NC Senate Health Care Committee meets to discuss Medicaid expansion bill :: WRAL.com

the House bill. That’s right. It’s amendment and this is for discussion only today you all have had the opportunity to ask a lot of questions and then we’ll hear some from the audience. Thank you Senator. Good morning. Um and thank you Senator brit and Senator Bergen for joining with me in this effort and Senator Berger has taken the lead on it. So there’s been a lot of work put into this. Our staff has been amazing. Um, so I’m just gonna go through hit the high level the 30,000 ft view and then we will take any questions that you might have. Um, this bill, uh North Carolina health works is what we’re calling it and it will expand coverage to those folks at 100 and 38% of the federal poverty level. It’s a technicality, some people say 1 33 but then there’s a 5% edition. And if you need details, uh jennifer Hillman will explain it. I can’t explain the details but it will be effective six months after passing of the budget, it will be paid for through a assessment um, in the hospital there will be no impact on state budget, has no impact on that at all. There is a program called I think it’s been out a couple of years but we have not utilized it in the past. Healthcare access stabilization program shortened to HASP And it allows hospitals to increase their existing assessments in exchange for drawing down more federal funds. So there won’t be a cost to the hospitals as well. The estimated um the minimum that we believe will, there will be revenue coming to the hospitals is $600 million dollars through this program. Um there will be a federal infusion of $1.5 billion 1.7 billion. Somewhere in that range will come to North Carolina over the next two years. Uh and the legislature will have the authority to appropriate those funds. There are two stopgaps in this in this bill. If the assessments do not cover the cost to the state, DHS secretary will have the authority to withdraw us from that expansion. Um that expansion program and if the federal government should reduce that 90% reimbursement rate, it will also stop that expansion and many of us and probably many of you in here. Excuse me And I know you’ve heard me argue against any Medicaid expansion for many, many years times are different now we had budget uncertainty. Medicaid was a mess when we first got here. When I first got here we were filling a budget hole of a billion dollars. Thank you sir. Part of every budget session we had huge budget holes to fill Medicaid is stable now. We have stabilized for quite a number of years. Um, and then we were going through transformation and so I have said many times over the last several years that I will not talk about any Medicaid expansion until we finish Medicaid transformation. Get through that and see how that’s going to work. It has worked remarkably well, we think the time is right now, it’s the right thing to do for the state, it’s the right thing to do for our folks who live here, who are low income, there is a work requirement in the bill. Um and I know some of you will question, we do have to get um see if we have to have a waiver from CMS in order to initiate those work requirements. Um and that is included in the bill. There is con reform in the bill, it is not a repeal, but it does make some changes to the current process. There are two pathways in the bill to getting the certificate of need, the services that will still be subject to the same regulations that we have today are air ambulances, emergency rooms, adult care homes, nursing home facilities, I cfs, linear accelerators, gamma knives and P. T. Scanners, pathway to we are carving out certain facilities equipment from the traditional con application that is based on what is needed. Um As Senator Berger said in our press conference, he’s not comfortable with the government deciding what is needed. So what will happen here that will still be subject to licensure that will still have to go through an approval process that will have to prove that they can perform that they can develop those quality measures, but they will not have to determine a need. It will shift the quality of care rather than need. The con exemptions, we have some monetary thresholds that we’ve we’ve also raised um the exemptions that are in the bill conversion of acute care beds to psych beds will not need certificate of need substance abuse treatment centers. MRI’s ambulatory surgery centers raising the threshold for replacement equipment from two million increased to four million. And it allows healthcare providers organizations to really relocate a calm approved project within that same region without having to go through an additional certificate of Need process. Um It also limits the appeals process. Currently if you have a bidding process and you have applications for certificate of need and you get awarded that certificate of Need, anyone can protest the bill will reduce that down to only people who were involved. Only people that were involved asking for that certificate of need can protest someone from the outside cannot come in and protest an award that they were not a part of the Save Act is in this bill and we talked at length about the Save Act last session and session before it’s been worked on for years in this body. We think this is the time to move it forward. It will how it defines advanced practice registered nurse as an individual licensed by the north Carolina board of nursing as an advanced practice registered nurse within one of the following roles. Nurse practitioner, certified nurse, midwife Clinical nurse specialist or certified registered nurse anesthetist. And um I know there’s been a lot of conversation around this particular piece, particularly the crn a piece. I want to let you know that 34 states have been doing this for a number of years where CR enos have full practice authority. Um Currently um the C. R. N. A. S. Are not allowed to practice at their full practice authority. But we have um I forget how many but there are More than 100 I think 140 locations facilities in this state that have nothing but C. RNA is they have no anesthesiologist. So we are we believe that the changes in this bill will be able to will be able to recruit more people particularly in our rural areas will be able to recruit providers by expanding their authority to practice in those areas. Um This bill amends the definitions of terms used in the nursing practice act. It adds definitions for advanced assessment, advanced practice, registered nurse uh Practice of nursing as any of those um Advanced practices. I just went through. It amends the components listed that defined the practice of nursing. Um uh It clarifies some nursing board and medical board clarifications. It requires the governor to submit an opt out letter to CMS within 30 days requesting an exemption that allows hospitals ambulatory surgical centers, critical access hospitals and rural hospitals in the state. The maximum flexibility to obtain Medicare reimbursement for anesthesia services in a manner that best serves each facility and their patients and their communities. So hospitals don’t have to change a single thing that they are doing. They can continue with their business practice model as they are today. Also included in this bill is Senate Bill 505, which was the medical bill, um transparency what we called surprise billing. And we went, we had that in our healthcare uh committee last year as well. It requires all contracts or agreements to um as an in network facilities between an insurer offering health benefits in this state that they will notify that patient when you make an appointment with your provider. If there is, you go to your hospital and they’re in network, you don’t expect to get a bill other than your copay or what you’ve paid. And it doesn’t work that way. Every one of us in the Senate. I’m sure I have lots of them. So I’m sure that my colleagues have as well where my where my constituents call and they’ve gotten a surprise bill for thousands of dollars that they can’t pay. It happens all the time. This just says it doesn’t change anything. Doeses’t say they have to be in network. It simply says you have to let that patient know that they may receive a bill and it has to be done within 72 hours of when that appointment is made Or as soon as possible if it’s an emergency or if there’s not 72 hours for it for it to take place. Um It sets um requires the notice to include all of the healthcare providers that will be rendering services who are not in network. It also has telehealth in it and we’ve had a lot of conversation about telehealth through the pandemic telehealth has been used widely. It has been opened up and it has been very successful. Many patients love it. Many providers love it. So this bill um opens up the tele health. It’s it’s quite lengthy so I ask you to um read through it and staff can tell us details if we need to know more about everything that’s in here. But I’m happy to answer any questions. I think this bill is a, it’s a hospital rescue plan. Almost our hospitals have had a really tough couple of years through the pandemic. Um This bill will provide additional funds for them from the federal government. It is not costing the state any money. We’ve got stopgaps in there to make sure that that doesn’t happen in the future. I think the time is right. We have um and I’ve been a huge opponent of Medicaid expansion as I’ve said before, but times are different. It is a very different policy today than what we were looking at even a few years ago And most of the people already on Medicaid are already working. I think it’s something like between 60 and 70% a member of that household is already working. So they’re just the working poor, they don’t qualify for benefits on the exchange, they make a little bit too much money to qualify for Medicaid. Um Senator burger used the example of a mother working full time Making $25,000 a year. She can’t qualify for the exchanges because she doesn’t make enough. She makes too much for Medicaid. She has two or three Children. They are covered under Medicaid currently, but she is not. These are the people that were trying to help. We want to make it possible for these people who are working, trying to take care of their families to have the medical care that they need and they don’t have to get treatment at the emergency department, which is what they’re doing now. So thank you all. And I’m happy to answer any questions with the help of our staff. Thank you. Thank you. Senator. Before we do that and open it up for questions. I do need a motion to move the amendment promotion motion. I think you had the motion up and then you had the second on their all in favor say, aye. Any opposed. All right now, open up for questions. What I would like to do is if you’ll get mine or Connors or Debbie’s attention. Uh So we can move it along. One question one follow up and then we’ll go through and come back around. So everybody will get multiple opportunities. Senator Robinson, You’re 1st before I make uh asked the question at first I want to commend both of you and everybody else and Senator Crawford, I hate to say I told you so in terms of the working poor but you’re not having to do that, I have to do that because and I thank you uh for finally moving forward on this to take care of working poor people who need healthcare access. Uh So I I just think that’s a commendable thing. Finally for north Carolina to do, we need to take care of our people. So thank you for that. The question I have I’m gonna ask one. Then I do have a couple of not about that section. But in terms of the C. O. N. Can staff explain that a little bit more in terms of you, you said what it excludes? And do you want to do it or do you want to answer? Well, well she’s asking for staff so they can get more Jason Moran bates, legislative analysis. What this does for the most part is it removes several things from Certificate of need review. Um Chemical dependency treatment facilities, ambulatory surgical facilities, psychiatric beds. Chemical dependency treatment beds. Um And M. R. I. Scanners would be removed from certificate of need review. The threshold for replacement equipment would be moved from $2 million $4 million. Um uh replacement renovation, relocation of equipment um would also be exempt from Certificate of need review. Uh There will also be some changes made to the current public hearing process. And I can go into detail on that if you would like that. Senator Robinson follow up. No no that’s okay. I had one other in that but I wait My turn for the next one. Senator would would you have your hand up? No no no. Okay. Who else would like to ask the question? Great. Great. Great. Great. Great. So 11 in terms of let me move to another area and I fully support nurses. I’ve hired them to do a great job. I want to know are we giving consideration to raising the requirements in terms of limits for medical liability coverage? Has any discussion gone to that because when nurses move up the level in terms of prescribing drugs etcetera, that’s a different level of liability. So has any discussion going into increasing the need or the limits for medical liability. It is not included in this bill. That will be up to the nursing board and their practice authority. Okay So we might recommend that. And and someone from the nursing board maybe here that could go into. Okay, we will come to them in a minute. Okay do you have a follow up and uh the other concern I’ll expresses in terms of nurse and Methodists and like I said I support nurses. But if I’m getting anesthesiology for any procedure and I’ve gotten it. I do want that to be under direct supervision of a physician. So I’m concerned about some clarification. Some amendment in that particular particular area is one of the areas of concern that I have. And I think most people who have undergone any kind of surgery or anything if it’s serious and you’re getting that at your and my age uh want to make sure I don’t know how to take. Uh Mr. Chairman uh Center Robinson. Um As I said earlier um most of the procedures that are done the majority are done by a. C. RNA. And and and I’m gonna share a story. My husband had a colonoscopy recently and they can do it with the supervision of a physician. Um So the physician was the gastroenterologist and he’s a friend of ours. So we were chatting and I asked him I said so I noticed you used C. R. N. A. S. And he said yes I said so you supervise her? He said heavens no I don’t supervise her. He said I haven’t looked at anesthesiology since I was in medical school. I wouldn’t know what to do. She does it all on her own. So that is not supervision. It is not and most C. R. N. A. S. Are in that position where they’re working with the physician and not directly with the anesthesiologist. There are 141 137 facilities in north Carolina that have no anesthesiologist only see RNA. So it is done every day and 34 other states have already done the advanced practice. So it is just as safe. There is study after study after study that it is just as safe with the Crn A. As it is the anesthesia but there’s room for all of them. Well my my concern still goes forward. I have a I know a lot of nurses, a lot of physicians and chief of anesthesiology is A. An M. D. And I just think that supervision is critical in terms of having physician supervision. Those are only concerns I have right now. So thank you. Thank you. Um Mr Chairman I’d like to make some comments and then a question I can’t be here tomorrow because we’ve got a son graduating from 8th grade and thank you very much that’s my 5th 8th grade graduation including my own. You’ll be good at it. I don’t know. Uh So um kind of the dovetail on Senator Robinson. I do think that as we kinda move forward there are distinct differences in the different types of nurse practitioners whether we’re talking about C. R. N. A. S. Versus Fn. Ps. And and the scope of practice. So I do have some concerns in that regard um with respect to rural access and and I want to say respectfully. I know everyone has worked really long and hard on a lot of these issues. Um The studies tend to show that that non physician providers so and P. S. And others, even in those states that have independent practice are more likely to practice in the same geographic locations, physicians and that has a lot to do with the economy, education and things that don’t really relate to to the practice of medicine. Another concern I have is really training. If you look at a lot of the states that have moved to an independent practice for nurse practitioners, there’s a transition period much like we did with phds several years ago and if and I don’t know how to slice and dice two different studies. Most of the studies that I’ve looked at really really focus on particular conditions, disease management, um psychiatric care and things like that when we’re talking about safety. Um And I don’t know which one of those studies took place in states where they had transition programs and by transition, I mean 9000 hours a transition. A certain number of years under supervision. Versus what I think this bill does is which says that essentially if you’re an mp, you you have the full scope of practice. Um You know, it concerns me because, well I have an intense amount of respect for nurse practitioners and nurses. My life’s an RN um I do have concerns about training requirements. A physician goes through 10, 15,000 hours of residency. A nurse practitioner goes through. I think 507 150 depending which program there, in which leads to another question of standardization. Uh Medical schools have much more standardization and rigor in those contexts. Uh You can do nurse practitioner school online, uh you have clinical requirements but but it’s different. Um I have a lot of concerns that that I know this is just for discussion, but I really think that we should take a step back and look at this differently. Um Look at FN PS versus C. RNA is, look at what the what the transition period would or should be in the context of training. I also think we need to look at what’s going to happen in the future in europe right now, you’ve got nurse practitioners doing surgery, so you can have a nurse practitioner doing surgery and a nurse practitioner on anesthesia handling the anesthesia. And I don’t know that that is the path we want to start down. I know it’s controversial over there right now. Um But I do think we need to take a step back. I do agree that F. M. P. S. Um under certain circumstances we need to start looking at some of those issues um and how we move forward with independent practice on that perspective. But I think we’re going many steps too far with the language that’s in this bill right now and we should take a step back and look at it differently. Thank you. Anyone else? Senator Ward, thank you Mr Chairman uh Center Kravchuk and Center Bergen and others. Let me just say thank you all. Um those of us who have been, I’m this is my 10th year now here. So um I’m just delighted that you all have picked up this ball that some of us have wanted to move for for 10 years now and I’ve got at least in the red zone to use the football analogy. Uh and I hope we can pick up the ball together and carried across the goal line and and get the care that north Carolinians needs. So let me commend you all and thank you all. I I know you have headwinds and a lot of different places. I won’t eliminate our enumerate those today, but thank you and uh center chronic, thank you. I know uh your thinking has changed a lot on this, so I just want to publicly in front of this body say thank you for the work and your thought on this. Having said that now, the question, I’m a little worried about your friend, the physician who hasn’t thought about hasn’t thought about anesthesia in a while. We might need to call the medical board on that. I want my doctor to think about that since he’s been out of medical school, whatever. Mr Chairman. I’ll bet if you ask a lot of physicians, they would all say the same thing. That’s not their expertise. I well I might disagree a little bit with you about that. So maybe because he was a friend, he was maybe a little more blunt of all the things here. I do want a little more knowledge because I was trying to scan the bill since I’ve just seen it. Um the C. O. N. Um protest. Um you had limited that and I don’t have an issue with that. I just want to understand that. So um only those involved in the specific request or actions. So I don’t know if that’s you or or Jason someone can help me understand that. Um Currently you can go through that certificate of need process. I’m sorry, Mr Chairman. Yes, ma’am. You have the floor. Um Currently you go through that process. People who are not even involved in that process. You may say you’ve got four entities vying for it. Um Currently, if you’re awarded that certificate of need, anybody can protest that wasn’t even involved. Sure in this bill going forward, only the people who were involved in that process may protest. Maybe I’m just missing it. Is there a language that defines who was involved I guess is what I’m trying to understand. We’ll call on Jason, we’ll call on Jason for that. Jason. I’d be happy to direct me to the lines. I’m happy to read it. Jason Moran bates legislative analysis. If you give me just one second Senator what I can find that for you and follow up while he’s looking. Um Let me just say um I would just join with uh some of the concerns raised by Senator Robinson sent early um And I just think clearly around the advanced practice nursing. So I’m I know we’ll have conversation around that. Um So I appreciate their comments, so I don’t have much to add there. Let me just say this on all of these though. Um Again I thank you all for starting this conversation um and with this bill because I know how much work has gone into it, so thank you and I look forward to a good robust discussion in the weeks ahead. I don’t know what your timeline is and I’d be curious to have that conversation with you as well because I think this is worthy of a lot more conversation um because clearly some of us have plenty of thoughts of this and we’re not part of the drafting of the bill. Um But but I hope you all will be open and receptive to um to the conversation, particularly given the work the Medicaid expansion committee has done to this point, so thank you. Yes, thank you mr Chairman. Um Thank you Senator Woodard. And yes we will have lots more discussion going forward and even though this is a new bill that we’re presenting today, most of these parts we’ve seen in past sessions uh the Save Act has been around for a while. Uh tell the help we’ve discussed at length. The con reform has been over and over again discussed. Um Senator heist and I started working on this the first year I got here. So um you know very little is new of course Medicaid expansion we’ve talked about but that is completely different now than when we discussed it before. So even though it’s a new bill as a whole, the parts of it are not new. But we we will be we will work on it going forward and be glad to include you in anything that we do. Jason Moran Bates is ready with your Jason Moran Bates. Legislative analysis. Senator ordered the term affected affected applicant is defined on page 19 and that’s lines 14 through 18. Mhm. Any other questions before we go to the audience question? Just procedurally. So if if all this kind of moves forward, does it, does the nursing boys go through like a rulemaking process or how does all that kind of work? I believe that’s correct. But we’ll refer to two staff to clarify what that process will be. Jason Moran Bates. Legislative analysis. Yes, that is correct. There are provisions in the bill that would require rulemaking any other questions. I’m going to open it up to have a follow up. We have another one that brought up another question in terms of the composition of the nursing board. Does it include provider in positions. I don’t remember that. I don’t think you’re talking about the nursing board. The members are that will have this responsibility. I will include physicians on that. I will refer that to Jason as well because I’m not sure who the members of that board are. While he’s looking that up. If anyone didn’t sign up to speak, I only have two names. I don’t know if there’s another list But we’re gonna go till 1130 right? If if if if not we’re going to cut it off on a journey in a minute. But but if anybody else wants to talk, if you will. Okay. Yeah, we’re we’re not going to belabor it were. But I do want to anybody who has a question I wanted. I want them to have an opportunity to ask. Okay. Alright. Jason Moran bait. You’re recognized. Jason Moran Bates, legislative analysis, GS 90-1 71.21. A The nursing board shall consist of 14 members. Eight members shall be registered nurses, three members shall be licensed practical nurses. Three members shall be representatives of the public to answer your question. Senator. Okay. At this time I have Alison Farmer from merger Ortho first and Jordan roberts from the john locke foundation second and then we’ll get another list up here. So if you wanna go ahead and step to the microphone. Yes. And you’re gonna have two minutes. But state your name, who you’re representing and then start talking. Thank you. Good morning. My name is Alison Farmer and the ceo of emerged Ortho emerged. Ortho is the largest physician owned orthopedic practice in the state and the fifth largest in the country. Thank you. Chairman Bergen and the members of the committee for allowing me to speak to you about the proposal in front of you today, emergent Arthur believes it is crucially important for the overall health of the state for everyone to have access to coverage and two providers to have the capacity to care for them efficiently. We support expanding Medicaid to meet the healthcare needs of more individuals across our state. While I’m looking forward to reviewing the details of this proposal, I understand that there are also provisions in this amendment relating to certificate of need merger Arthur prides itself on offering our patients the highest level of patient centered orthopedic care and we’re constantly seeking opportunities to enhance our services to our patients statewide. This includes ensuring that they can obtain adequate services when they need them at a convenient place and the best value. Often the lowest cost. The need to reform C. O. N. Laws for ambulatory surgery centers has been a topic of debate for years and emerged. Ortho supports this effort. We also want to highlight the real need for lawmakers to loosen restrictions to obtain certain advanced imaging units. Not all scanners are regulated to the same degree as M RI undersea. Oh in law for example a Suen is not required specifically obtain an x ray machine. We’re constantly monitoring opportunities to apply for certificates of need for M. R. I scanners and this includes mobile scanners that can reach more underserved areas and operating rooms through the competitive application process. The existing method obstructs some patients from receiving the level of health care they could and should be receiving across the state with our offices coming from Asheville to Wilmington’s. I applaud the bill sponsors for including provisions in this proposal that will better have a better pathway for increased access to high quality, lower cost surgeries and M. R. I. Services merge. Ortho also formally supports efforts to ensure coverage for telemedicine services and we look forward to continue to work with you all of these important changes. Thank you so much. Thank you Mr Jordan roberts and then chip bag will be next. Thank you. Good morning. Committee members, thank you so much for the opportunity to speak. My name is Jordan roberts, I’m director of government affairs for the john locke Foundation. First off, I’d like to say, I appreciate all y’all’s work on this. It’s an important issue. Health care costs and lack of access in our state um Having not reviewed the bill in its entirety. Just listening to the press conference. Um we support about 75% of this bill but we cannot support it with Medicaid expansion and it going forward. Um we believe that regardless of the supply side reforms that are in the bill, the um State accepting a 10% share, threatens the budget stability that that you all have done such a good job on keeping our budget and uh spending in check. Um If if expansion happens, there could be upwards of 3.3 million people on Medicaid, that’s one out of every three in the state and we don’t think that’s a sustainable program going forward. Um We believe that the Medicaid program should be, should be kept for the populations of it. Designed for the Affordable Care Act, certainly had some shortcomings and we don’t believe the state should be on the hook for pricing out a lot of the health insurance market. Um so, so what then we believe that the supply side reforms looking at alternative insurance products all the way to go about this lowering healthcare costs, putting downward pressure on prices for insurance is the way to go. Um and we believe that uh you know, there’s too much focus on on coverage instead of care. We need to focus on folks getting access to the care they need rather than just having an insurance card. So we commend you, but we cannot support the bill in its current form. Thank you sir. I heard 75%. Yes. Is that what? I just never just tease it. He’s a great guy. So I just have to tease him a little bit chip back, You’ll have to thank you. Thanks Senator Bergen, I appreciate the opportunity to speak today. I’m chip maggot, Excuse the frog in my throat. Uh Chief executive officer for the North County Medical Society, representing a little over 8000 physicians and phds from across the state of north Carolina in every specialty that you could possibly name. Uh huh. This is a great day. Uh this is a great day because I joined the course of people commending you for recognizing the benefits of Medicaid expansion and the uh the way that we can help the working poor in the state of north Carolina. Uh, we appreciate the time that you’ve taken to go through this analysis and recognize that this money is not a new burden on the state of north Carolina, but it’s money that is due to the state of north Carolina to serve the citizens of north Carolina. That being said, you are all aware of a significant concern that we’ve communicated about with you on a regular basis. And even very recently and I appreciate Senator Lee and Senator Robinson’s questions about the inclusion of the Save Act in this bill. At this point in time, the North County Medical Society continues to hold significant reservations about the training, both regular training program and graduate postgraduate training program for nurse practitioners or a P. R. N. S. Uh as well as the broad scope of practice that is included in this bill and in the Save Act as it was originally filed. We are opposed to that. We continue to want to work with our nurse partners to make sure that the best possible care is provided for all citizens of the state of north Carolina. But we think the inclusion of this is a significant harm to this bill and to potentially to the citizens of state of north Carolina. We think that there are also other provisions that we would like to analyze closer and come back and have a conversation with you. So we look forward to continuing the conversation as we always do with you and working out some kind of resolution as you move forward with this bill. Thank you. Thank you Mr bag. We’ll put you down as a maybe um Erica palmer smith from care for Carolina. I was thinking, what would Senator Woodard say in a moment like this and so good. Thank you. Senator Bergen, I’m Erica palmer smith with care for Carolina. We are a coalition of 146 organizations across the state. When I first say, we are not taking a position on any other part but section one of the bill, but I do want to say thank you. Um this is an incredibly important step in north Carolina to make sure That 600,000 of our residents have access to quality, affordable health insurance. The majority of these folks as senator chronic referenced are working the latest numbers are 76% of these folks are working a third of them are parents with dependent Children in the home. They need our help and you are working toward an incredible step to make sure that they have what they need and thank you, thank you anyone else or I’m going to close this out. Just a quick question if you don’t Mr chairman. Um and this really and I meant to ask it earlier on the surprise billing piece, are there issues um with them tallulah, when people go to the er as far as what they’re allowed to ask and how that information will be transmitted so they can provide that notice? Sit across. I don’t believe emergency room, I’m gonna I’m gonna defer that question to our all knowing Jason chair recognizes Jason Moran bates, Jason Moran bates legislative analysis. Uh Senator lee, I honestly do not know the answer to that question. I don’t know if I’m tola limits what can be asked in in terms of billing or anything like that. I apologize. We will find out sir. I have 11. Just one question. Can I go to senator heist. Sure. I just thought he was silent on the whole thing today. He wants to say something. I’m sure Senator high, you know, and I think I’ll kind of leave this as a comment and get it instead of trying to direct it as a question, but I would just say um I think it’s been obvious over the 12 years that I’ve been here is that uh, none of these provisions that a lot of people have worked on for a lot of years are going to pass by themselves. It’s just not, there’s not gonna be a day where Medicaid expansion alone comes, where the Save Act alone comes where those kinds of things, there’s just too many others. And I dare to bet that this is a bill that has been put together, That there’s nobody 100% for like, I wish we could eliminate surprise building altogether. I wish and have proposed and voted for that. We could end certificate of need altogether. Uh, This was coming in, I wish we weren’t in the Medicaid expansion side of things because I think there were better ways to do it, that the federal government shutdown that would expanded private insurance, uh, and others. But this bill is one that kind of takes the reality of all the issues and says at least from the Senate perspective, this is what we believe is the sweet spot that makes all this possible. Now, everyone in here can pick out one part and say, I didn’t get what I want for my industry doesn’t get to maintain its dominance in this area or those type of things. Uh, there’s nothing in here that’s not been done in multiple other states, were not jumping off any cliffs. Let’s be realistic about that uh, and oppose this bill. Uh, but this is one of those examples of kind of a culmination of more than a decade of different policies and others that we think can move north Carolina for. You can’t do Medicaid expansion without supply side, reforms the supply side reforms, uh, change the dominance in the market and nobody likes to be knocked off the top and not be in charge anymore. Those things are all within their, but I feel like from the committee work from the sponsors of this bill and others, they have put together the bill of what is possible. Now, we’ve got a long work to go with the, with the House and others and they’re not taking it up. But I, as I told people, I remember that course when we were talking about Medicaid transformation and how they were never going to take that up and all the other things they were never going to do. Well. It took a while, but we got there to, uh, that’s coming in and uh, we need the governor, we need everyone else on board. And uh, this is a bill of the possibility that can come through and, you know, maybe small interests find a way to disrupt it. But those battles are things we’ve been fighting for 12 years now. And uh, I thank the sponsors for putting this bill together and uh, actually making some movement, improving health care and kind of breaking that stalemate. We all know that we’ve seen for a long time. Thank you sir, Senator robeson thank you. Um Chair co chair Bergen uh and again for your support. My question is, is about the timetable for this uh in terms of moving forward, but I want to say Senator Heisei came in 12 years ago to with this very concerned as a community health professional and having provided health care for uninsured people in the clinic we set up. So I knew the real issues. So I’m thinking I’m thankful that you know, my colleagues have finally come together. Okay, I’m not gonna beat you up for that. I want to thank you for where you come, but say to that collective minds on how we really finalizes is the best approach and we’ve always said that. So I want to concur but tell me what is our timetable for this? Well, today the bill is for discussion only, we will vote it tomorrow is my understanding, we will and uh I think it has a stop in finance and then we’ll go to the floor but we are planning to move the bill over to the house as soon as we can and hopefully they will start working on it on that side. That’s the sponsors plan anyway. Any other questions? I just want to say a couple of things, I encourage everybody, read the whole bill, there’s a lot in it. Read the bill. Leadership is not, leadership is about making hard decisions and and I’ve learned from the soon to be four years I’ve been here. We we collectively make a lot of hard decisions. And I said this earlier, Medicaid can’t be a final destination for people. There has to be a path to get folks off Medicaid to become self reliant, self sufficient. And that’s going to be part of this as we move forward. We’re gonna have funds to be able to really concentrate on. How do we get people? We need folks in the workforce. Ladies and gentlemen, if you have looked at any of the numbers and our unemployment numbers and and I’m in the business where I talk to business people every day and we desperately need workers in this state are our success has also been one of our burdens is that we’ve done so well economically that we have, we we need workers. So we have a path I think now to get people to where we can get them training, we can get them employed. Thank everyone for being here, being here and we will see you tomorrow. Thank you