organizations that are funded by DPH. When families lose their access to nutritious food, they seek out support from the WIC program, which is funded by DPH. When people are unable to access the resources they need to live healthy, productive lives, Public health, DPH, is there to pick up the pieces. DPH provides the ultimate safety net, offering services, support,8737 and hope for our most vulnerable communities.8739 The work we do is not just about preventing disease or promoting health. It's about being there, responding, addressing gaps in resources when others, including the federal government, are not. Let me give you a few concrete examples of how we're8757 mitigating the potential impacts of8759 federal actions. With the Trump Administration attacking evidence based clinical care and health8765 guidelines for the LGBTQ community and removing vital information from federal websites, we quickly created a webpage that maintains access to important information for LGBTQ individuals and those who care for them. With federal leaders casting doubt about the value, effectiveness, and safety of vaccines, we8786 use state resources to promote routine childhood vaccination, push back on rampant misinformation, and remind people that vaccines are the best way to prevent childhood and respiratory illnesses. And we redoubled our efforts to maintain Massachusetts status as 1 of the most highly vaccinated states in the nation. With our health equity work under threat, we're working quickly to implement the comprehensive maternal health legislation passed last year to expand coverage of midwifery8815 and doula services for birthing people across the Commonwealth with a particular focus on Black communities and our commitment to advancing racial equity. And with the Trump administration demonstrating complete disregard for climate change and its adverse impacts on health and health equity, we stood strong with state leaders at last month's Global Movement for Climate Change Resilience Conference to commit our and this state's leadership to address the climate crisis urgently, proactively, and equitably. And now, with the proposed federal cuts to CDC, HRSA, FDA and EPA, communities across Massachusetts are going to feel8856 the impact with the most vulnerable individuals being hit the hardest. We are not merely standing by. We will not let these cuts dismantle the public health infrastructure we have worked so hard to build. When we face threats like this in the past, the state stepped forward to stand in solidarity and in opposition To support the programs, the policies, and the people that make this state what it is, a beacon of hope for so many and a place that we're all proud of. When the first Trump administration threatened Title 10 funding, which supports sexual and reproductive health services and maternal and child health outcomes, we stepped up. We assisted Title 10 funded clinics in providing care without fear of8901 restriction. We passed a shield law that protects providers across the state. We were true to who we are. The stakes are higher now than ever before. We must be proactive. We must be resilient. And we must use every tool at our disposal to prioritize the health of people of our state, no matter what happens at the federal level. The Governor's H-one budget8925 strengthens our ability to respond to8927 these threats. The federal administration has essentially tried to erase transgender and non8933 binary individuals. Here in Massachusetts, we refuse to let that happen. In the governor's budget, we propose making our vital record system more affirming for everyone in our state, following on the investments and the changes made in the last 2 years that make our forms more gender neutral. The8952 trans and non binary community will be recognized, valued8956 and affirmed in the Commonwealth of Massachusetts. We must take similar actions to prepare for the potential threats to our vaccine infrastructure. DPH is responding by advocating for the Universal Adult Vaccine Trust Fund. This new trust fund will establish a formal adult vaccine purchasing program guaranteeing continued and equitable access to key vaccinations for adults across the state. This critical initiative would give Massachusetts, not the federal government, control over our vaccine distribution and our recommendations,
We don't yet know what We don't yet know what's going to happen to the Center for Medicaid, for Medicare and Medicaid Services and its longstanding commitment to quality and safety of nursing facilities and acute care hospitals. But we do know that DPH must continue to play a significant role in overseeing excellence in care. Massachusetts is a leader in health care and will maintain that distinction with facilities that match. We need resources from the state to do the job and to do it well. In this budget, we proposed a modest increase in determination of need fees to help us implement the quality and safety measures included by the legislature in the recently passed long term care legislation.
We also know that we have to make some investments in our 4 public health hospitals, in particular, Pappas Rehabilitation Hospital for Children in Canton. We continue to evaluate the best future course for this institution, looking for a way to accommodate the most medically complex young patients who often depend on technology like mechanical ventilation to9070 live. HAPIS is sorely in need of major renovations to its facilities and its infrastructure. And we can be assured the federal government is not going to step in and provide us them. A plan to relocate the hospital to a renovated unit in Western Mass Hospital in Westfield was put forth in the original H-one proposal. And as you all know, the governor has asked that we pause that plan and that we convene a group to look more deeply into the facilities and the needs of the patients and to suggest a path forward. That group, including some of you, will begin its work shortly. In closing, while the federal government may be walking away from its obligations, Massachusetts will not. Our state will stand strong. Will not allow the severe9118 actions in Washington to undermine or lessen the values that define Massachusetts. And
we'll
make
sure
that everyone and we'll make sure that everyone has access to the care and the support they deserve. We look to the state, to you, for support in keeping the people of our Commonwealth healthy and safe. Together, we can preserve the strength and vibrancy of Massachusetts as a model of equity, fairness, and excellence in health care and public health, a place we're all proud to call home. With that, I will thank you and I'm happy to answer any questions that you have.
SPEAKER1 - Thank you, commissioner. Once again, a reminder to members, if you, wanna join the queue, just text myself or representative Beal, and we'll get you in for a question. I will start, doctor Goldstein. And again, I appreciate the many, many challenges that you're facing, especially at DPH, compounded by the federal volatility and the unknowns and the questions that we all have going forward. And the fact that Massachusetts is a leader in public health. I know it's a goal that we all share certainly on this committee and as legislators, with you and the administration as well to do everything we can. Maybe we have different ideas about how we accomplish that, but we certainly want to be, maintain our leadership in public health across this country. I want to9202 start with, something you mentioned in your remarks regarding Pappas. And you and I have had multiple conversations in this, and I appreciate your team, for being available and accessible to have those conversations over9213 the last couple of months. Heartbreaking to see the announcement in in in House 1. Since then,9220 we've done a lot of work to try and go down there and understand the, pressures that you're facing and the reason that's that went into that decision to put that in the draft. Since then,9229 the governor, as you said, has asked all, the administration to put a9233 pause on that. And curious to, to, in, in your mind, what, what, what, in your view, what a pause actually means. Right? You know, presumably it was it was put in the budget. So it means that that9246 will not be advocated for as we go through the budget cycle through the house and the senate. But is there more to9252 it than that? Right? Does the pause mean9254 that it's status quo? You know, we9257 continue to operate as usual with admittances, with discharges. What does that mean? And then I just have a quick follow-up on that as well.
SPEAKER19 - Yeah. Thank you for9265 that question, Senator Benin. Thank you for your your support and your, proactively thank you for the work on the working group as it begins to convene. I think to put it really plainly, a pause to me means we go back to where we were in December of 20 24. The facility continues to operate exactly the way it was operating in December right now in April of 20 25. But to to dive into that a little bit, there has been a shift in the operations of Pappas over the past 3 years, And that is really a reflection of a post COVID environment and a recognition of the facilities that are available. So if we go back to 2023, when we really began to look at the infrastructure of Pappas to understand what services could be provided At the time, we had to make some really difficult decisions about what is safe to provide on that campus. What patients are going to be safe, safely cared for in Canton. And9322 it was clear to us at that time because of the facilities that we had to shrink down to 1 of the units. Only 1 building on that campus was able to maintain the clinical services that are necessary. That's the Nelson Unit. And it only has space for 45 children. And so starting in 2023, we had to go through a process of discharging patients so that we could safely get down to 45 or less and keep patients in that safe facility while still admitting patients. And so in 2023, we9351 discharged a significant number of patients during that year. We also evaluated around 10 new patients for for admission and ended up admitting 3 patients. So that's what operations look like in 2023. They look very similar in 2024. We discharged a decent number of patients in 2024. We also evaluated many patients for admission, 53 evaluations, and we ended up with 23 admissions. So far in 2025, while we've been, living through this pause, we've continued to see that same amount of flow through the hospital. So, there are still discharges that are happening. In fact, there are 4 discharges that are planned over the next 2 months and there are admissions happening. We've evaluated 13 referrals in the first 3 months of the year. We've admitted 3 patients so far in the first 3 months of the year. So when I think about the pause, I think we should go back to the operations that we had in 2023 and in 2024. It should look just like that while we're having these very important conversations about the future of the Pappas campus.
SPEAKER1 - Thank you, doctor Goldstein. I know there are a lot of members that wanna ask questions, but I just, wanna take a moment to follow-up on that. Are they are you know, we talk about DCF referrals and those, students and and patients that are under the care DCF.9430 Other agencies, are they aware that there's a pause? Because what we're hearing back, the feedback that we're getting from from folks that that have been at Pappas for many, many years is, look,9440 you know, we're hearing over and over again despite the announced pause that Pappas is closing. So, you know, discharges are happening, at an accelerated rate, admittances on what they used to be. You know, families are being told, look, if there there's no long term plan here. Right? This is something if if if it's, you know, something that that you're gonna be discharged in 4 or 5, 6 months. Are other agencies aware? You know, is this as we work through the working group, I just wanna make sure that we're not doing it in vain. Right? That there that there is a possibility that the working group could recommend and say, look, we have, you know, recommendations x, y, and z to keep Pappas open, to expand, to do, you know, whatever it is, for appropriations to make sure that we're9488 taking care of the kids safely here. I don't want it to be a self fulfilling prophecy where we cut the census down, change the methods and procedures, change the operations, kids are being discharged, others aren't being admitted for long term. And then we're, you know, we turn around look at each other and say, well, there's no need for this anymore. So, the question is, you know, are other agencies on board here, Is there some synergy? Does everybody understand what this pause means as you just articulated it? And while the working group does this work, are we gonna continue to see, you know, the census drop with additional discharges, or are we going to keep it kind of leveled off where it is now?
SPEAKER19 - I think I'll I'll, say 2 things. So the first is, while I can't speak for all of the other agencies and and how they're interpreting this pause, I can say that we have gone out to do the work to9540 engage with people, to let them know that campus is open, referrals can continue to exist. Our largest source of referrals is actually the acute care hospitals. Pappas9550 is a hospital for children with complex medical needs, oftentimes seen as a step down therapy after they leave the acute care hospital. We have gone out to Boston Children's Hospital, Mass General Hospital for Children. We've gone to UMass and Bay State. We've spoken to the large pediatric providers to make sure they know that they can continue to refer patients to Pappas for admission when they finish their hospital level course. So we're doing our part to try to engage, but I can't speak for what they may be experiencing or how they may be taking in the the stories that are being written in the context of the current environment. The second thing I might just say is that, I do think we have to be very clear that hospitals admit and discharge patients. If we want to continue the operations as they were in 2023 and 20 20 24, that means we need to admit and discharge patients. Holding a patient in a hospital when they've completed their hospital course and when they've completed their level of care and preventing them from getting to a community location where they may be better served would actually be against the goals of Pappas. Pappas is about rehabilitating9616 children, giving them the tools and the support they need so that they can get on to the next step of their independent life. And so we should not be expecting that all discharges will halt at Pappas because9628 that actually is not in the spirit of the pause. That would be a shift in operations from where we were in 2023 and 2024 to now.
SPEAKER1 - Okay. Alright. I'll reserve because I know there's others that won't ask questions. Representative Beal.
SPEAKER2 - Thank you, Sheriff. First up, we have Rep Hawkins.
SPEAKER9 - Thank you, chair. And thank you, Doctor. Goldstein for a very difficult9652 job, I'm sure. My question is kind of similar to, Senator Feeney's. We didn't compare notes before the before the hearing, but, my my inbox blew up when Pappas was was they were told Pappas was gonna be closed. And my kudos to you. These my colleagues know that I'm a little stubborn. I don't change my mind too easily. And for you to agree to a pause, I commend you for being that flexible. These should be in my mind, should be our utmost priority. These are the most fragile individuals, most vulnerable individuals in the entire state. There should be no compromise with the way that they're treated. But there have been since the pause was some some programs that changed therapeutic writing, aquatic therapy, horses. And I understand that the admission senator Feeney brushed on this, attached this a little bit with his question, and then you kind of answered this. But,
it was before that these, patients could stay until they were 229715 and now they're being admitted for just 6 to 9 months. So, by all appearances, this. The people9721 who work there, the parents are concerned that this is more than a pause. It's9725 it's it's more than that. I'm just hoping that you can address this because this is so important to people in in this region. I mean, I'm, I'm from Attleboro and people from Attleboro have children there. They work there, and they're committed to helping these kids.
SPEAKER19 - Thank you for the question. And and I share your commitment and your passion to9744 support these children who are incredibly vulnerable. I think it's important for us to put this into context. Right now, there are 32 children at Pappas Hospital. There are 32 admitted individuals at Pappas. We estimate9756 that there's around 10,000 children with complex medical needs all across the state. There's about 800 of those that have severe medical needs, severe medical complications that would require them to come to9769 a hospital like Pappas at some point in their life, whether it be as they step down from the acute care hospital or for a period of respite so that their9777 caregivers can take a vacation, go to a graduation for another child, attend a wedding of a family member. And so we are really trying to look at this as how do we best care for this population of incredibly vulnerable children in Massachusetts and make sure we have the resources and the facilities to match those needs. I think, you know, I want to highlight 1 point that you brought out, which is this, the sense that people have had that Pappas has shifted in the past 3 or 4 months when in9808 fact, I think the shift is something that has happened over the past 5 to 8 years. If we look back 15 years ago, 20 years ago, Pappas Rehabilitation Hospital for Children was actually the Massachusetts Hospital School. It was a school. It was a residential location for individuals to go and receive their education and also get additional medical care. But over the past 10 years, it has shifted to be a hospital. It is a hospital accredited by the Joint Commission. We are reimbursed through CMS and through the Center for Medicaid and Medicare Services, as well as through MassHealth and through other insurers, we bill as a hospital. And so over the past9845 10 years, there has been a shift to make sure that we are providing hospital level of care for the individuals that are admitted to Pappas, that we work with them so that they can move towards independence, that they can go through rehabilitation, and that they can move on to the next stage of their life, whether that be in a community based setting, like a group home, back home with parents, or in some other setting that is most appropriate for their level of needs.
SPEAKER4 - Thank you.
SPEAKER1 - Next up is Senator Robin County.
SPEAKER12 - Thank you so much. And Commissioner, thank you for always being such a great partner. I want to especially thank you for your clear and unequivocal support, for members of our communities that face particular targeted attacks these days. And I appreciate you speaking on behalf of the state and with your support and for your leadership in, always looking forward at evidence based models to address challenges we face, including those who struggle with substance misuse. I do want to actually continue. Obviously, this this is an important topic. Continue on the PAPIIS, conversation. You know, I I I wanna particularly note, and I think it's it's very clear that over the last several years, we've seen a shift, COVID being a a large factor in it, but we've seen a shift in other HHS agencies. And I appreciate this might be more of a question for secretary Walsh beyond just specific to DPH. But we know there's been a a shift in behavioral health needs and medical complications. And as such, we've seen shifts in census in9941 DYS facilities, DCF facilities, and certainly DPH, DMH, and DDS funded facilities. And so I feel like we constantly have this conversation where it's a hospital closure, there's outrage and push back and there's a pause. And then we look to see how we can keep that space moving and keep it open. I had the opportunity recently to meet with the director of the interagency review team because I know 1 piece of the factor that took off in a complication is what agency is going to pay for the individual. Often like to remind it's the state that's paying for the individual, so let's, you know, figure out the right services. But I wanna, I guess, more part of is a comment of figuring out as as we look at that, look at our our entire the entirety of our facilities that we currently have. Urge the administration to be looking in totality of the
totality of the change in census in different spaces, the change in, for example, within DCF, some of the higher acuity needs that we see, the higher behavioral health needs, and where different types of facilities, including some higher security levels might be needed. I think this is another perfect example. And certainly in this conversation, don't wanna lose sight of the families, Canton to Westfield. I mean, that's the other side of the world for so many families. I have a DDS, medically complex home in Worcester. I have a resident there who's from Lawrence, and the family often speaks about the fact that they have to take an entire day off to be able to just go visit their loved 1 there. And so I wanna put that into to context. Wanna ask you to speak a little bit more. This was the the10034 comment, but also want to ask you to speak to10036 the cost when you're looking at over the last several years, we've invested significant dollars again, not just a DPH. Excuse me, but across the board and upgrading so many of our facilities, some that we'll talk about later that are also on the the block to be closed. Is there is this part of a, HHS wide planning process? Can it be I appreciate the working group thinking about Pappas, but we know a lot of these facilities can be transitioned, can be multi, program based facilities rather than this is just a DPH. This is just a DDS facility. And so, want to encourage that, but also want to ask about that and and the cost that's going into the whole kind of system that we're seeing.
SPEAKER19 - Yeah, I think it's an excellent question. And, I'll respond from DPH's perspective because that's, I think, all I'm authorized to do. I'll start by highlighting what you brought out. The shift that we're seeing to, a population of children with significant behavioral health needs and trying to make sure that we have the resources, the facilities to provide care for those individuals. The unfortunate truth about Pappas right now is that it is not equipped to take care of children with complicated behavioral health needs. And we have had a very sad number of critical incidents on that campus related to the physical infrastructure and the complicated behavioral mental health needs of the children. We want to avoid having any of those critical incidents ever happening again in a state facility. So we did actually take a big step back here and try to think about from the Department of Public Health, from our perspective, we have 4 hospitals under our umbrella. 2 of those actually have had significant investment over the past few years. So 1 being, the10140 Nemuel Shattuck Hospital, which is in the process of a very complicated move from the Morton Street campus to East Newton Pavilion.
SPEAKER4 - But we will end up with an incredibly beautiful infrastructure for individuals with complicated
SPEAKER19 - medical needs. Now, that will be
infrastructure for individuals with complicated medical needs. Now, that will be geared towards adults and also geared towards those, who are involved with the criminal justice system. Probably not the best place for us also to put our children with complex medical needs. The other campus we've invested in is the Western Mass. Campus. It's actually a beautiful campus that sits on almost 200 acres of land. And we have used, state resources to build it into a really remarkable facility, 1 that could provide care for individuals with many types of complicated needs. It has medical gases on the wall so we can take care of those who are ventilator dependent. It is ligature free or could be ligature free in many of its areas to take care of those with behavioral health needs. It has a really great feel10194 to the campus and is integrated into the community in Westfield. It10198 is really a remarkable place. And so we are10200 trying to utilize that better to10202 make sure that we can match that campus with the needs of people in the Commonwealth. We've talked a lot about, over the past few months about the feasibility study that brought us to some of these decisions around Pappas. And I think important to10215 say that that feasibility study included the Tewkesbury State Hospital campus as well. And we have looked not just at Pappas, but also at Tewkesbury and the significant needs10224 of that campus. We'll say that in Tewkesbury, it is a enormous campus that has over 200 medical beds, nearly 200 psychiatric beds. It has 68 vendor program beds for people who are staying for substance use disorder. And then buildings all across the campus that house 27 vendor programs. And we look at all of those buildings that exist. The feasibility study told us that only 3 of the buildings are in good shape or better, and the rest10253 are in fair or worse shape. And that includes very important structures like the Dietary Building where we provide the food for everyone on that campus. And so there is a significant amount of public health10266 programming for individuals with complicated medical and behavioral health needs.
SPEAKER1 - Thank you, commissioner. We're we're in a pause right now.
Go blue. Alright. Great announcement.
SPEAKER19 - Sorry for the interruption, but to say we have evaluated that campus. There are significant needs across the Tewkesbury campus and significant public health programs that exist. And we want to10356 have we want to go through the same process with Tewkesbury to understand what is the investment that might be necessary here and how can we maximize resources for the most vulnerable individuals.
SPEAKER2 - Thank you, Commissioner. Next up, Representative Sally Cairns.
SPEAKER3 - K. Any other after school club changes we wanna go over? Thank you, mister chairman. Thank you, commissioner. Actually, doctor Goldstein, which is 1 of the reasons I just wanted to quickly ask if you could share some of your thoughts,
about what we're seeing on the federal level and these sort of reckless ill considered cuts to staffing everywhere from the Veterans Administration. I have a constituent who works with women at the VA,
completely uncertain about her status. People who are worried about being able to access10431 even a phone line at Social Security to10435 get their status clear. And in another category,
because the FDA and the CDC
couldn't or refused to hold a meeting, I guess the staff was prevented from holding a meeting. There are vaccines that flu vaccine that is being held up. Do you have thoughts from from that vantage point of your experience that helps to put this in context?
SPEAKER19 - Yeah. Thank you10467 for the question. And if you'll allow, I'll answer10469 from my perspective as a physician and my perspective as a federal employee for 2 years prior to being in this job.10475 For those who don't know, I was a senior policy advisor at CDC for the 2 years prior to joining the10481 state. As a physician, I'm incredibly worried about the impacts that these cuts will have. There is the impact of the financial cuts for sure. And I described some of that in my testimony at the beginning. But the impact of mass firings across health and human services will be felt by the individuals in the Commonwealth. The programming that these individuals supported is so critical to the work we do. And some specific examples, the entire program that supports maternal morbidity and mortality at CDC was dismissed last week. The entire program was10517 shut down. We no longer have the10519 individuals, their experience, their expertise, their support as we try to address what is an incredible tragedy, right? The rising rates of maternal morbidity and mortality here in Massachusetts and across the country. The division at CDC that manages immunizations, the Immunization Services Division, was summarily fired last week. That closure of the Immunization10542 Services Division, let alone the funding that it put out, but the support that it provided to states10548 and to individuals to know10550 that vaccines are safe, vaccines are effective, and vaccines are available in every community so that you can receive that vaccine. We are going to now be missing that support from the federal government. You mentioned specifically 2 meetings that were pulled down, 2 federal advisory committee meetings that were pulled down in the past couple of months. 1 being10569 a meeting by FDA's vaccines and related biologics advisory committee, BRBAC, and another being the advisory committee on immunization practices,10577 ACIP at CDC. Those 2 committees work hand in glove to help our country think about vaccine policy. They select the strains of influenza that need to go into the vaccines that are produced over the summer. And then they make the recommendation to the nation of who should receive that vaccine at what time and on what schedule. Fortunately for this state, we have other ways10603 to address those policy decisions. We have a Massachusetts vaccine purchasing advisory committee that is in statute that meets to talk about vaccines. Currently, it is specific to pediatric immunization, but we've proposed in an outside section to expand it through the adult vaccine trust to make recommendations on pediatric and adult vaccines. We are fortunate to have a really robust academic network here. Individuals who sat on that FDA and CDC committee and individuals who can help us think about the right recommendations, the right policy decisions. And I would also say we're very fortunate to be in a state that is really the home to life sciences in the country. The vaccine manufacturers for most of the vaccines that are recommended for children and adults exist here in Massachusetts. We have innovated and we produce the flu vaccine, the measles, mumps, rubella vaccine, the COVID vaccine. All of the major vaccines that we give to our children and adults in this country really do have some connection here to Massachusetts. And so while I am incredibly concerned as a physician and as a former federal employee about the cuts and the rescissions at the federal level, I do have hope that Massachusetts can be that beacon for all of us. It can make sure that we do what is right and that we make the right recommendations to the people in the Commonwealth.
SPEAKER3 - I thank you for that. And I'm usually pretty optimistic, But I have to say, I appreciate the determination that you're showing, but I feel as though all the might we can muster to hold the door, It will be blown open pretty soon, and we can prepare as best10708 we know how. But10710 I don't want us to10712 lose sight of the collateral damage that's gonna come our way. I I don't mean to10719 be negative or political or anything. I'm just very worried about it. So thank you. I hope you're10725 right.
SPEAKER1 - Just a quick status report for the10729 edification of the members. It's almost 02:00. We're on panel 3 of 10. So the chair, and I will Institute kind of the 1 question per per member, rule. If a follow-up is absolutely necessary, just please keep the preamble short and we'll get through this. We want to make sure that we get to every panel and we get all the questions asked. So with that, I'll turn it over to Senator Joe Commerford.
SPEAKER11 - Thank you, Mr. Chair. Commissioner, thank10760 you, for your opening statements and for all the values that you, hold dear, and are projecting,10766 through the work of DPH. You talked a lot about the importance of the public health infrastructure and now amid what we're losing at the federal level, right, what you just characterized and more, it seems even more, necessary that we maintain local and regional public health and all that they can do to ensure health equity for the Commonwealth. So in the budget, it's projected at $9,000,000 but I would love you just to expound on what the actual cost of supporting local and regional public health is and how you're getting it done currently. Because I do think that it's important for us to be under the weight of that, especially as Rep. Kearns said, I think so well, you know, right. Everything's at the door right now. And I believe these10817 folks, the local and regional public health folks are part of what's bolstering us10821 as a Commonwealth. Yeah.
SPEAKER19 - Thank you for that question. And thank you for10825 your support of local public health and your your advocacy for Safe 2 and its passage last fall. As you note, our local public health workforce is the front line. These are the individuals who are out in communities doing home visiting, helping with tuberculosis management, providing vaccination. They're doing blood pressure checks for folks who can't leave their house. It is really important that we continue to support local public health in the way that this state has over the past few years. As you note,10855 our state line item for local public health is10857 around $9,000,000 That's level funded in the fiscal year 26 budget or the proposal from the governor. But we provide additional resources to local public health. And we do that10867 largely through federal support. I want to be clear. This is federal support that we have already received and federal support that is here in this state that we do not anticipate being clawed back by the federal government, but10879 it is sizable. So, through both the American Rescue Plan Act and through the public health infrastructure grant at CDC, we're able to push out around $50,000,000 a year to local public health. That means that we can support the hiring of individuals and municipalities. We can do the technical10897 assistance, the training that's necessary10899 for them. We can provide them with the resources to start pilot projects and get them moving forward to show that they're effective in the local public health space. This is all at the spirit of the10911 original SAFE and SAFE 2. Right. Really giving local public health the tools that they need to do the work. In addition to that, nearly $50,000,000 a year that we're pushing out over this year and next year, we are working collaboratively across the10926 state and with municipalities to fund a local10929 public health data infrastructure to the cost of around $100,000,00010933 Now, that is American Rescue Plan Act dollars that the legislature had given to us to do this work. We are happy to do it. Local public health is eager for it. It means that we will take 3 51 cities and towns, many of which are largely operating now on paper and fax machines and putting things in the mail and transform it into an all electronic system that allows them to10957 send data directly to the Department of Public10959 Health and the and DEP, the Department of Environmental Protection. That will be a huge step forward for local public health and an investment that we need to continue to make so that they can maintain that system, invest in10972 that system, and utilize that system to its fullest capacity.
SPEAKER2 - Thank you, doctor. Before we get10982 back to the queue, I just have, 1 question. H 1 includes substantial decreases to the line items for behavioral health supports in the Bureau of Substance Addiction Treatment. Can you talk a little bit more about the reason for these decreases and what
SPEAKER19 - the programmatic impacts will be? Yeah. Thank you for the question. And I and I think also we had a similar question from Rep Moran earlier in the the session to the secretary. So, as folks know, there's around a $20,000,000 decrease in the total budget to the Bureau of Substance Addiction Services. What does that actually represent? It's actually a shift towards the department focusing on evidence based, effective and efficient programs, programs that work and programs that we know work better than some other programs that we've implemented. So a really good example here is prior investments in temporary low threshold housing that can cost us upwards of $100,000 1 hundred and 50 thousand dollars per year per unit, and a shift towards permanent low threshold housing that costs us on average around $40,000 per unit per year. That is a great shift in dollars. It means we need less. We have to request less of the legislature in order to do it, but we know that it is highly effective. Over the course of the past few years, we have seen over 600 individuals move into this permanent low threshold housing. We have a 95 percent success rate in keeping them in that housing, keeping them housed,11066 engaged with services in recovery, making sure that they11070 can move on with the rest of their life. And so the cuts that are11074 represented in that BSAS line item reflect us really thinking critically about what programs work and what programs don't and how can we shift to the more efficient, more effective and less costly programs.
SPEAKER2 - Thank you. I appreciate that context. I look forward to reviewing that. Next up, we have, Rep. Kilcoyne.
SPEAKER20 - Alright. Here we go. Thank you, mister chair. Commissioner, thank you so much for being here. I just wanted to briefly, touch on a response that you had given earlier regarding the Pappas facility and its, the the process by which you're going under. And I I understand that the Western Mass facility is is state of the art and new and and you feel that it would be11125 a good alternative. But I did want to pick up on, you know, some of the differences with the populations currently that are treated by the Papas facility, which serves children 7 to 20 2 from all of roughly 7 to age 22 all over the state. And you mentioned that in11140 the Western Mass facility, it is adults11142 of of all different backgrounds, including some of those who are, involved in the criminal justice system. A concern I have is that I've seen in, you know, other facilities that if you are if you have specific populations that you're trying to integrate, there can be many challenge for challenges. For instance,11160 if you are dealing with, populations that are involved in the criminal justice system, you may need a facility that has11166 to deal with frequent outbreak, lockdowns and have a far more secure facility where there is a potential for, greater, what's the word I'm looking for, where they may not be able to move as freely as they would say at a Pappas facility where many of these children are, as you said, of complex medical needs and are there primarily to get an education. So the campus is is not designed for that kind of population. So my question to you is, I know there's a working group that is going to be looking at these questions, but are you prepared to deal with the challenges that might be involved if you are trying to consolidate what is a very specific population at Pappas that serves a very specific mission with a wider population that could actually, due to the needs of those patients, create unintended consequences and even harm for some of the children that rely on and the families that rely on the services of Pappas?
SPEAKER19 - Thank you for the question. And I'll start by saying, I apologize if I misspoke earlier. Most of those individuals involved with the criminal justice system are either at the Tewksbury State Hospital campus or the Lemuel Shattuck Hospital campus in Boston. Western Mass Hospital functions much more as a, long term acute care facility for people stepping down from acute hospitals, mostly in the central and western parts of the state, although they come from all parts of the state. But that said, I think your point is incredibly well taken that integration of a new population into a hospital campus is really challenging. I don't want to get ahead at, Chair Feeney has left us for a moment, but I don't want to get ahead of the working group as he mentioned. There's no predetermined conclusion here. It's important for the working group to think about the challenges of integration of a pediatric program into a hospital that has traditionally served an adult population. We also have to match that though with what, who are the children that need the care? What are the resources that they need? And how can a facility match those resources? I highlighted before those numbers around 800 children with significant medical complexity and behavioral health needs. A large percentage of those are dependent on mechanical ventilation. They're dependent on a ventilator to breathe for them every day of their life. And we want to be able to provide a place for them to go. Right now, we cannot do that on the Pappas campus. And that has to be a part of the working group's discussion. Do we want to make sure that we have a location for these children who are ventilator dependent, who may need a long term acute care hospital, who may need a brief period of respite? And where in the state should we be able to provide11322 those resources?
SPEAKER2 - Thank you. Next up, we have Rick Zaras.
SPEAKER7 - Thank you, Chairman. Good to see you again, sir. You brought up Pappas and good work, by the chair and people to try to work with11343 you to keep that open. My concern is Poughcasset at the same time that Pappas was talked about closing, so was Pacasset on Cape Cod, which is the only facility that serves those people on the Cape And Islands. The last we knew there was a pause put on that as well, and there was supposed to be some type of, I think you called it a working group. So could you update us on that? What's the plan with Paccasset and the working group and any other thoughts11378 in that realm?
SPEAKER19 - I mean, if it's okay, I'm going to defer that question11382 actually to Commissioner Doyle. The Paccasset facility sits under the Department of Mental Health, not the Department of Public Health. And so I think she would have the latest updates when she comes to testify, where PICAS it stands and how that
SPEAKER7 - will move forward. Perfect. Thank you. Thank you, Chair.
SPEAKER1 - Thank you, Representative. Next question is from Senator Pavel Pallano.
SPEAKER21 - Hello? Alright. Testing, testing. Commissioner, thank you so much for for being here. My question is around 1 of the programs that you guys help support. I think DPH has, does incredible work, in my district supporting up to tons of, incredible programs. And, 1 in particular is around, gun violence, and I think which is, a priority for many of us. I know it's a priority for the Administration as well. It doesn't just affect, my district. It affects, you know, cities across the State where we're looking for. Ways to engage the community, train people, and mobilize folks around this issue. So we could, hopefully decrease it, 1 day, maybe end it. And, my, my11461 questions around, you know, I've, I've been seeing for the last couple of years that there's been, Ace, a trend of decreasing, this amount that is going to these, organizations that are doing, this type of work and, just wanted to understand more the strategy around that. And what are ways that DPH is doing to, sort of help these efforts,11489 even though that it might mean that,11491 they're receiving less funds in, the last few years?11495
SPEAKER19 - And thank you for the question, Senator, and for your commitment to addressing the threat of gun violence in our communities. I I see this as a public health threat. And I was actually very encouraged last year by the passage of the Gun Violence Prevention Law, which makes Massachusetts the the state with the, toughest gun restriction, in the nation. And I think that's really important,11516 but more important is that that bill recognized the importance of community based investments and community violence reduction, which is the strategy that11524 we take at the Department of Public Health. We think about gun violence not as a single act, but as as really a failure of us building the right community support. And so we have done, I think, a lot with the resources that we have been given by the legislature in the gun violence prevention space. But we've also had to make some necessary difficult decisions about how we fund things going into fiscal year 26. Part of that decision making was to think about what are the resources across the Executive Office of Health and Human Services And how can we work collaboratively across all of the programs? And so while there are programs that sit in the secretary's office focused on gun violence prevention and programs that sit within the department of public health focused on gun violence prevention, We're beginning to merge these programs at least in their strategy, in their investments, in the way that they materialize, that the approach to gun violence prevention. By doing so, we can do more with less. Right? We're not doubling up on individual, investments, but yet we're weaving together the right investments. And this collaborative approach really is gonna allow us to stretch the dollars as far as we possibly can to make sure every community has the resources that it needs and that we're appropriately spending significant dollars in the communities with the highest rates of gun violence. I think we also have to just be cognizant that we're going to be doing this at a time when federal support for gun violence prevention is going away. I talked about some of the rescissions and the firings at CDC. 1 of the major firings happened, was the closure really of the National Center for Injury Prevention. The Injury Center funded all gun violence prevention work out of CDC. That center no longer exists. It doesn't have a center director. It doesn't have individuals who work for it. I don't know where that funding will go. And so we're going to have to shift our approach as that federal money dries up and as our federal support goes away to make sure we continue to appropriately invest state resources in the right communities.
SPEAKER21 - Just a follow-up. Thank you. When you're saying, merge, different programs, you mean different programs that are being executed in certain areas, that they're similar programs, that are doing this work in different can you just give me an example so I can understand a little bit better?
SPEAKER19 - Yeah. I think merge is probably too technical of a word to use what I'm describing here. I'm just describing that the 2 teams are getting together. They're sitting in the room. They're talking about shared approaches to gun violence prevention. They're thinking about how 1 program can invest in 1 community and a different program invests in a different community so that we take the resources that we have and spread it as widely as possible. And and
SPEAKER21 - and that makes sense. And and are, are these teams are coming together and having these conversations? Are they gonna be releasing some type of report, some, you know, some type of document, showing sort of what the outcomes were? So they're, they're all focused on the data and the outcomes. And certainly we, report back
SPEAKER19 - to the legislature on the outcomes of our efforts. But I think probably more relevant is that they're going to release some funding opportunities over the next year that are going to, allow us to make sure we get the dollars out the door into the communities. And that's a reflection of their shared work together and their commitment.
SPEAKER21 - Yeah. Thank you.
SPEAKER2 - Thank you. Next up, Rep. Garcia.
SPEAKER13 - Thank you, Chair. Commissioner, thank you so much for your continuous leadership. Well, my question is actually, I'll start off with with saying during my time on the joint committee on public health, I really appreciated the discussions around the renovation of the state public health lab. And I know it's been the theme today. Obviously, there's a lot of federal, cuts that are going to take place. And my question to you is, do you anticipate any impact on the plans to renovate this, state public health lab?
SPEAKER19 - Thank thank you for the question. And for anyone who hasn't visited the state public health lab, let me know. We are happy to11763 arrange a tour. It is nearly complete, the renovation. Thank you for your investment over the past few years to11769 support that campus, the newly renamed Alfred de Maria Public11772 Health Campus. You know, the federal funding that was in the news over the11778 past couple of weeks did include significant dollars that went to our state public health laboratory. And they weren't dollars specifically about the renovation of the11786 building, right, Moving fiber optic cables and shifting from floors. But they were about supporting the infrastructure needs of the campus, buying equipment for the campus. As we did the renovation, we realized some equipment had reached an end of life and we have to find dollars to support replacing that equipment. That's what the epidemiology and11806 laboratory capacity grant from CDC11808 was intended to do. That's the grant that had been in the news over the past couple of11812 weeks. Fortunately, thanks to the leadership of the attorney general, we have a temporary restraining order in place. Those dollars continue to flow and we will continue to11821 spend them appropriately to make sure we're investing in a state public health laboratory. But if that temporary restraining order were to fall, or if11829 at the next hearing an injunction is11831 not granted, or if at some point in the future an appeals court or the Supreme Court reverses the decision, there will be dollars that we were intending to use to help finish the renovation, federal dollars that will no longer be available to us.
SPEAKER2 - Thank you. Next up, Rep. Sabadoso.
SPEAKER13 - Thank you so much, Commissioner. It's really just been wonderful to hear your responses and how proactive you are being in light of all the many things that we're facing. So I wanna just really, truly say thank you. And I have another Pappas related question for you just to add on to the file, but with a slight Western Mass focus this time. So, I appreciate your comments about the campus. I grew up in Westfield. It is in fact a lovely place. But I, I wonder about the number of patients who are currently at11886 Pappas who will actually be eligible to transfer to, the Western to the facility in Westfield to Western Mass. And I I also wonder about the nonmedical supports. I know Pappas offers, as my colleagues have stated, educational opportunities. And I don't believe that Western Mass does. So I'm just curious as to how you view this.
SPEAKER19 - Yeah. Thank you for the for the opportunity to expand on this. And again, I'll take this as an opportunity to echo what you said. We are not there are no predetermined conclusions here. We want the working group to do the work and to understand these 2 campuses and11917 the future of pediatric care in the state.11919 But the Westfield campus does offer us a lot of really great opportunities. So currently11925 right now there isn't a pediatric program, but we are entertaining how we would build a pediatric program that starts with our commitment to education for every individual who comes in. And so we are working closely and we'll continue to work closely with DESE to make sure that we've thought through how do we educate any individual who may be in Westfield? How do we continue to educate anyone who's in Canton on the Pappas campus? We also want to think really creatively about the resources that existed in Canton, both on the campus and around the campus that might be replicated, recreated, or reimagined in Westfield. So I think folks know there's currently an Olympic sized pool on the Pappas campus in Canton. Within a couple of miles of the Westfield campus,11969 there are multiple handicap accessible11971 pools. And we would like to begin discussions with those pools and to talk about, can we bring folks11977 there? Can children come over? Can we11979 continue the aquatic therapy? I mentioned the nearly 200 acres11983 that exist in Westfield, which11985 would be ripe for a lot of outdoor programming. Programming like farming and gardening and thinking about how we can utilize the outdoor space to help folks gain independence and move forward in their rehabilitation needs. So, while there's, not an apples to apples comparison here, it's not 1 for 1, what's in Canton versus what could be in Westfield. We want to use the working group and the community to identify the reimagined way of providing pediatric care in12012 the state.
SPEAKER13 - -Uh, to follow-up, I also said, if you do know how many children would actually be eligible, though, to complete that12022 transfer as well?
SPEAKER19 - That's that's a hard question to answer right now. As12026 I said, there are 32 children on12028 the Canton campus. We continue to admit and to discharge because we're living through the spirit of the pause.12034 And so, 6 months from now, 12 months from now, 18 months from now, I can't tell you how many children will be on the campus. We really do wanna see folks progress through their stay. We hope that everyone gets discharged to their next forever home, whether it be a group home, back home with family, or living independently.
SPEAKER2 - Thank you. I12055 have, 1 question here, in my notes. Over the last several years, the early intervention services line item has reverted roughly 1 to 2000000 dollars each year. However, this year, H1 includes a $6,800,000 increase for the line item. Can you talk a little bit more about the increase, the reason behind the increase and does DPH expect to revert any funds for FY '25? Yeah. Thank you for the question.
SPEAKER19 - And I'll answer the second 1 first. We do not expect to12079 revert anything in fiscal year 25. And that has largely, the reason for the increase as we go into fiscal year 26. A lot of that has to do with the increase in, the salaries, the12090 reimbursement for the individuals who are working in early intervention. There has been a sizable increase in salaries, which is great to see. It means we have, folks who are coming into the workforce. They're remaining in the workforce. The12103 turnover that we saw before has really slowed down, but that costs money to continue to be able to pay individuals at those higher rates. And that is part of the increase. The other thing to note is that, there was an increase in the overall the rate for the services for EI. Not all private insurers match the state rate. And in fact, 0.32 did not match the state rate for the first 3 quarters of the fiscal year. As the payer of last resort, we are responsible to make sure that kids can receive all of the services that they need as they enter early intervention. That costs money,12136 and that is part of why you're going to see,12138 no reversion likely this year in fiscal year 25 and likely an increase in our total, responsibilities in fiscal year 26.
SPEAKER2 - Thank you for that context. Next in the queue we have rep Russell Holmes.
SPEAKER4 - Good day. My question is in regard to the Shattuck.
Obviously, we put out a proposal 1 response. What a response with the community and how they responded. And so I know there was a little pushback or quite a bit of hesitancy with so much happening at Franklin Park. But now that, the Hawaii Stadium decision has been made, I'm trying to figure out, can we move forward12186 on where we are in this process? And can I know, you know, my understanding was there was some hesitancy because there was just so much happening at Franklin Park? Can you give an update on where we are? If you're gonna do a new RFP, what what's gonna happen with the Shattuck? That would be great to understand. Or what your plan would be. Not that you're picking up first and right now, but what was then we're all in the process.
SPEAKER18 - Thank you, David. And then I'll start with some independent, and I can say about12220 that.
SPEAKER19 - We'll move from 1 Street to East Newton Pavilion in the coming 18 to 24 months. Not going to give you a specific timeline because construction projects are unpredictable, but we will move the campus from Morton Street to Newton Pavilion. That, there that begs the question of what will happen to the Morton Street campus following that move. And I think what I can say about it is that we've all learned a lot through the past year and a half, the past 2 years of, the community engagement around this project. And what is necessary is going to be a community engaged dialogue about, what should we provide on that campus? We have to do that taking into account what we're seeing with substance use disorder, with homelessness and housing insecurity all across Boston. And recognize that currently, the Morton Street campus provides a lot of support to individuals with substance use disorder and those experiencing homelessness. There's a methadone clinic on the Shattuck campus right now that's incredibly important so that we can continue people in care and we can make sure they can access recovery. There are, low threshold beds that exist there for people experiencing homelessness. We wanna make sure that there is a location somewhere in the city, hopefully in12294 that community, where people can access that type of support and have a place to stay overnight. So we I don't have specific answers for you about what the campus is going to have after this whole process, but I do think this gives us an opportunity to think about the holistic needs of Boston, recognize all of the possible locations where we can provide those, that type of care and then utilize the Morton Stream campus to the best of its ability.
SPEAKER4 - Sorry, my follow-up is this, right? So what I've said to the mayor is the same thing I'll say to you and to the governor. We don't get these jobs to do easy things. We need to have the courage to do what is hard, even when people are loud. So people will be very loud, and then all of a sudden we stop. That is not why we have these jobs. And so, as I have said in other meetings, if they want to elect someone else, let them elect them. But we have been elected to make hard decisions. So I'm just hoping you express that to the governor, the entire team. This is not easy, but this is the job, and and this is what we need to go and do. Thank you.
SPEAKER1 - Thank you, Representative. Commissioner, I know we we talked a lot this afternoon about Pappas, And I know I've talked to you about it and I can sense that you feel the same, as us with this passion, to make sure that we're treating these kids right. These are,
miracles happen at Pappas. I've said frequently, miracles happen to these to these kids, these students that deserve it more than anybody. The, the passion, the advocacy comes from, it comes from a place that I hope you can understand is, you know, very, very few times in this job. Do you get stopped in your tracks? We're constantly going and we're doing things like this embedding line items and budgets and, with Pappas. This is 1 of those times certainly in my career. And I know many of my colleagues share that as well. Very, very concerned, about this pause and what the, real work, you know, that needs to be done by the working group, whether or not that's going to result in, in any changes in the decision making. In speaking with, many of the staff and the family members up there and former staff and community members, APIS is more than just a hospital. Right? It's a school. It's a community. It's where kids can, you know, go outside in nature and and be together and and learn, and they thrive there. They really do. They thrive. I've seen it firsthand. 1 of the concerns I have is as the working group continues to do this work and we have these conversations, is that decisions are being made down the road. For instance, we have educators. Right? Again, more than just hospital school, incredible educators at Pappas. Are they going to be held on beyond the end of the school year? Or is there a plan to to lay them off? And and I mean this question sincerely, just, you know, you must be thinking a few months ahead and and curious if if there is a plan for that. What if the working group comes back with recommendations to say we're going to do X, Y, and Z at Pappas, you know, in Canton, but by that point you don't have any educators left. Right? Is there a plan by, by the administration to actually keep those teachers beyond the end of the school year now?
SPEAKER19 - So I might defer that question to DESE because, as you know, DESE operates the school at the Pappas campus. But there is a commitment from the Department of Public Health to make sure that for any kid that is in Pappas, in the Canton campus of Pappas, that we are, tending to our obligation to provide education to that individual. So it is ultimately up to DESE how they want to provide that education. And I I don't want to speak for them around what they will do with their workforce and how they'll manage the school, but we are committed to making sure we meet that constitutional obligation to provide education to every child in the Commonwealth. And if that means they're in Canton on the Pappas campus and they need schooling, we will work with DESE to get them schooling.
SPEAKER1 - Thank you, Commissioner. Seeing no other questions, we've gone through our list. We really, really appreciate your time today. I know it's been a long day for you. Thank you. Thank12554 you, Doctor. Goldstein. Thank you, Matt.
SPEAKER4 - We
SPEAKER1 - appreciate your time. Thank you.
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