Vermont Legislature SmartTranscripts:

[Rep. Robin Scheu, Chair, House Appropriations]: We are back after a roll call. It's House Appropriations, Thursday, 05/21/2026, 10:48AM, and we are continuing our walk through S-one 190, which is related, among other things, to reference based pricing. And there'll be a couple of amendments after we get through this part. So Jen.

[Jennifer Carbee, Legislative Counsel]: Also make a change in the provision that was passed in last year's Act 55 that limits hospital claims for outpatient prescription drugs that are administered in an outpatient or office setting under current law to the cap is 120 percent of the average sales price for any drug that the hospital charged and insure more than that as of April 1. This would change that cap from 120% to 130% of the average sales price. It was connected to some of the financial aspects of section two as it came out of that committee, and it would be deleted, proposed for deletion in the amendment from representative Black and others. So I think maybe it makes sense at this point to take you to that amendment since it deals with the same topic we were discussing.

[Rep. Robin Scheu, Chair, House Appropriations]: It only deals with sections two and three? Yes. Okay, so this would be

[Rep. Alyssa Black, Chair, House Health Care Committee]: the time to do that,

[Rep. Robin Scheu, Chair, House Appropriations]: and then we'll go to the other sections of the bill. So this is draft 2.1.

[Jennifer Carbee, Legislative Counsel]: Draft 2.1, and it is from representative Black and several other members of the Home Health Care Committee. This was after the bill had been voted out of the committee. So it has a few instances, but the substantive one is this first instance. So it's strike out section two, which is what we're looking at around codifying provisions for fiscal years '27, '28, and '29, hospital fiscal years, with limits on the amounts that could be charged or that hospitals could get paid by QHPs and the BHANA plans. This strikes out that section and puts in a new section that's just a standalone session law. It's not going in statute, still the law, just not going in statute, that would have limitations on hospital reimbursements still for QHPs and BHIM plans, but just for FY '27, just for Hospital Portfolio '27. It has definitions in it again, including I've added the definition of Medicare adjusted face rate that we've looked at in combination with the language in the other version of Section two. It does not define hospital because it is not limiting. It is not doing any carve out. So it applies to all hospitals within the Green Mountain Care Board's purview. And it starts on page two by saying, Notwithstanding any provision of, and that citation is to the Green Mountain Care Board's rulemaking, the requirement that they use rulemaking to exercise their rate setting authority. So notwithstanding any provision of the part that says they have to adopt rules to do rate setting. For hospital fiscal 2027, the board may order hospitals to reduce their commercial reimbursement rates for QHPs and BeHype plans based on a percentage of the Medicare adjusted base rate determined by the board for each item provided and service delivered in Vermont to enrollees in these plans. So it takes out a specific percentage or backing into a percentage through a defined dollar amount and just allows the board to order hospitals for hospital fiscal 2027 to reduce their commercial rates, specifically for the QHPs and BHAT funds.

[Rep. Robin Scheu, Chair, House Appropriations]: So it's more tailored this way, would you say?

[Jennifer Carbee, Legislative Counsel]: I would say it's more discretionary, I guess, the board greater discretion. With

[Rep. Robin Scheu, Chair, House Appropriations]: the hospitals, each the hospitals. Right.

[Jennifer Carbee, Legislative Counsel]: Yes. That's what I mean, sort of more tailored to each

[Rep. Robin Scheu, Chair, House Appropriations]: hospital situation. Yes.

[Rep. Eileen Dickinson, Member, House Appropriations]: Okay.

[Jennifer Carbee, Legislative Counsel]: Yes, I think you could say it is less of a one size fits all.

[Rep. Robin Scheu, Chair, House Appropriations]: Right. This is somebody who doesn't know much about health care. That's why. I mean, they ask questions the funny way.

[Jennifer Carbee, Legislative Counsel]: And then it still has language saying that a carrier shall not reimburse or agree to reimburse a hospital more than the percentage of the Medicare adjusted base rate that the board specifies, if any, for the applicable hospital fiscal year for anything provided to the enrollees in QHPs and BI plans. And then it carries in a lot of the same language about if it's not for service charges. What do you do? No balance billing. If a hospital has to reduce its rates more than the reductions achieved through that, authority given to the Greenland Care Board, then they're still supposed to target the highest rates starting with those over 500% of the Medicare adjusted base rate. We're directing the board and DFR to make sure that those reductions show up in rates. So those

[Rep. Eileen Dickinson, Member, House Appropriations]: two groups, the Health Connect and the VHI groups, do not have the kind, are they going to be exempt from the what other hospitals have to do if you're looking at reductions? So 250% or We're not. Are the other insurance covered insurances, are they subject to more stringent reductions than these two groups with Health Connect

[Rep. Wayne Laroche, Member, House Appropriations]: and Beehive?

[Jennifer Carbee, Legislative Counsel]: Likely no, because this is giving the board specifically the authority to direct hospitals to reduce their rates for these hospitals. I mean, they could or for these plans. I, you know, I would defer to the board on the extent to which they address rates generally, reimbursement rates generally. But the way this has been discussed has not suggested that there would be more stringent reductions, I think, particularly given concerns around hospital sustainability, that this is looking at

[Rep. Eileen Dickinson, Member, House Appropriations]: directing reductions My question isn't directed at possible sustainability, which is a whole other issue. My question is, and maybe it's an E. This is the same language as in the other piece that we have.

[Jennifer Carbee, Legislative Counsel]: E is the same language, yes.

[Rep. Eileen Dickinson, Member, House Appropriations]: But if it's going to go and have its budget cut, they have to start at the 500% and then lower those people that are paying more. I'm just looking at mean, if look

[Jennifer Carbee, Legislative Counsel]: at the way first of all,

[Rep. Eileen Dickinson, Member, House Appropriations]: if look getting favored more as a plan than other plans? And that's the question. It could be The pen rules can be adjusted to all kinds of plans, I suppose, if they choose, but is it equity, or is it somebody getting favored? That's the point.

[Jennifer Carbee, Legislative Counsel]: Either way Yes. I think this is giving different treatment to qualified health plans and the high plans. And you can talk to the chair of the committee about the rationale for that. Think

[Rep. Eileen Dickinson, Member, House Appropriations]: there There's is a group for the The

[Jennifer Carbee, Legislative Counsel]: small group that is purchasing qualified health plans is included in the QHPs. They are. I thought they were separated. No, they're still qualified health plans. So they would also be included. If they are purchasing a fully insured product, they're purchasing from.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Wayne, thank you.

[Rep. Wayne Laroche, Member, House Appropriations]: Maybe wrapping this the same question, but specifically carving out school employees. So between these two

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: the

[Rep. Wayne Laroche, Member, House Appropriations]: amendment and the original draft, can you tell us exactly what's changing in terms of who employees?

[Jennifer Carbee, Legislative Counsel]: I mean, they're still included in the for for whom the rates would be limited, but it's not specifying what the rate what the hospital reimbursement rates as a percentage of Medicare would be.

[Rep. David Yacovone, Member, House Appropriations]: Care Board would determine that.

[Jennifer Carbee, Legislative Counsel]: Right. The agreement and care board would determine that by hospital based on their hospital budget orders. So I see 250% and the 300%

[Rep. David Yacovone, Member, House Appropriations]: are taken out of the

[Rep. Wayne Laroche, Member, House Appropriations]: Right. And

[Jennifer Carbee, Legislative Counsel]: that was for fiscal years 'twenty eight and 'twenty nine, which are not addressed in this at all.

[Rep. Wayne Laroche, Member, House Appropriations]: So 500 is the upper limit and the care board can decide

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: below that?

[Jennifer Carbee, Legislative Counsel]: Not necessarily. It's directing the board to order or allowing the board to order hospitals to reduce their rates. It doesn't give a floor or a ceiling on what it would direct them to reduce their commercial rates for the QHPs and the BHIP plans too. It just gives them the authority to do reference based pricing, you know, pricing as a percentage of the Medicare adjusted base rate for those plans for hospital fiscal year 2027 while they work on rulemaking for the broader reference based pricing statewide. The 500% is if a hospital is required by the board's budget order to reduce its commercial reimbursement rates by amounts that are greater than what can be achieved by doing the reference based pricing for the QHPs and PHYP plans, then it directs the hospital where to start. It says the hospitals should reduce their commercial reimbursement rates that are more than 500% of the Medicare adjusted base rate. So anything else that they have that is over 500%, if they don't have any of those, start with whatever the rates are that are the highest in relation to Medicare.

[Rep. Wayne Laroche, Member, House Appropriations]: So this language is less restrictive than the previous language?

[Jennifer Carbee, Legislative Counsel]: This, so this E piece is exactly the same, but B is less restrictive on the board and, you know, maybe less restrictive for an individual hospital that would have been covered by the 3.5 or the 250% of reimbursement.

[Rep. Robin Scheu, Chair, House Appropriations]: That's the more tailored to each hospital as opposed to the one size fits all.

[Rep. Eileen Dickinson, Member, House Appropriations]: Okay. Okay.

[Jennifer Carbee, Legislative Counsel]: All right. So as far as this amendment, that was really the substantive parts. It strikes out section three, which increased the cap on the outpatient prescription drugs, comparable prices. So you'll stay at 120% on the average sales price. And then it struck out the effective date section because it had a whole piece on how to implement that change to the hospital outpatient prescription drug cap, and just put it back in as the act will take effect on passage. I'm going to hop over to the back of

[Rep. Alyssa Black, Chair, House Health Care Committee]: the regular bill. Yes, please hop back to

[Rep. Robin Scheu, Chair, House Appropriations]: the regular bill. Before you do, just procedurally, we have possession of the bill. This is an amendment being proposed by members of the health care committee. Are we going to have to vote on this? Is this being presented on the floor? Do we approve it? Do we say something? I guess we should do a straw poll on it here.

[Jennifer Carbee, Legislative Counsel]: We want to do a straw poll because it'll save you the time of coming back and doing a straw poll on 100 Okay. And

[Rep. Robin Scheu, Chair, House Appropriations]: That's what I was trying to figure out. So we will listen to the bill. We also have a committee amendment, which is a language transfer. And then we would vote in. But this we'll do a straw poll on separately from the bill. Okay, John.

[Rep. John Kascenska, Member, House Appropriations]: So just to hear, was there a straw poll on this in committee? In your committee? Yes. And what was that?

[Rep. Eileen Dickinson, Member, House Appropriations]: Chair Flatwood Chief. That is seven-one-zero.

[Rep. Thomas Stevens, Member, House Appropriations]: Okay.

[Rep. Robin Scheu, Chair, House Appropriations]: And the original bill was ten-ten. Okay.

[Jennifer Carbee, Legislative Counsel]: Okay, there's a question. Go ahead.

[Rep. Trevor Squirrell, Clerk, House Appropriations]: Oh, sorry. Chair Black,

[Rep. Wayne Laroche, Member, House Appropriations]: what was the basis for the folks voting on?

[Rep. Alyssa Black, Chair, House Health Care Committee]: I guess

[Rep. Wayne Laroche, Member, House Appropriations]: No discussion?

[Rep. Alyssa Black, Chair, House Health Care Committee]: There wasn't any discussion. I really don't know. I do know that because this bill had already moved out of our committee and James and Means had possession of it, We wanted ways and means to be able to hear the amendment while they were doing their walkthrough of the bill. And the amendment, because, and maybe this is my fault and I take full responsibility, the amendment was presented, it was very quick. Know, I don't think that there was really time, frankly I don't think that there was time for some people to understand what exactly it was doing and again I think I take full responsibility. I did hear some concerns of I'm not quite sure. So I did hear that.

[Rep. Wayne Laroche, Member, House Appropriations]: Was there any potential place that we could run off the rails of this amendment?

[Rep. Alyssa Black, Chair, House Health Care Committee]: Do you want me to when I come up

[Rep. Robin Scheu, Chair, House Appropriations]: Yeah. Why don't why don't we because we're not gonna vote on it right now. Let's hear the rest of the bill, and then we'll get chair Black up to talk about this. Because she can also explain the reason that they wanted to do this amendment, which probably would be helpful for us to understand. But we'll get there. Let's go back to the bill.

[Jennifer Carbee, Legislative Counsel]: All right. So now we're back to the bill as it was voted out of House health care. This is section four is on hospital outsourcing.

[Rep. Robin Scheu, Chair, House Appropriations]: We're on page 10.

[Jennifer Carbee, Legislative Counsel]: We are on page 10. Yes. And there was some It came to late last year during the hospital budget review process, at the Green Mountain Care Board that the hospitals were outsourcing clinical services that some people hadn't previously been aware was occurring, and, the bill, as introduced in the Senate, would have put some limitations on that. This is taking a step back and gathering some information. So it says for fiscal year twenty seven hospital budgets, the Green Mountain Care Board shall direct hospitals to provide such information as the board may require regarding the clinical services that the hospital outsources to external entities. And by 01/15/2027, the board, after consulting with hospitals and their contracted independent providers and assessing the impact of outsourcing on access and quality and availability of care, will provide findings and recommendations on hospital outsourcing to HealthSouthCare and Ways and Means and the Senate counterparts. And in addition, the Board, in collaboration with the Agency of Human Services, will report on the extent to which hospital outsourcing affects provider tax revenue and recommend any needed changes to the provider tax statutes to appropriately reflect expenditures for patient care at Vermont hospitals.

[Rep. Robin Scheu, Chair, House Appropriations]: Is this related to the fact that the federal government is requiring us to reduce provider taxes?

[Rep. Eileen Dickinson, Member, House Appropriations]: No, it is not. Okay. Lynn? Is this targeted at things like these birthing centers that are independent or

[Jennifer Carbee, Legislative Counsel]: No, this is looking as there was some, I believe some hospitals, outsource their emergency departments, to independent contractors, who are delivering, providing services in hospital facility but are not employed by the hospital. Some of the billing then doesn't go through the hospital and doesn't get reflected in provider taxes, although the services are being delivered in Vermont.

[Rep. Eileen Dickinson, Member, House Appropriations]: That's actually very common from what I understand.

[Jennifer Carbee, Legislative Counsel]: Think it has been fairly common in the radiology and lab services areas. From testimony I've heard it may be less common or less known for things like anesthesiology, emergency departments, inpatient departments or hospital based departments.

[Rep. Eileen Dickinson, Member, House Appropriations]: That's been going on for a long time for ERs. I would suspect most of them contract out with an ER. Did you hear me? Well, never mind.

[Jennifer Carbee, Legislative Counsel]: So you will find out more when the reports come back. Section five deals with reference based pricing as it relates to healthcare provider professional healthcare professional bargaining groups under existing law the Green Mountain Care Board can approve creation of healthcare provider bargaining groups and there are certain things that they're authorized to negotiate on behalf of providers on, but this would exclude would say notwithstanding anything in this section of the contrary, the Green Mountain Care Board is not required to negotiate with a provider bargaining group or engage in a non binding arbitration process in connection with the Board's establishment of reference based prices in accordance with the various statutory provisions. Section six is on Appeals of Green Mountain Care Board orders, and this is largely codifying what has been the existing practice. Under its enabling language, the Green Mountain Care Board is directed to adopt procedures for administrative appeals of its determinations. And then those the issuance of the final order and the record from that would serve as the basis for judicial review at the Vermont Supreme Court. In practice, there have not been there's not been an administrative appeals process and appeals go directly to the Vermont Supreme Court. And so this would eliminate references to administrative appeals because there aren't aren't there. Section seven and eight, deal with data infrastructure and a new health system performance tool. This amends an existing statute that requires the Greenland Care Board to have an interactive price transparency dashboard. And this directs the Board to develop and maintain a public interactive tool that displays information on health system performance, including information on quality, access, and affordability, and to update it regularly. Section eight says the requirement to develop this tool is only required if the Board receives sufficient funding from the federal government or another source for purpose and I don't know if that we know if that has been received yet we do know GQ. So

[Rep. Robin Scheu, Chair, House Appropriations]: does this mean I could go on to the website and find out how much my standard surgical procedure will cost?

[Jennifer Carbee, Legislative Counsel]: Think that's the existing law requires the board to have a public interactive internet based price transparency dashboard allowing consumers to compare prices. This really would be more about health system performance.

[Rep. Robin Scheu, Chair, House Appropriations]: Oh, so how's my hospital doing?

[Jennifer Carbee, Legislative Counsel]: How's my hospital doing? How easy is it to access care? Are people able to access care for a particular condition? I don't know exactly what it's going to look like. So the board will have more information, I think, when they develop

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: it. Okay.

[Jennifer Carbee, Legislative Counsel]: Our last substantive section here is on critical access hospitals and Medicare outpatient cost sharing. And I think the leading language is a fairly good, summary of the situation if this committee is not aware of it. It says the General Assembly and Green Mountain Care Board have recently become aware of a federal requirement that Medicare beneficiaries have to pay, bear financial responsibility for 20% of the amount charged. This gets back to our charges versus payments discussion. So 20% of the amount charged for outpatient services delivered by critical access hospitals, not 20% of the amount that Medicare pays for the service. So again, Medicare beneficiaries have to pay are responsible for 20% of the charge, not 20% of the Medicare allowed amount.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: That's significant, right? Yes.

[Rep. David Yacovone, Member, House Appropriations]: And we're doing this because

[Jennifer Carbee, Legislative Counsel]: So this is a federal requirement.

[Rep. David Yacovone, Member, House Appropriations]: The feds are making use.

[Jennifer Carbee, Legislative Counsel]: Well, it's not new. It's been in place for a number of years, but it was not necessarily on people's radar, including my own. It's my understanding this was brought to the board's attention by a public comment. And so as it's been looked into more, there's been a lot of interest in ways to address. So it continues to say, while the General Assembly understands it cannot invalidate this federal requirement, it also recognizes both that it has a significant unfair and negative financial impact on Medicare beneficiaries in the state's most rural communities and that Vermont's critical access hospitals are some of the state's most financially vulnerable health care facilities. And so the intent of this section is to provide information to Vermont seniors and other Medicare beneficiaries about the federal requirement while a working group tries to come up with appropriate and enduring solutions that don't undermine the financial sustainability of our critical access hospitals and that comply with federal law. Are significant complications in this area. Right.

[Rep. Robin Scheu, Chair, House Appropriations]: So it's costing seniors more. And if we were to just change it, it's going to hurt our hospitals, our critical access hospitals, potentially, financial situation. So we're kind of in this

[Jennifer Carbee, Legislative Counsel]: and there are federal limitations on what

[Rep. Alyssa Black, Chair, House Health Care Committee]: we can actually do about it.

[Rep. Robin Scheu, Chair, House Appropriations]: Wayne, and then I think Dave probably.

[Rep. Wayne Laroche, Member, House Appropriations]: So how long is this federal 20% thing been in effect?

[Jennifer Carbee, Legislative Counsel]: Twenty years ish, yeah, approximately twenty years.

[Rep. Wayne Laroche, Member, House Appropriations]: And is there any potential liability upstate? We have not been

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: following that for twenty years.

[Rep. Alyssa Black, Chair, House Health Care Committee]: We have been following that. That's the problem.

[Jennifer Carbee, Legislative Counsel]: Vermont seniors have been paying this 20%. They don't

[Rep. Wayne Laroche, Member, House Appropriations]: need to.

[Jennifer Carbee, Legislative Counsel]: Well, do need to.

[Rep. John Kascenska, Member, House Appropriations]: They do need to.

[Rep. Robin Scheu, Chair, House Appropriations]: The way the hospitals charge. And there was a great article in one of our, I know it was seven days or who it was in. And I remember reading that article that said, if you go to a critical care access hospital for the same procedure and then you go to UVM, it actually costs you end up paying a bill that could be two to three times higher of what you would be paying if you'd gone to UVM. And they explained the math in there, which I will not attempt to do here because I can't remember.

[Jennifer Carbee, Legislative Counsel]: But if end up paying more than what Medicare will reimburse the hospital, the hospital doesn't keep the money. Hospital has to send the access to Medicare.

[Rep. Robin Scheu, Chair, House Appropriations]: So we're paying more as a Medicare beneficiary, and the extra money is going back to the feds.

[Rep. Wayne Laroche, Member, House Appropriations]: Yeah, so we're not getting the full benefit that we could get from the feds.

[Jennifer Carbee, Legislative Counsel]: So this is outpatient services at critical access hospitals. And there is a lot of attention on this issue now on the various stakeholders, including the critical access hospitals. And so this requires that by 09/01/2026, each critical access hospital must do all of the following. They must identify all of the outpatient services for which the amount that the hospital charges equals five or more times the Medicare allowed amount for that service. They must post prominently on their website and in their outpatient departments disclosure about the federal requirement that Medicare beneficiaries have to pay 20% of the charge for outpatient services, that Medicare beneficiaries may be able to receive care with reduced out of pocket costs from other providers, and how to contact the hospital's Patient Financial Assistance Department for more information. And it requires the hospitals to file their proposed disclosure materials with the Green Mountain Care Board before or before posting. And then it also says that to the extent the Green Mountain Care Board tries to address this issue in hospital fiscal year 2027, it must consider any proposals from the critical access hospitals and other interested stakeholders and must ensure its actions are consistent with ongoing hospital transformation efforts and the principles for health care reform that are codified and are sometimes referred to as the Act 48. Then the effective date as amended by the representative Black and others amendment would just have the effective date say take effect on passage and would change the title of the bill to an act relating to reference based pricing and the Green Mountain Care Board because, as you may have noticed as we went through, there was no mention of creating a public employee health benefit authority in the House Health Care version of the bill.

[Rep. Robin Scheu, Chair, House Appropriations]: Lots of digents.

[Rep. Eileen Dickinson, Member, House Appropriations]: Questions? Lynn? Okay, the effective date, Section 10, it'll take effect on passage. Excuse me. The original bill has got a lot

[Jennifer Carbee, Legislative Counsel]: of language there. Yes, because that was related to that section three price to the average sales price cap.

[Rep. Eileen Dickinson, Member, House Appropriations]: So we already took those out.

[Jennifer Carbee, Legislative Counsel]: So if the representative and others amendment is successful, section three comes out and you don't need all that information. Questions? Yes.

[Rep. Eileen Dickinson, Member, House Appropriations]: Any questions at the moment?

[Jennifer Carbee, Legislative Counsel]: The other amendment or do

[Rep. Robin Scheu, Chair, House Appropriations]: you want to have the question? Why don't we look at the other amendment just quickly and then we'll get to

[Rep. Alyssa Black, Chair, House Health Care Committee]: your block. Noah, did we need

[Rep. Robin Scheu, Chair, House Appropriations]: to have people on? I'm not entirely sure why. I think this came because of the public health benefit study, which was an appropriation, which we since took out because it was in the underlying bill. That's why we're getting this bill.

[Rep. Eileen Dickinson, Member, House Appropriations]: Do I

[Jennifer Carbee, Legislative Counsel]: have that right, Nolan?

[Rep. Trevor Squirrell, Clerk, House Appropriations]: I think so.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: For the record, Nolan, was at the office. What I told Ways and Means, they had the same question, whether they said, thinking it was coming here, it's one of the potential impacts on the head fund, Al Riley.

[Jennifer Carbee, Legislative Counsel]: If the VI premiums are reduced.

[Rep. Robin Scheu, Chair, House Appropriations]: Reduced, that would help the Ed Fund.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: If it's if.

[Rep. Eileen Dickinson, Member, House Appropriations]: I know there's a lot

[Rep. Robin Scheu, Chair, House Appropriations]: of ifs in everything, yes,

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: in this. And then there would stuff around provider tech. There's none of this.

[Jennifer Carbee, Legislative Counsel]: I it was

[Rep. Robin Scheu, Chair, House Appropriations]: I think it at $50,000 the

[Jennifer Carbee, Legislative Counsel]: The money as it came over from that. And I think if Yeah. There was ever

[Rep. Robin Scheu, Chair, House Appropriations]: a whiff of money in appropriation, we end up seeing the bills.

[Rep. Eileen Dickinson, Member, House Appropriations]: I think

[Jennifer Carbee, Legislative Counsel]: the money was in the Senate's budget as it came over, but maybe it has been modified.

[Rep. Robin Scheu, Chair, House Appropriations]: Okay. So let's show our amendment quickly. Dave, did you have a

[Rep. Eileen Dickinson, Member, House Appropriations]: question before we get to it?

[Rep. David Yacovone, Member, House Appropriations]: No, I'll get it from you. Okay. Thank you. Okay.

[Rep. Robin Scheu, Chair, House Appropriations]: This is what I talked about, because it's really related to this bill sort of. We're just gonna take it out of the budget and stick it in here. Right.

[Jennifer Carbee, Legislative Counsel]: So this would add a new section four a on reinsurance and the authorization to pursue a section thirteen thirty two waiver. This would authorize the Department of Vermont Health Access in consultation with the Department of Financial Regulation to submit a state innovation waiver under Section thirteen thirty two of the Affordable Care Act to establish a program for reinsurance and to seek federal pass through funding of amounts attributable to premium tax credits under the federal premium tax, advanced premium tax credits.

[Rep. Robin Scheu, Chair, House Appropriations]: So this was in one of the bills. It was in the budget. But since we're talking about trying to look at health care and reduce prices and all that, that just makes more sense to have it all be in here. This was something that came from the administration. I

[Rep. Eileen Dickinson, Member, House Appropriations]: have to present this.

[Rep. Robin Scheu, Chair, House Appropriations]: All you have to do is say

[Rep. Eileen Dickinson, Member, House Appropriations]: there's Yeah, no there's impact. No So this we're taking out of the budget, putting it into

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: the bill. That's all we're doing.

[Rep. Wayne Laroche, Member, House Appropriations]: Short report. Wayne. Give us an example. Can you give us an example of

[Rep. David Yacovone, Member, House Appropriations]: something that would merit a waiver?

[Rep. Robin Scheu, Chair, House Appropriations]: The reinsurance?

[Rep. Wayne Laroche, Member, House Appropriations]: Yeah, no, you're right. So you know, an event or something that

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: would be done that would have not done a thirteen thirty two ever. Several states have for different reasons. It was added in the Affordable Care Act as a way to help states come up with ideas. Reinsurance is one of the places that some states look at using it. It's an idea around allowing states to make it easy to it in the money in other ways. We have to look to make sure we're approvable from the federal government. So it

[Rep. Wayne Laroche, Member, House Appropriations]: gives flexibility to use the money that will get someone under a certain level.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: We have a plan. It's like we want to do this thing and one of the big examples that when it was initially passed in the broke character was to be able to do these like state based reinsurance programs. Just gives us

[Jennifer Carbee, Legislative Counsel]: some flexibility. But this authorizes the administration to submit a waiver.

[Rep. Robin Scheu, Chair, House Appropriations]: For some potential And expenditure it was in our budget as it passed out but it makes more sense to just put it in here so we're going to take it out

[Rep. Eileen Dickinson, Member, House Appropriations]: of the budget and put it in this field.

[Rep. John Kascenska, Member, House Appropriations]: Assuming that's passed. Okay,

[Rep. Robin Scheu, Chair, House Appropriations]: assuming yeah okay So, any other questions? Well, Jen, we won't go away too far, but why don't

[Rep. Alyssa Black, Chair, House Health Care Committee]: we get Chair Black up here to talk about a little bit

[Rep. Robin Scheu, Chair, House Appropriations]: more about things. We've heard some questions from committee members. We have some hospital trustees here on

[Rep. Alyssa Black, Chair, House Health Care Committee]: the mid age, so For the record, representative Alyssa Black said, You don't know much about health care, don't sell yourself short. You know what a Medicare EOB is, so that's often. And MEOB. So think I'm going I mean, I'm more than happy to answer any questions around the underlying bill. But I wanted to talk about the amendment, and I wanted to talk about the process mainly. Personally, transparency is very important to me. And I will just like this bill, S-one 190, this has been a bill that has been being worked on since the beginning of this session with multiple stakeholders, administration, hospitals, the insurance companies, the Green Mountain Care Board, the Senate, House. The ideas contained in here came out of a lot of working group, of a lot of people. There were different things on the table. They morphed over time. The Senate would put something in, and then people would be running numbers in the background and then say, oh, we need to tweak this and we need to change that. Hospital budget guidance came out in the middle of this from the Green Mountain Care Board. So that had an effect on things in here. But at its core, this bill started as one purpose and one purpose only. Act 68, from 2025, we tasked the Green Mountain Care Board with implementing and starting reference based pricing in fiscal year twenty seven. That's October of this year. That is five months away. We knew it was a tight timeline last year, and they were not able to complete the rulemaking process. But that was the intent of the general assembly. That was the intent when the governor signed that bill. We wanted this to start in 2027 fiscal year because it is really, really important. So the bill began as what do we need to give the Green Mountain Care Board the authority to be able to move forward, notwithstanding the rulemaking process, which they will be complete with in maybe early twenty seven, but not in time for this. So what can we do for them that the legislature can say, you can move forward? And then there were lots of ideas and lots of ways that we could target things. I want to make really clear, every single person in every single stakeholder group, we all had one thing in mind, and that was affordability for Vermonters. Everybody agrees on that. And the hospitals have dedicated themselves with finding savings and helping remove I say remove money from the system, but decreasing the cost of care. And we wanted to target these savings to the markets that are most vulnerable. The QHP market. So it's made up of I call it the QHP market, but it's really two markets. And Representative Dickinson, were sort of getting to this. It is people who purchase on the individual exchange, normally self employed people, people who do not have access to employer based health insurance. You have to actually not be eligible for anything else to be able to purchase on the exchange. The other group, and they're about equal size, or they were about equal size until the subsidies, is a small group. Small group, these are small employers, or in Vermont, you have to be under 100. But there are also employers that don't have the option of going with any other possible mechanism to insure their employees. They're usually priced out of the self insured market. They're too small. Maybe their employees at a higher risk, so they're not able to self insure. So this is a market who it's kind of the market of last resort for any small employer. These are our small businesses, and they have been bearing the brunt of these increasing premiums more than any other group because they've never gotten subsidies. The individual market subsidies, they haven't. And then the other group, obviously the VHI. We have heard over and over, and I know you have heard just as much as I have heard, education, property taxes. This is one thing that we can do right now to help taxpayers by decreasing the cost of school based employees' health insurance. We can do that right now. And if we're going to have these savings, let's target them somewhere.

[Rep. Robin Scheu, Chair, House Appropriations]: So we have a question. Yes.

[Rep. Wayne Laroche, Member, House Appropriations]: Oh, I'm sorry. So my question is in the rulemaking process right now. Are you aware of what the process is proceeding? I don't know if it's proceeding slowly or not, if it's on track or proceeding slowly. Is there any substantive reason for it to go slowly? Is there anything that you're aware of that might be problematic? Or is it simply procedural?

[Rep. Alyssa Black, Chair, House Health Care Committee]: I think it is simply procedural. I do not think that it is dragging on. I will say that I am well aware of the people who are going through this process at the Green Mountain Care Board are trying to go as quickly as possible. You might wanna ask them because, honestly, I'm not an expert on The reason why I ask is making process.

[Rep. Wayne Laroche, Member, House Appropriations]: We have a an amendment that simply the city is gonna sidestep that for the get into effect before the rules are are

[Rep. Eileen Dickinson, Member, House Appropriations]: For the first year. For the first year.

[Rep. Alyssa Black, Chair, House Health Care Committee]: We are making the rule for the first year.

[Rep. Wayne Laroche, Member, House Appropriations]: The first year, we're doing something. So if there's something subsequent that's being discussed, rule making process. So that's why I asked the board, is there any way we can run off the rails by passing an amendment?

[Rep. Alyssa Black, Chair, House Health Care Committee]: No, because we're only targeting it for this one year. So this is a one year session, will go away, and the Green Mountain Care Board, who is working on reference based pricing, have completed their rule, and then they will start implementing reference based pricing for the entire commercial insurance market. So it is just allowing them for this first year to begin, because there will be savings coming out of the hospitals. The hospitals themselves have already committed.

[Rep. Robin Scheu, Chair, House Appropriations]: So Tom has a question.

[Rep. Thomas Stevens, Member, House Appropriations]: Yeah, think it's a question. First of all, I just want to, after listening to Ledge Council and to you and to your attempts, the health care committee's attempts over the years to wrangle this, and it seems from a distant, I'm not in your silo, so it seems from a distance that it's impossible. And I appreciate the efforts. I mean, every silo in this building, including ours here, can say the same thing that it's impossible to do that which we are trying to do, which is make it cost less and be more affordable. And yet here we are putting our noses into the engine and trying to get it to fix. Using another, a simpler analogy, this breaks my brain, and

[Rep. Trevor Squirrell, Clerk, House Appropriations]: if I'm not used to this vocabulary,

[Rep. Thomas Stevens, Member, House Appropriations]: I'm eating less food than I used to, but I pay more at the grocery store than I did. And that's what this sounds like to me is that we're trying to reduce costs at some level or usage or something and yet it still costs more. Is that Am I off base in thinking that way in terms of what is it you're trying to manipulate here that's going to be systematic and at least permanent for a little while?

[Rep. Alyssa Black, Chair, House Health Care Committee]: I think to use that analogy, we have been eating the same and prices just keep going up and up. And now we know we have to eat the exact same and the only way, but we can't afford it because the prices have gone up so high and we're trying to produce the price of groceries.

[Rep. Thomas Stevens, Member, House Appropriations]: And the effect of that though, and this goes to the education question, this goes to this question. So when I see that, when I see that we want to lower this number to get back underneath what we think we can afford without necessarily increasing our income or increasing our ability to pay is who's getting the short end of the stick. Is it the, I mean, in healthcare, it could be the manufacturers of Q tips or medications or sheets or whatever, but where do we when you say that the hospitals have reduced the car or have an idea of where costs can be reduced, I get worried that someone's going to get the short end of the stick whether it's starting with the patient, which is the first thing I think of or the client or is it the amount of staffing, is it the amount, is it the quality of machinery, is it who's getting where is the fat in this system And I don't know that there is fat, can just, you know, we all have very one dimensional ideas of where there's too much expense, but what are you identifying in this to be able to, because I'm hearing a lot of this is what we want to do, but I'm trying to get a concrete hold on what it is you're trying to do here.

[Rep. Alyssa Black, Chair, House Health Care Committee]: Why is it every time I come to appropriations I end up crying?

[Rep. Robin Scheu, Chair, House Appropriations]: There's a whole box of tissues.

[Rep. Alyssa Black, Chair, House Health Care Committee]: We know that the monumental growth in our health care spending has been concentrated in two areas. Hospitals, specifically actually outpatient hospital, and prescription drugs. That is where we are seeing these two types of services are consuming more and more and more. And We can't afford it anymore. We cannot afford it anymore. And so what are we trying to do? Am I trying to hurt some hospital? No. But at some level, whose pocket are you gonna reach into to pay for it? I'm not willing to reach into Vermonters' pockets anymore. They're the ones who have been paying for it. We have to bring costs down. We have to. We can't afford it anymore.

[Rep. Robin Scheu, Chair, House Appropriations]: But we're the most expensive We are the most

[Rep. Alyssa Black, Chair, House Health Care Committee]: system nation. In the entire nation. And The US is the most expensive in the world. That makes Vermont number one in the world.

[Rep. Robin Scheu, Chair, House Appropriations]: Don't want to be number one. Case of This is being a patient who don't

[Rep. Alyssa Black, Chair, House Health Care Committee]: want to be number one.

[Rep. Robin Scheu, Chair, House Appropriations]: I see hands raised. I've got limited pain.

[Rep. Thomas Stevens, Member, House Appropriations]: I just say, again, I want to emphasize my appreciation for you carrying this and your community carrying this and working, having that on your shoulders as you're trying to find a solution for all of us. Really, I don't mean to be antagonistic. Just want to make sure that we understand that the work that you're doing here is while the details are important, just, I think we don't appreciate our own work, and in this case, your work enough.

[Rep. Alyssa Black, Chair, House Health Care Committee]: All care. We all care about our local hospitals. I mean, like, frankly, UVM is my community hospital. And UVM is probably targeted most in this. No one wants to hurt their community's hospital, but I don't wanna hurt Vermonters anymore. And I know another thing. The Green Mountain Care Board, they don't want to hurt hospitals. They have been doing everything they can to sustain hospitals. Hospitals are closing all across this country. We haven't lost one. We're lucky. And I credit the Green Mountain Care Board with ensuring that. Everybody cares, but we can't afford it anymore. I wanted to make one last point about the amendment.

[Rep. Robin Scheu, Chair, House Appropriations]: Then I've got questions.

[Rep. Alyssa Black, Chair, House Health Care Committee]: Okay. So, there was this whole process, and the process was all these runnings of numbers and everything. And then it got to the very end and we passed it out of House health care. And then there was a concern that was raised that we weren't prescriptive enough that we weren't constraining the Green Mountain Care Board. It became about regulating the Green Mountain Care Board's hospital budget authority. That is what it morphed into. It stopped being about reference based pricing, and it inserted the legislature into a process of saying, Green Mountain Care Board for 2027, here's what your budget orders are going to be. We don't do that. That is long established. It is a process that happens every year. It is a very well thought out process. I encourage anyone to watch it starting in It starts in March when they send out their guidance and they go through the whole process. There are dozens and dozens of people who work at every individual hospital, who work at the board, whose expertise in this area, and it is not the legislature's role to constrain the Green Mountain Care Board and tell them exactly what they must do and do a one size fits all. That's the amendment. The amendment is saying, here, Green Mountain Care Board, hospitals, go through your regularly scheduled process. And Green Mountain Care Board, if you're able to find savings at some hospitals, which hospitals have already committed to, then please go forth for this first year with reference based pricing, which is what we invented and we wrote into law, and concentrate on these two markets that are going to help Vermonters the most. That's what the amendment is. Thank you. Thank you,

[Rep. Robin Scheu, Chair, House Appropriations]: Chair Black. Lynn and then Dave.

[Rep. Eileen Dickinson, Member, House Appropriations]: Yeah, I said this to you yesterday when you were talking about I said I directed it because you were sitting there inside. But what your The conundrum that you have, the issue that we all have to face, is that you're relying upon human behavior to remain healthy. Because the cheapest health care is the health care you don't need. And I served on a school board, and we actually had, with our unions, agreed to go, our teachers, agreed to go into what we called BISBET, which was the Vermont Insurance School Trust, whatever. Apparently, it still exists. At the time, it was created, and this is something that the associations that also were in the state also used as a model. If you had a healthy cohort of insured people, you were rewarded with a rebate at the end of the year. It encouraged and supported wellness areas, healthy people doing logical good things to remain healthy. And these were employers, of course, but associates. The chamber had it. All sorts of different professional organizations had it. And a conversation I had in the cafeteria, apparently that ended. There was a lawsuit that got rid of that. VHI is a self insured group now that does the teachers. And when we went toward trying to get a statewide process, the people who were affected the most, I suppose, if my memory serves me correctly, were the paraeducators and people who were the less paid. Sometimes they get more on benefits than they got to pay with that health care plan. What, if anything, does When we got the ACA, we got rid of associations. But what do you do, or what can you do, or what kind of testimony did you get about trying to do things that are more healthy, keeping people healthy? How do you expect the hospitals, and any perspective on this, to try to reach out, to reduce the number of people who get no care, show off the hospital emergency room on Saturday night, or have every kind of chronic disease you can think of, and really just where do we put that in here?

[Rep. Alyssa Black, Chair, House Health Care Committee]: So you started with that we know that if we can deal with prevention, actually, I frankly don't like to use the word prevention, I like to use more manage, that if people are healthier, they will cost less. I would also say that the, and you said that's the best, most affordable care. I would say that the lowest quality of care is the care that's never received because people can't afford it. We are watching right now. We have seen almost a 20% loss in the individual market, the individual QHP market. We've lost close to twenty percent of people that were in there. It's something like 5,000 people. That happened on January 1 with the loss of the enhanced Those premium tax are people who were in that market because they didn't have other options for employer based insurance. We

[Rep. Eileen Dickinson, Member, House Appropriations]: don't

[Rep. Alyssa Black, Chair, House Health Care Committee]: know where they went, but I am deeply concerned that they have no insurance. We had Doctor. Steven Loeffler, who's the CEO of UVM Health. I'm still trying to not say network. They dropped the network. UVM Health. And he testified in our committee, and he was talking about how they are taking in close to half $1,000,000 more per day than what they had budgeted. And that has nothing to do with the rates that are being set. It has nothing to do with any action the legislature has taken or that the Green Mountain Care Board took. That is being driven strictly by utilization. We watched the QHP market go from people like the majority of the market wearing gold planes the very low out of pocket costs or lower out of pockets. And it has almost completely flipped over where all those people are now in these high deductible. If you are a family a Bronze plan, your max out of pocket is, I think, 40,000. And you're paying close to $35,000 a year just for a plan you cannot afford to use. That is what I am concerned about. I'm concerned about people not receiving care. That is what is going to hurt our hospitals the most. If people cannot afford to use the care, they are not going to receive services at their hospitals, and that is what is going to have the most profound effect on the financial stability of our hospitals. That's where the danger is. It's not in a 0.5% reduction fight between Green Mountain Care Board and a hospital. That's not what's going to do it.

[Rep. Robin Scheu, Chair, House Appropriations]: Okay, I'm going to pass the move on to Dave. I think health care is like education. We can all talk about it all day, but we're going to move on and reschedule the agenda. I'll tell you later. I'll try to be Go ahead, Dave.

[Rep. David Yacovone, Member, House Appropriations]: My concern is whether the Green Mountain Care Board has the tools, the statutory authority, whatever they may need to assure the public is safe. It's one thing to say you have the authority group to set what people can charge, tied to some reference, It's entirely another to say you shall be able to intervene with surgical precision and say, you should do this or you should do that. People may argue, good Lord, don't give the authority to do that kind of micromanagement to government. Yet without it, what if a hospital said, we're so excited, not excited, but we're meeting our obligations, we're reducing costs by closing a birthing center. And 200 women are now forced in the dead of winter or anywhere to travel sometimes up to an hour to deliver their babies. At a cost significantly higher than at the birthing center that closed. No money was saved, but it looks like on my balance sheet, I'm able to say to the regulators, look at this. And are the regulators helpless, maybe the wrong word, but are unable to say, wait, there's consequences to that, you shouldn't do that. Maybe you should look at the fact that your CEO at your critical access hospital is the highest paid in the state. I say these things not to be uncomfortable or unkind, but to make my point, there is a whole array of expenses in hospitals, and who are we giving the authority to make these kinds of community decisions to? Not criticizing the healthcare committee, they've been working hard.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: I'm gonna

[Rep. Robin Scheu, Chair, House Appropriations]: ask Chair Blatt to answer that. And I've looked at it-

[Rep. David Yacovone, Member, House Appropriations]: My question is simply, does the Green Mountain Care Board have the authority to protect people?

[Rep. Alyssa Black, Chair, House Health Care Committee]: This is the beauty of reference based pricing, because I listened to what happened this past summer in your community, and this is why we designed, and this is why we have given the Green Mountain Care Board authority to be able to design discrete reference based pricing. Other states have just said, Okay, public employees won't pay over 250%. That's what other states have done with reference based pricing. We wanted the Green Mountain Care Board, and I know that there are a lot of really smart people who are working on this right now, we want them to develop reference based pricing so they can do in because they know the challenges of, say, Copley. If Copley is recommending that they have to close their birthing center because they're losing money on the birthing center, the Green Mountain Care Board can say, Hey, Copley, we're going to set your reference base price higher than other facilities because we want to ensure that you are providing the services that your community needs and your community needs this. And they can do that for Copley, and then they can set somebody else's prices lower. Perhaps instead of paying 12,000 at Copley and 30,000 at UVM, they will say UVM, you're going to get 18 and Copley, you're going to get 18. They can level the playing field. That is why reference based pricing, it's probably never over. It's an iterative thing. And that is why we're doing the statewide strategic plan in collaboration with the Agency of Human Services to say, to come up with a plan of, okay, what does Morrisville need for services at their hospital? What are the essential services that that hospital service area needs? And the board will be able to then say, what are we doing to ensure that they have the resources to encourage the services your community needs? Instead of what happens now with our RVU and RVRVS system and DRG system and PPS this and critical access that. We have these payment models that have been developed over dozens and dozens of years that incentivize providers, hospitals, to provide the services that they get the highest reimbursements for in order to subsidize the services that are essential to communities. That's the beauty of reference based pricing, is we can disrupt this system to ensure that we're paying for the services that remoners need and not just let's buy a fourth MRI machine, because if you buy it, you will fill it.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Thank you.

[Rep. Alyssa Black, Chair, House Health Care Committee]: I'm just John?

[Rep. John Kascenska, Member, House Appropriations]: Yeah, I don't have a question.

[Rep. Alyssa Black, Chair, House Health Care Committee]: Oh, okay. Right.

[Rep. John Kascenska, Member, House Appropriations]: So I have a couple of things in mind.

[Rep. Robin Scheu, Chair, House Appropriations]: You are welcome to make mistakes. Go with talking about one.

[Rep. John Kascenska, Member, House Appropriations]: I don't we never wanna pick you up. I know.

[Rep. Alyssa Black, Chair, House Health Care Committee]: You're weepy lately, anyway.

[Rep. Robin Scheu, Chair, House Appropriations]: So anything We're we're gonna wrap up, folks, because we've been here for a while.

[Rep. John Kascenska, Member, House Appropriations]: So I'll be as brief as

[Rep. Eileen Dickinson, Member, House Appropriations]: I can.

[Rep. John Kascenska, Member, House Appropriations]: I think one of the things that kind of adds to the whole mix of everything here, is a lot of the stuff we've been talking about here, demographics are changing here. Hospitals, their payer mix is way different than it was when I first got on their board six and a half years ago. And so I'm very familiar with the process of how we try to determine our budget based on the budget guidelines that Green Mountain Care Board provides. And sometimes it's really challenging, because the cost of some things are just simply not under our control, in terms of contracts we have, and our nurses and our doctors and other staff that we will provide the services here. But I think one of the things we've been seeing here in a significant way are two things. We have patients that have come to us and have gone to other hospitals as well, that if they don't receive some medication that will keep them functioning, to keep them alive, the cost of a lot of those things is significant. And I will say the Green Mountain Care Brisbane been very good in working with us to not count that against our larger expensive things. Because we have medications that cost like a million dollars for the year. Yeah. I think we've all talked about that last year here. So we've had some relief there and we're very appreciative of that here. I think, and then with some of the change in demographics, some of the services being offered across two or three hospitals, it's changed here for sure. And each hospital, especially in the rural areas, they only have so much capacity. And sometimes the capacity is not great, and they may make decisions that we have read about here recently here. Those are not good things, and perhaps that was not the best decision to make. I don't think it was quite frankly here, because some of those services, we may not have large volume to like pay for that area, the hospital. We understand that we have other areas that do pay and there's some shifting going on. Know with the two regional hospitals in my area here in St. Johnsbury, up in Newport, we're starting to try and share a few things, I would say on cost, and that's been a very positive thing here. But we're also seeing more patients coming from one hospital to the next year, because there's only so much capacity for actual care and service. And that does drive up two things, revenue here, obviously here, no one complains about that, but there's also expense by that too. And I think our hospital just looking for better predictability, so we can be more assured of our sustainability with the services we're currently offering here, because our communities need those types of things. And I guess one of the concerns I had was about a question I asked about. You

[Rep. Alyssa Black, Chair, House Health Care Committee]: said you had no question.

[Rep. John Kascenska, Member, House Appropriations]: What I asked, I'm not asking your response, but so but I think, you know, there's been some time for that rulemaking to take place here, and it concerns me that we're not quite there yet. We're gonna move it to, like, a next year. And I understand that takes time, be careful about that, because words matter, just like words matter, and all the things that we review every day here. So it's a big conundrum here, and I'm a little unsure. I don't disagree with moving things forward here. I think Green Mountain Cure for Priority has the capacity to start doing that. They started doing that last year. As soon as we moved out of this, time to start talking to hospitals about this. I just want to kind of make sure that the hospitals are able to respond in the most timely way to provide what they need to hear and vice versa as well. And that's my big concern.

[Rep. Alyssa Black, Chair, House Health Care Committee]: Yeah, and I will say regarding the reference based tracing and the ability for the Green Mountain Care Board to do just this discrete part of it. The reason the numbers were changing so quickly in this bill, and they were changing like almost daily, it felt like

[Rep. John Kascenska, Member, House Appropriations]: ability thing that was just

[Rep. Eileen Dickinson, Member, House Appropriations]: Well, no, no, no.

[Rep. Alyssa Black, Chair, House Health Care Committee]: They were changing because a new number and the calculation to get to those things like the two fifty, the 300, the $3.50, those calculations were made via an email sometimes. Hey, how much would this be? So this is just I'm considering this reinforcing our intention of Act 68. And you talked about predictability. I did want to mention reference based pricing is established in Act 68, but ultimately by, and I don't know the date, it's '29 or '30, global hospital budgets. There's your predictability. Once hospitals have been right sized and they are able to provide the services that their communities need, then we are moving to global hospital budgets. But I do not think this is a difficult task for them to do in this year. And this year, we have the opportunity to really help Vermonters. We have the opportunity to ensure that people are able to receive the services that they need so they're not getting sicker, so that they're able to go to their hospital and not fear a $30,000 bill. That's what this is doing for one year.

[Rep. Robin Scheu, Chair, House Appropriations]: And we have a larger issue, which is that we're a small state, and we have these big problems, and we can only pibble around the edges of a lot of this. Some of this ought to be national, not statewide. But here we are. So I think people are everybody, hospitals, Green Mountain Care Board, health care committees, everybody's trying to do the best they can to ensure people get what they need and hospitals survive and patients can afford to

[Rep. Alyssa Black, Chair, House Health Care Committee]: pay for their care. And I know that this committee is very familiar with what is happening on the federal level to many multiple different systems, including and especially the QATB market. I won't even get into what happened this week

[Rep. Robin Scheu, Chair, House Appropriations]: on the federal level. That's federal stuff. We'll hear about that at some point. Thank you

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: very much.

[Rep. Robin Scheu, Chair, House Appropriations]: So we still have to hear. I think the order is we should pass our amendment, and then we vote on the bill as amended, and then we take a straw poll on the other. I'm looking at Jen. That sound all right to you? Okay, so we're going to do three votes. Two are we I mean, they're all real, but the third one is a straw poll. Okay, so back to our amendment, which is just transferring something that was in the budget to this bill. Is there a motion to support So moved. Thank you. Dave, is there a second? And thank you. This is the easy one. Okay, if there aren't any further questions, so we're just voting on the appropriations amendment to the Bill 190. Let's call the roll, please. Representative Bluemle?

[Rep. Trevor Squirrell, Clerk, House Appropriations]: Yes. President Dickinson? Yes. Representative Feltus? Yes. Representative Yacovone? Yes. Representative Laroche? Yes. Representative Laroche? Mrowicki? Yes. Representative Nigro? Yes. Representative Squirrell? Yes. Representative Steven? Yes. Representative Yacovone? Yes. Representative Michelle? Yes. 1100.

[Rep. Robin Scheu, Chair, House Appropriations]: That's 1100. So now we're gonna take up the bill as amended by us, but it's probably amended, amended a few times.

[Rep. Trevor Squirrell, Clerk, House Appropriations]: And it's passed on it, and amended by House Health Care, and further amended by health care, and further amended by

[Rep. Robin Scheu, Chair, House Appropriations]: I don't know if we have two, we don't have two health care amendments, because we're not doing the second amendment.

[Rep. Wayne Laroche, Member, House Appropriations]: I'm sorry?

[Jennifer Carbee, Legislative Counsel]: Will, as amended by the committee, also for

[Rep. Robin Scheu, Chair, House Appropriations]: example, health care, as amended by appropriation.

[Rep. Alyssa Black, Chair, House Health Care Committee]: That's fine. That's right, not blacks amended.

[Rep. Robin Scheu, Chair, House Appropriations]: Yes, Dave, is there a second? Are we voting on the amendment from the

[Rep. Eileen Dickinson, Member, House Appropriations]: health check

[Rep. Robin Scheu, Chair, House Appropriations]: committee? Bill, no. We are voting on draft 3.3 of S-one 190. That's the full bill.

[Rep. Alyssa Black, Chair, House Health Care Committee]: That's 16 feet long

[Rep. Robin Scheu, Chair, House Appropriations]: that we just amended. So it's that bill as amended by this We haven't gotten to that. It's a straw poll.

[Rep. Eileen Dickinson, Member, House Appropriations]: So the second the amendment that we heard from

[Rep. Robin Scheu, Chair, House Appropriations]: the representative That will And be a straw this is our vote of our committee on S-one 190 as amended by us. Tom? Do we already have Dave? Do we have Dave and Tom? Dave and Tom. Okay. I may be making that up, but I think I saw you raise your hand.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: I did it. Okay. It's okay.

[Rep. Robin Scheu, Chair, House Appropriations]: So are we clear? So this is the original bill that we got

[Rep. John Kascenska, Member, House Appropriations]: Just a little bit.

[Rep. Robin Scheu, Chair, House Appropriations]: As amended. So it's not the Black Amendment.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Everybody good on that? John, are you clear? I just need to

[Rep. John Kascenska, Member, House Appropriations]: think for half of this. I'll see you.

[Rep. Robin Scheu, Chair, House Appropriations]: Okay, so this came out of House Health Care ten-one-zero.

[Rep. John Kascenska, Member, House Appropriations]: Yes, when a lot of this was what had already been passed, but then came out of the Senate, some of the language.

[Rep. Robin Scheu, Chair, House Appropriations]: Are you looking at the 16 page bill?

[Rep. John Kascenska, Member, House Appropriations]: The 16 Yeah. Page

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Okay. Alright.

[Rep. Robin Scheu, Chair, House Appropriations]: So just as a reminder, the bill itself came out of health care on a ten one vote.

[Rep. Alyssa Black, Chair, House Health Care Committee]: Nothing yet?

[Rep. John Kascenska, Member, House Appropriations]: Yes, came out of, it's a nine-two vote. Ten-one. Ten-one, sorry.

[Rep. Robin Scheu, Chair, House Appropriations]: I wrote it down, ten-one-zero.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Everybody good? What if you're undecided?

[Rep. Robin Scheu, Chair, House Appropriations]: We have a responsibility to vote.

[Jennifer Carbee, Legislative Counsel]: I think some of our concern is, what about the Black

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Okay.

[Rep. Thomas Stevens, Member, House Appropriations]: Goes together as a priority.

[Rep. Eileen Dickinson, Member, House Appropriations]: I want to ask all of this. Oh.

[Rep. Robin Scheu, Chair, House Appropriations]: So if we voted on this.

[Rep. John Kascenska, Member, House Appropriations]: Okay. Think we can second

[Rep. Eileen Dickinson, Member, House Appropriations]: Let me just say that I think that I was not inclined to want to vote on the Black Amendment until the representative explained why she's doing way it's I changed the way it understand other people voted against it, but I'm not going to

[Rep. Robin Scheu, Chair, House Appropriations]: Don't worry about it. I think it was What

[Rep. Eileen Dickinson, Member, House Appropriations]: I think is that it almost was like a pilot of the larger amendment just to one year.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Got that?

[Rep. Robin Scheu, Chair, House Appropriations]: Yeah, well, Black Amendment is directing activities for just one year, and then the rest of the bill says, here's what we think is gonna happen in 'twenty eight and 'twenty nine.

[Rep. John Kascenska, Member, House Appropriations]: So package wise, it's really kind of considered going together.

[Rep. Robin Scheu, Chair, House Appropriations]: It is together. But I think we have an order. I mean, do you wanna do the straw poll on the amendment before you do the bill? I'm not sure that works. Sorry, Jen, can you help us out here? We had to vote on all three. Guess if you know where you want to end up, if you voted no on the coal bill, straw poll becomes moot. Right.

[Jennifer Carbee, Legislative Counsel]: But if So Jen Carvey, legislative council. If people support for the bill is contingent on the Black Amendment language, then one possibility would be for this committee to propose the black amendment language as part of your committee amendment. Yeah. And then people could support Then we can support the whole thing. Whole thing.

[Rep. John Kascenska, Member, House Appropriations]: The sufficient point of this with

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: the Right. Right.

[Rep. John Kascenska, Member, House Appropriations]: One could vote. No one can So

[Rep. Robin Scheu, Chair, House Appropriations]: Jen's just said, if that's really important, the Black Amendment's really important, do we want to adopt the Black Amendment as our own, and then we can amend S-one 190, and we would do the bill as amended.

[Rep. John Kascenska, Member, House Appropriations]: That sounds cleaner.

[Rep. Robin Scheu, Chair, House Appropriations]: Yeah, it does. It does sound cleaner. Are people okay with that? Enough people okay with it?

[Rep. Trevor Squirrell, Clerk, House Appropriations]: Yeah, I

[Rep. Eileen Dickinson, Member, House Appropriations]: think I like that better.

[Rep. Wayne Laroche, Member, House Appropriations]: I have a discomfort. I'm not exactly going exactly to walk.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Okay. So can I restate this?

[Rep. Alyssa Black, Chair, House Health Care Committee]: Yes.

[Rep. Thomas Stevens, Member, House Appropriations]: So putting aside what we just voted on for our ornament.

[Rep. Robin Scheu, Chair, House Appropriations]: Yeah, that's still fine.

[Rep. Thomas Stevens, Member, House Appropriations]: That's just there. That's just the technical change, essentially. So what I'm hearing is that if we amend the bill as whatever the version is, but if we amend the bill with this black amendment, call it ours, it will gain more support at least within this committee because there will be an understanding that we just improved the bill as opposed to here's the bill and, oh, we're gonna improve it over here. Right. And so rather than having a messy vote of seven four on the bill as we amended it versus whatever we would get, however many votes that would I'm just saying it

[Rep. Robin Scheu, Chair, House Appropriations]: It sort of guarantees it gets into the bill.

[Rep. Thomas Stevens, Member, House Appropriations]: Right. Right. From a floor perspective, though, it just seems easier and cleaner for us to amend the bill so that when it's on the floor, it's just when you vote for this amendment, here's this bill, explain, explain, explain, and then here's this amendment that fixes that which overrides

[Rep. Robin Scheu, Chair, House Appropriations]: If

[Rep. Thomas Stevens, Member, House Appropriations]: I heard that correctly, that's what I'm imaging. Okay,

[Rep. Eileen Dickinson, Member, House Appropriations]: so look at the bill, the 16 page bill. The amendment that I think is the pilot, section two, takes out those other years. It's only twenty seven. Yes. And I do have a question that I didn't really get a chance to ask the member from the committee. And that was the question on the external entities. Oh, which section was that? That's in section four that we have to go I mean, are lots of things that hospitals have contracted out for. Oh. Emergency room is one of those.

[Rep. Alyssa Black, Chair, House Health Care Committee]: I think radiologists You would ask that question.

[Rep. Robin Scheu, Chair, House Appropriations]: I'm just going to keep us going. Okay.

[Rep. Eileen Dickinson, Member, House Appropriations]: I'm sorry. I'm sorry. So explain to me where that comes from and

[Rep. Alyssa Black, Chair, House Health Care Committee]: what So honestly, it came from was in the hospital budget process this year. Several hospitals were coming in and they were contracting out their services. There was one hospital who was contracting out their hospitalists. Those are basically the attending physicians. One was actually moving, I think, the emergency department back in house, but it had been separate. There's instances which we've known about a long time, radiology, pathology, things like that. But it kind of became a little jarring in this year's hospital of, wait a minute, the Green Mountain Care Board actually has mean, I'm sure they have in some regard, but have they been adjusting the budgets for hospitals when hospitals actually remove the service and the billing from the hospital. So if you're building a budget based on last year's budget and your order is you can increase 3%, you're increasing 3% on a budget that was approved last year when those services were in house, and now they're out of house, which is driving up the cost of care. This this part of the bill is really and and the thing is, remember, hospitals have to pay a provider tax. So when you remove services and you're billing them separately, the state is not receiving that provider tax. And this is really, hey, let's look and see how this is actually affecting because it has not been And yes, there have been emergency There are some emergency departments. It's not all of them, but there have been at times.

[Rep. Eileen Dickinson, Member, House Appropriations]: I think they also do a lot

[Rep. Alyssa Black, Chair, House Health Care Committee]: of locum tenens, but that's still in house.

[Rep. Eileen Dickinson, Member, House Appropriations]: Yeah, I'm just concerned because one of the things that My experience or my understanding is that a lot of times they did this because they saved money.

[Rep. Alyssa Black, Chair, House Health Care Committee]: Yes. But if they're saving money, is that being reflected in their budget orders?

[Rep. Robin Scheu, Chair, House Appropriations]: So the budget has to take out what the actual They have to only budget for their

[Rep. Eileen Dickinson, Member, House Appropriations]: own services. Not to budget. I have to pay this contractor $1,000,000 for Yeah. Yeah. I mean, it's still there as part of their budget. Some of

[Rep. Robin Scheu, Chair, House Appropriations]: them are way than they would be budgeting.

[Rep. Alyssa Black, Chair, House Health Care Committee]: But some of them are not working like that. What they are is they're contracted providers who actually they are the ones doing the billing. So it's not being billed by the hospital, which means the provider tax is not being They're collected on

[Rep. Eileen Dickinson, Member, House Appropriations]: included in the budget.

[Rep. Alyssa Black, Chair, House Health Care Committee]: Not if they're well, it could be, could not be. That's why we're that's what this section is, is, like, we should probably look at it. It's a

[Jennifer Carbee, Legislative Counsel]: report. It's a report.

[Rep. Robin Scheu, Chair, House Appropriations]: Okay. So Jen is drafting, the black amendment to be the house appropriations amendment. You just sent it. You sent it to me. So we know what it is. It's now going to be changed to say House Appropriations.

[Rep. Alyssa Black, Chair, House Health Care Committee]: And I will say that I thoroughly appreciate that, because now I'll be able to do the appropriations amendment to my committee. And I think my committee has had some additional time. But as I said, it happened really quickly.

[Rep. Robin Scheu, Chair, House Appropriations]: You posted on them? Yeah. I'm just going to assume it's Reich, cause it's Jen. Usually my assumptions also. The only thing I changed in

[Jennifer Carbee, Legislative Counsel]: it is in walking through it,

[Rep. Alyssa Black, Chair, House Health Care Committee]: we started by saying just the more, because you said it's

[Rep. David Yacovone, Member, House Appropriations]: Okay.

[Rep. Robin Scheu, Chair, House Appropriations]: All right, is it posted on? Okay. This So we can withdraw our other amendment that we just did because you added the reinsurance amendment to this. So we don't have two different pieces of paper floating around. This would be the one that we would give to the clerk's office. Do you want me to just send it via email to the committee?

[Jennifer Carbee, Legislative Counsel]: Can put it on the screen if you want.

[Rep. Robin Scheu, Chair, House Appropriations]: Why don't you do that?

[Rep. Alyssa Black, Chair, House Health Care Committee]: Alright.

[Rep. Robin Scheu, Chair, House Appropriations]: But yes, Jen, if you want to just throw it on the screen quickly. So I don't know how we do this, Trevor. We kind of cross off that other one.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Yeah, but it's fine.

[Jennifer Carbee, Legislative Counsel]: Just tear off that piece of paper. Great. Alright. I'll just show the word version.

[Rep. Eileen Dickinson, Member, House Appropriations]: This show up on

[Rep. Alyssa Black, Chair, House Health Care Committee]: our website as the same one? Did you delete the other one? I

[Jennifer Carbee, Legislative Counsel]: get a 2.1 or something. All

[Rep. Robin Scheu, Chair, House Appropriations]: right, I will forward this to the committee. I'm going forward it to House Appropriations, so you'll have it in the meeting. That may be the fastest way to get it. I just emailed it. And I just got it, so you should have it. And Jen has it

[Jennifer Carbee, Legislative Counsel]: on the screen. Yes. And it's on the screen. Okay. We have on the screen striking out section two, putting in the new section two. That's just the one fiscal hospital fiscal year. The one change that I made was it had said in subsection b, it had just said the board. I added in the Green Mountain Care Board. Okay. And that was the only change there. Otherwise, it's the same language that you had looked at. So just it doesn't specify the percentage. Just the order. Okay. It was to reduce their. Rates. Go ahead. Then we have the second instance of amendment is striking sections three and deleting it. Third is your new reader assistance heading and section four a on reinsurance. And then a fourth instance of amendment is striking out, effective date is putting it back in as just. Right. Okay. All

[Rep. Robin Scheu, Chair, House Appropriations]: right. Well, everybody has it. Okay. Thank you for doing that so quickly, Jen. This is why we have to take

[Rep. Trevor Squirrell, Clerk, House Appropriations]: the room.

[Rep. Robin Scheu, Chair, House Appropriations]: Is everybody clear on what we've just done? Okay.

[Rep. Thomas Stevens, Member, House Appropriations]: We've turned it into universal healthcare. That's

[Rep. Eileen Dickinson, Member, House Appropriations]: So

[Rep. Robin Scheu, Chair, House Appropriations]: now, is there a motion to approve the new House Appropriations Amendment that we just saw? Tiff, Dave, any other questions on this? You okay,

[Rep. Wayne Laroche, Member, House Appropriations]: Wayne? Not really, but I'd just like to know if anybody in the room, is there any reason for us to be a little nervous about this?

[Rep. Trevor Squirrell, Clerk, House Appropriations]: Go ahead, John. Jump in real quick.

[Rep. John Kascenska, Member, House Appropriations]: I just want to be reassured this roommate is going to happen.

[Rep. Robin Scheu, Chair, House Appropriations]: We have the executive director of the Green Mountain Care Board here. If you could introduce yourself.

[Susan Barrett, Executive Director, Green Mountain Care Board]: Part of the reason why it's also taking longer is because we, this is a branding program, had to get a contractor, and that, as you all know, takes time to that process, but we now have 100 working, so now we are able to officially start drafting our rules. So it's just we had like a two step process that we had to do to get the loan repayment, and we have a timeline. It's going to be hopefully finalized by early. So we have enough money and we can bill it.

[Rep. Robin Scheu, Chair, House Appropriations]: So that will be ready for 2020, correct?

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Rich? Great. All right. Okay.

[Rep. Robin Scheu, Chair, House Appropriations]: Are we ready to vote? We we we already have a motion in a second. I've kind of lost track of

[Rep. Eileen Dickinson, Member, House Appropriations]: where I'm

[Rep. Alyssa Black, Chair, House Health Care Committee]: at. Okay. So, clerk, you call the roll, please. Representative Bloomling?

[Rep. Trevor Squirrell, Clerk, House Appropriations]: Yes. Representative Dickinson? Yes. Representative Feltus? Yes. Representative Kascenska? Yes. Representative Baroche? Yes. Representative Michael? Yes. Thanks for all the yes. Representative Steven? Yes. Representative Yacovone? Yes. Yes. So

[Rep. Robin Scheu, Chair, House Appropriations]: now we are going to do the bill as amended with our amendment in there, right.

[Rep. Trevor Squirrell, Clerk, House Appropriations]: Amended by health care, amended by

[Rep. Robin Scheu, Chair, House Appropriations]: And amended by appropriations. So now our amendment is in that bill. Is there a motion to approve that bill? Dave? Did

[Rep. John Kascenska, Member, House Appropriations]: somebody second? It's Dave.

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: Go ahead, Tom. It's the

[Rep. Robin Scheu, Chair, House Appropriations]: Yeah, it is the tribes. Is there a second? Yes, Dave. Okay, great. Any other questions or comments on the bill? If

[Nolan Langweil, Senior Fiscal Analyst, Joint Fiscal Office]: not, let's call the roll.

[Rep. Trevor Squirrell, Clerk, House Appropriations]: Representative Bluemle? Yes. Representative Dickinson? Yes. Representative Feltus? Yes. Representative Kascenska? Yes. Representative Groat? Yes. Laroche? Representative Wickettold? Yes. Cannot order here. Representative Nigro? Yes. Representative Sperling? Yes. Representative Stevens? Yep. Representative Yacovone? Yes. Representative Chen Shi? Yes. Seven zero 0.

[Rep. Robin Scheu, Chair, House Appropriations]: All right, great job everybody. I so appreciate everybody who's been in the room and hanging in there with us as we got through this. I think we're in a better place than we were before. Wayne, is it serious to report? It's more complicated. It won't be today. All right, committee, before everybody runs off, which I know you want to, you're going to hear the cannabis bill this afternoon at 01:45 and the Miss Ag bill at 02:30, and those were our last two bills. They should be a lot faster than this bill. But we think