Vermont Legislature SmartTranscripts:

[Francis "Topper" McFaun (Vice Chair)]: Good

[Alyssa Black (Chair)]: morning. It is February, March 13. Were in the office healthcare.

[Karen Lueders (Member)]: Sorry. Thank you everyone for your patience.

[Alyssa Black (Chair)]: We're going to need it. Legislative council is here with us and we're going to walk through some changes

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: to H585. Good morning, Jen Kirby, Office of Legislative Council. So you got five eighty five. I've incorporated all of the changes from the last draft and done markup for new

[Alyssa Black (Chair)]: or revised provisions. Yeah. Can I interrupt you really quickly? Just I'm not sure. What time do we have you till? I know you've got a lot

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: of Typically, 10:00, and we're supposed to go down sooner if you're done soon. Thanks. So the fairly minimal number of changes in this draft. The first is in section one in the health insurer governance sections. And after discussion with the chair, at least for this draft, we've maintained, so I highlighted it, but not bold, that the governor would appoint the two representatives of the public. Don't know if you want to say anything more on that. I will just

[Alyssa Black (Chair)]: say that after discussions with Department of Financial Regulation, we were having back and forth about, well, maybe the legislature should have a say or somebody else should have a say. It would require creating a whole apparatus around, similar to the nominating committee for the Green Mountain Care Board, which would mean people would have to be named to the nominating committee, and then they would have to And it just seemed like a lot of work, not much bang for the buck, guess, is what I wanted to say. So I'm just putting it back out there the way that it originally came to us. That's all. All right.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: Then nothing changes in the next few sections until we get to association health plans. So the sections on association health plans themselves are unchanged, but the effective date is delayed two years with a report here coming back to you on what I call the federal landscape. Think this would have by January 15, DFR report to this committee and the senate committees on the status of federal law regarding association health plans, including the extent to which federal law would allow for the expanded access to association health plans permitted beginning 01/01/2028, pursuant to the changes in sections three and four of the Act. So basically, based on what you had heard, I think, from DFR and others that federal law currently would not permit a more expanded use of association health plans, this would delay implementation in Vermont for until 2028 with the report back in 2027 on whether things have changed at the federal level. And then I've just renumbered the remaining sections. So you'll see all the stuff that was struck in the last draft has gone from this one. We've got the site neutral billing for physical therapy in here. We've got the removal of the prescription drug specific out of pocket maximum language in here. Got the health care sharing plans language in here, and no changes to any of those except section numbers. And then in the effective date section, I have carved out the associated health plan changes to take effect on 01/01/2028, consistent with that report fact. Can

[Alyssa Black (Chair)]: Can we go back to the Association of Health Plans

[Nolan Langweil (Joint Fiscal Office)]: section? So, we have all the same language that

[Alyssa Black (Chair)]: they may do all of this, but then we just delay it and add it that they have to report back. So that means that if they report back, would we then have to repeal what's in Section three that we're putting in there? Or if

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: you wanted to keep the narrower scope of association health plans in Vermont, regardless of what happens at the federal level. So if we do nothing, then they can move forward with So if you set up the expanded access to association health plans for 2028 and the report comes back in 2027 and says whatever it says, if you if you're okay moving forward with expanded access to association health plans as soon as the federal law allows, then you make no changes. If the report comes back and says, it's permitted under federal law, and you decide you don't want to allow expanded access in Vermont, you would need to make changes at that point. And I apologize. I don't think I was in here the

[Alyssa Black (Chair)]: last time we

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: talked about this. But the language in here doesn't also require anyone to study the effects of association health plans. No, it just expands the access. Okay, thank you. Yeah, it provides the expanded access. And I do want to know if you, I think there may be some conforming changes I need to make on prescription drug out of pocket language? Just there's some references in other statutes, and there's a separate statute allowing for bronze plans to be developed in a way that has some exceptions from the otherwise applicable limit that you guys need to go

[Alyssa Black (Chair)]: through and clean up. Thanks for mentioning that. So currently, in current law, we have this language that is being struck through. We have the prescription drug out of pocket. But we then have in other places a carve out where bronze plans could be developed.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: Yes, it is my recollection and understanding from several years back that the prescription drug out of pocket maximum that is in what is now ABSA 4092 created plan design challenges for the carriers creating bronze plans in the qualified health plan market because of the 60% actuarial value, plus or minus a little bit, that they have to meet. And so in order to design plans that had a little bit more

[Alyssa Black (Chair)]: flexibility let

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: me just pull up the statute on that. But a little bit of an or exception language was provided. So maximum out of limit for prescription drugs and. Alright. Let me stop. So it is and it was curious. '33 birthday 1814. And that language says, notwithstanding any provision of ABA forty ninety two, which is where that prescription drug limit is. To the contrary, the Board may approve modifications to the out of pocket prescription drug limit established in that section for one or more Bronze plans, as long as the Board finds that offering those plans will not adversely impact the plan options available to consumers with high prescription drug needs who benefit from that out of pocket prescription drug limit. It requires the Diva to certify at least two standard bronze level plans that include the out of pocket prescription drug limit in that statute, as long as they comply with federal requirements. And then notwithstanding that limit, the department may certify one or more bronze level qualified health plans with modifications to the prescription drug limit, out of pocket prescription drug limit. And then there's some language about auto re enrollment, trying not to adversely affect someone who is relying on that smaller out of pocket drug limit. We're in enrollment language there.

[Alyssa Black (Chair)]: Oh, Brian and then Daisy? I had a question.

[Brian Cina (Member)]: I feel bad admitting this, but I really am struggling with understanding all of this. Okay, and I want to be honest, because read it and you're explaining it, I'm still having a hard time understanding how it all works and what the bill's doing, because we got this letter saying they're concerned about it, making prescription drugs not affordable. And I want to be able to explain to people how it's helping and not hurting things. So I don't know if there's any way you could, in third grade language, or maybe I can ask AI to do it, but somehow tell

[Nolan Langweil (Joint Fiscal Office)]: us

[Michael Fisher (Chief Health Care Advocate)]: giant question Whatever will help, yes. That

[Alyssa Black (Chair)]: might address them. So let's say instead of doing what we've done in this bill, striking out that language, what would it take to allow insurers to develop plans across the metal spectrum? Would we repeal this or would we add to the section, the statute that you just read that says you may develop? So like, what if Right. Yes.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I think I think you could take up this specification for bronze plans in that carve out language and and potentially authorize more, you know, plans at any metal level that vary from the 4092 language while requiring that some member continue to meet that. So would we keep

[Alyssa Black (Chair)]: the existing standard that we're striking out and that's added to May? Would we keep that if we wanted to require that insurers develop that they have plans that have this cap? And then would we go into the other section of statute and say you may develop plans of any meta level that don't adhere to it, but that you have to maintain the ones that are currently there?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I mean, I think there's different ways to approach drafting it. But considering we're only talking about qualified health plans having greater flexibility, I think it would probably make sense to modify the statute that's currently only applicable to bronze plans.

[Brian Cina (Member)]: Okay.

[Daisy Berbeco (Ranking Member)]: Daisy? I'm still not crystal clear.

[Alyssa Black (Chair)]: I don't know why.

[Daisy Berbeco (Ranking Member)]: Right now and Jen and I have had a little bit of back and forth, and I really appreciated that through email. Right now, have Jen, correct me if I'm wrong. We have a max out of pocket for prescription drugs and then separately for medical. Right now, we

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: have the federal level The federal law under the ACA sets a maximum combined out of pocket. And and I am not the expert on this. So you may wanna hear from Diva that it's We will. Does this, for the carriers. But it's my understanding that the federal maximum out of pocket does not does not or does not, for the most part, distinguish between medical and prescription drug. It's generally a combined maximum out of pocket. Vermont law specifies a prescription drug maximum out of pocket, which by definition establishes, or by its existence, establishes then a medical maximum out of pocket because it's the difference between the federal total out of pocket and the prescription drug maximum out of pocket. So yes, right now you have and I'm trying to actually pull up. I think you had testimony on your website yesterday I recently from that that gave you the numbers because otherwise, I have to look them up.

[Daisy Berbeco (Ranking Member)]: The removal of prescription drug cap does not change the overall max, but it would mostly impact people who have high prescription drug costs because now that cap potentially is removed. But it would potentially benefit. And as this the intent is allowing flexibility for the plans to create across the metals plans that would accommodate people that have higher medical costs. So if you were going to get heart surgery and then your follow-up medication is aspirin, it's not cancer medication or something. I'm just trying to think the real world, like who is

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: So this again, based on my understanding and my recollection of some of the conversation when the bronze carve out was done is that there are that some people have high prescription drug out of pocket. You know, high prescription drug needs and having this statutory limit is very helpful. Other people have higher medical non prescription drug needs and having the higher out of pocket across plans for those people is less helpful for them because they don't get the benefit of the lower cap on the prescription drug cost because they don't have prescription drug costs that hit that cap. So a potential benefit would be to create greater flexibility in plan design that could meet different Vermonters' needs. What the impact would be on individuals and what the impact would be on plan offerings and and the costs for the plans, I don't know.

[Alyssa Black (Chair)]: Right. Oh, Leslie, but I just wanted to say, I just sent Tasha. Vermont Health Connect has a rate sheet with every single plan that's offered and it breaks down and I've asked her to print a large paper because it's really tiny writing on it. So we'll have Toni down and printing just so that people have so that they kind of know what we're talking about here. So we'll get that, but that'll take a little while. Leslie?

[Leslie Goldman (Member)]: So I was just struck by what you said about not knowing the impact on the individual or the system as a whole. So do we have enough information or do we need some actuarial help in understanding?

[Alyssa Black (Chair)]: I think we're going to hear from Blue Cross Blue Shield who has done some analysis around this. A little curious.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: So just for informational purposes, and you'll probably see this when you get the sheet as well, because of the way the language in the existing prescription drug maximum out of pocket is framed as being deductible for which a plan qualifies as a high deductible plan under federal law, which is really just a way of pegging an index. That number is currently so the current prescription drug out of maximum out of pocket in Vermont is $1,700 for self only coverage and $3,400 for family coverage. The overall maximum out of pocket from the federal law is 10,600 for individual and $21,200 for family coverage. So to put those in context, and I'm not gonna try to do the math, but the overall maximum out of pocket is $10,600 for an individual, of which $1,700 is their prescription drug cap. And the difference there, I think it's $8,900, is their medical out of pocket max. Similarly for family coverage, the 2026 maximum out of pocket is $21,200 for family coverage, of which $3,400 is the prescription drug maximum out of pocket, and the rest is medical.

[Alyssa Black (Chair)]: So does everyone understand that? Okay.

[Karen Lueders (Member)]: Oh, no, the health care, because

[Alyssa Black (Chair)]: I was thinking, where's the health care advocate when we need him to testify? Can you just take us back

[Debra Powers (Member)]: to why we're talking about the bronze plans right now in relationship to this?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: So we're not we're not really specifically talking about bronze plans except the fact that that there has already been a change in Vermont law affecting bronze plans because of the pressures that this prescription drug out of pocket maximum places on plan design for a bronze plan that has to be, have a 60 actuarial value, meaning that the patient is responsible on average for 40% out of pocket. Okay. Brian?

[Brian Cina (Member)]: So this may not be the best question for you, but I'm going to ask it because you might at least give us the legal explanation, but it might be better for the healthcare advocate or someone. But I'm trying to conceptualize. I'm not asking you to explain to me again how it all works, I need to read it and digest it. But what I'm getting is that we're playing with variables in an equation and changing the variables. And I truly believe the intent of everyone involved is to make things better for people, but I'm really concerned of who are going to be the winners and losers, because in every decision we make, there's inevitably winners and losers. And I'm wondering how this is going to play out for people. Are there going to be certain individuals who suddenly are spending a lot more than others? And it's hard because sometimes we have to make a choice in that regard, but I'm really struggling with understanding how it's going to affect people. Like for example, you mentioned the different numbers being caps on different kinds of services. If someone goes over their prescription drug cap on prescription drugs, does

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: that not count to their overall deductible? Don't think about the cost accumulators, Debra. This is really, at what point does the insurance pay 100% and the patient is done paying out of pocket? Okay,

[Brian Cina (Member)]: that was actually a very helpful, clear thing you just said. Because now I'm imagining a person going to the doctor and have a health condition, they're racking up bills, and the insurance company is barely paying because they have a deductible or not paying. Not to be disrespectful to anyone by that, but it's just how it works. They don't pay until a certain threshold. So they're not paying. So this person is struggling, trying to figure out how they're going to pay this medical bill. And so they hit their prescription drug cap first. Now the insurance company is paying all the prescription drug, But then they are still responsible for the rest of their deductible up to a certain point, then the insurance kicks in. We're also

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: talking about deductible versus maximum out of pocket.

[Brian Cina (Member)]: This is why it's so confusing. Yeah. But we don't need to keep going with it. I'm getting a better sense of how it's this complicated equation and how for each person, depending on their situation, it's going to play out differently. I guess my ultimate question is, who are the winners and losers here?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: Right. And you'll see if you look at Diva at Addison's testimony that she submitted yesterday, Diva says it is willing to study the impact and and that it would take actuaries to assess what a change would mean for the QHBs. K. Which also means I didn't see that. Yeah. I just said don't ask. It's an actuary question. Okay.

[Alyssa Black (Chair)]: Any other questions? I know there's lots of questions.

[Leslie Goldman (Member)]: Let me see that Addison's testimony is on our website.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: It was from yesterday, I believe. Maybe it'll be posted again today.

[Leslie Goldman (Member)]: Oh, it's posted today. Look at today. I wish it

[Karen Lueders (Member)]: the wrong day. Okay. Great. I think it

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: was yesterday too that I read yesterday.

[Alyssa Black (Chair)]: Any other questions for problem. Questions?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: Did you have another question on the AHP? Yeah. I'm wondering if since we're putting in this language that says we're in twenty seventh, right, and do it in twenty eighth. I feel like when we've had the testimony on the age fees, there's been no information from the administration that shows what the effects would be to the market, to plans, businesses. Would it actually be cheaper or not? I don't have in my mind what the language would be, but I'm wondering if can add something in that makes them have to come back and prove this is actually gonna work and not

[Karen Lueders (Member)]: be detrimental to other people.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I can't help with language, but I would be interested in.

[Francis "Topper" McFaun (Vice Chair)]: Could you explain what you mean by if this is actually gonna work when you just said that?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: So I think the administration came in and said, businesses, too, have said, we need the Association of Health Plans because businesses need a plan that's cheaper that we can afford. Totally support that. Businesses, especially small businesses, it's really, really difficult. But there's no data that shows it actually would provide cheaper plans. It's been a long time since we've had association health plans, and a lot has happened with our health insurance market since then. And there's been nothing that shows what the effect would be on the individual market if we start pulling more people out. And so since we're not putting it in place right away, can we have the administration come back in 2017 as part of this other report to really talk about the effects of what association plans would be to businesses and individuals and the market at large?

[Francis "Topper" McFaun (Vice Chair)]: And just in common, this is my own opinion, just common sense. If you bring together, for instance, the Chamber of Commerce, all the businesses, and you then apply, let's bring it all the way down. You get the okay to have an association plan. You found an association, you didn't do it just for the insurance, but insurance is part of it. I cannot believe that it wouldn't be cheaper for those people that work in those

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: businesses Right, in the and so probably, but to what extent? Is it going to be cheaper by a percent or two, but yet individuals are going to go up 20%? So think about when we did the individual and merge and unmerge. We didn't just say we're going to do it. We knew that if we separated, it was going to be a 17% I might be off my numbers increase for individual or 7% increase for individuals and a 17% decrease for businesses. We knew that. And we can make an intelligent decision on what to do, plus we have the subsidies on the individual side that made sense. I'm just looking for that same type of analysis behind this very important move that I really want to support because I want to support our businesses, but right

[Alyssa Black (Chair)]: now I can't. I see you, Daisy, and I wanted to add to that is, not only what is it going to do to the rest of the market, there's this assumption that these plans will be cheaper, but do we know that? Has anyone looked at it?

[Francis "Topper" McFaun (Vice Chair)]: Well, my opinion, any time that we ever did that, did the prices to individuals go up? When?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: When we unmerge the market to help the Yeah. Small business

[Francis "Topper" McFaun (Vice Chair)]: We're talking about

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: So now we're talking about even unmerging it more, really, quite frankly.

[Alyssa Black (Chair)]: We've done analysis. Which I'm concerned that it will destabilize the small group market we've tried to stabilize over. And the other things that and I keep asking this question and people have actually come to me and said this, some representatives and senators, frankly. I'm not even sure if we know, if you have an association health plan, you have an administrator of that plan, the underwriter, the insurance company that underwrites it. We're not even sure who would be underwriting the And I'm a little concerned about some of the companies that do underwrite these plans that we don't know what their reimbursements are and their contracts. And I mean, I know one insurance company that tends to underwrite a lot of associated health benefits. And it's the same insurance company that we've received lots of written testimony from before that frankly doesn't pay nearly enough for mental health services, physical therapy services, and that there's no negotiating power for providers to actually negotiate with them. And I'm worried about adding on to already the burden that our qualified health plans, because we do regulate them and we regulate the rates of hospitals, that we're putting even more of a cost shift onto our QHP plans because we don't regulate the costs for the third party administrators or the underwriters of association plans. And I'm not saying that that's true. I mean, I'm just making an educated guess. It might not even be an educated guess. But the point is, we don't know. And I just feel like we should look at all of these issues before we jump full in. Go ahead.

[Brian Cina (Member)]: Yeah, I don't know if what I'm going say is that different, but it's maybe simpler, which is, like, my concern is that we already have a limited demographic the demographics. Like, we have this limited population, and even if we unified all Vermonters, we'd have a 600,000 person risk pool. So every time we divide people to different plans, different insurance carriers, it's different risk pools. So they when we merge the market, it was a it's larger risk pool. We unmerged it, and that caused the individual to go up at the benefit of the businesses dropping. It was worth it because the individuals got the subsidies, but now we're talking about pulling more people out of possibly out of the group. That's gonna shrink that risk pool in already limited environment, and that to me would make me concerned that that that the prices will go up. Or but we don't know that. And so I think what I would support would be, like, further analysis of this and then us having numbers. And then we can look at those numbers, and we can make an educated choice. Do we want to do this? And it's not always exact, but it's projections. And so we might the projection might say, you know, that it's not gonna have a big impact or it might have an unintended impact, but I don't I'd rather us not take like, not gamble on it. And I feel like I learned the hard way because we went through this once before. But, you know, I'd rather us just merge everyone, and I think everyone knows that. But, like, you know, so I feel like unmerging people more is, like, is risky. If if it made sense in this current system, I would support it. I'm just nervous too.

[Francis "Topper" McFaun (Vice Chair)]: That's all. Oh,

[Brian Cina (Member)]: this is a different thing. You can look at this if you want. I'm just holding this right now.

[Karen Lueders (Member)]: Yeah,

[Brian Cina (Member)]: this was about the prescription drug thing, and it's just in my hand. There's like a comfort item right now. I can hold the zebra instead.

[Francis "Topper" McFaun (Vice Chair)]: I thought you had something else.

[Brian Cina (Member)]: No, no, no, There's no one else in it.

[Alyssa Black (Chair)]: That's the whole thing. Daisy, crushed yesterday.

[Brian Cina (Member)]: It's in my hand

[Alyssa Black (Chair)]: stuff. It's been said. Oh, okay.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I think my final point is just we're already pushing it a year, right? So let's add an analysis behind it. I will say even pushing it a year, I can't support it like it is right now without having additional data to be able to understand the impacts, good and bad.

[Francis "Topper" McFaun (Vice Chair)]: When you say the way it is now.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: And that it would just go into effect. There's no analysis.

[Francis "Topper" McFaun (Vice Chair)]: Are we talking about this new draft? You can't support this new one.

[Alyssa Black (Chair)]: That section.

[Brian Cina (Member)]: We're only talking about the association health plan.

[Alyssa Black (Chair)]: Exactly. The association health plans.

[Francis "Topper" McFaun (Vice Chair)]: Well, how about if we're gonna do something like that? How about if we also do an analysis of the pool and we find out approximately how many people may be left in the pool and do what we did with Catamount Health and subsidize food, then nobody gets hurt.

[Karen Lueders (Member)]: Oh, I thought we were rocking money. Did come

[Francis "Topper" McFaun (Vice Chair)]: right over the green space.

[Brian Cina (Member)]: No, it didn't.

[Daisy Berbeco (Ranking Member)]: I'm like, I'm What you said except like with Catamount Health.

[Brian Cina (Member)]: I was wondering, can we subsidize the group market? That's what I was wondering. That's why I was being quiet. That's what I was thinking.

[Alyssa Black (Chair)]: So we have When we talked about subsidizing the market, all I'm thinking about is the Vermont premium assistance. And I don't believe we can subsidize the small group market. We can only subsidize the individual market.

[Nolan Langweil (Joint Fiscal Office)]: Trevor Eichner, go online with the giant fiscal office. You can subsidize whatever you want with general fund.

[Brian Cina (Member)]: That would be fantastic. Where

[Nolan Langweil (Joint Fiscal Office)]: does it come from? You can't use $98 to subsidize small group part. Individual market is certain people of certain FBLs. And the only reason we got away with it

[Michael Fisher (Chief Health Care Advocate)]: is because it was kind

[Nolan Langweil (Joint Fiscal Office)]: of piggybacking about catamount, which results in an individual market. Would also say that I think any kind of thing that we do would require a CMS waiver which we are unlikely to get in this environment, especially as we go into renegotiating global commitment in

[Francis "Topper" McFaun (Vice Chair)]: the very near future.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: That was going be my point. I don't know the extent to which we can subsidize the group markets. I just use small group market. I just we'd have to look into that. So I don't wanna declaratively say yes. If you use general fund, it's fine. I don't know.

[Francis "Topper" McFaun (Vice Chair)]: We could find out.

[Brian Cina (Member)]: Yeah. So I just wanna make sure I understand what I heard that we, one, we could subsidize what we want with the general fund. However, there might be a barrier for subsidizing the exchange because of our agreement with the federal government.

[Nolan Langweil (Joint Fiscal Office)]: And just kind of corrected me and said she'd have to do a little research to find out if we could even subsidize the small part of it just to ensure that we're not violating it.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I just don't know. We have never talked about it. I have

[Brian Cina (Member)]: no Absolutely. Okay.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I have no awareness under the Affordable Care Act with the way premiums have to be developed, whether there is whether there is an avenue. I mean, we we added Vermont premium assistance on top of the federal premium federal premium tax credit and cost sharing subsidy assistance that is specific to the individual market. I don't know what our authority is around the small group.

[Nolan Langweil (Joint Fiscal Office)]: And I think I just said it because I was trying to make the point that we can't get Medicaid. Yes. I was really I shouldn't have said the general public, but I'm trying to

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: it's like we will Adding an additional caveat. Correct. Unlikely to what? I was just adding an additional caveat.

[Nolan Langweil (Joint Fiscal Office)]: Okay, alright.

[Francis "Topper" McFaun (Vice Chair)]: So we just heard that we need to study the association plan, way it was set up. So what I just heard here, we need to study this and see if we can do it. That's all we're just asking.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: That was about a separate, I think a separate question about providing subsidies to the small group market. Right.

[Karen Lueders (Member)]: Go ahead.

[Brian Cina (Member)]: You're looking at me, but I don't know if it was like a don't talk or talk. Probably both. So I'm wondering if a compromise would be to replace any action with association health plans with some kind of study that includes an analysis of the impact of these policy changes on the overall market and the potential ways that we the potential federal barriers or opportunities in terms of the Affordable Care Act and to fund the subsidies. And then I would also suggest a third thing, which would be what might be income sources to fund those subsidies, because it would be nice to get some ideas and not us be just making things up. Because I know what I would wanna do, which is tax the wealthiest people and use it. But there might be another way that we can do it. So should be analyzed, and we should have all the choices on the table. That's just one thought about the things we need to study. And I would support some kind of analysis like that.

[Alyssa Black (Chair)]: Okay. This is Okay, sorry.

[Debra Powers (Member)]: I guess my question is, when

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: you talk

[Debra Powers (Member)]: about subsidizing small business, are you talking about with the association that you would subsidize that? No. No, the small group that's in the marketplace.

[Karen Lueders (Member)]: Another question I have, allow me

[Debra Powers (Member)]: to do my thought process here. So if this were to pass right now as it is, then we would the associations cannot form yet, right?

[Alyssa Black (Chair)]: Well, they can't form yet anyways because of federal law. Correct. But it looks like it's

[Karen Lueders (Member)]: probably headed that way.

[Alyssa Black (Chair)]: Well, I think that DFR testified that it's not on their agenda for the next year.

[Debra Powers (Member)]: So But if we were to pass this, we're doing this. I get the study part of it. I get the delay, the start date. But that would make it a real thing. Correct?

[Alyssa Black (Chair)]: If we added the report and then we took action when the report comes back to make a final decision on not doing it, then we would have to change it. If no we decision once getting the report back, then it would be allowed if the federal government has subsequently done that. I have Lori. Gonna cut lines.

[Karen Lueders (Member)]: For some reason you get out of my peripheral

[Nolan Langweil (Joint Fiscal Office)]: medicine I should have worn some black and purple.

[Karen Lueders (Member)]: I

[Nolan Langweil (Joint Fiscal Office)]: think study will cost you money because it's actually worth now, so you would need an appropriation, we will just have you to say, who can we do in the study with the DFR, but they will have our actuaries in the new model.

[Alyssa Black (Chair)]: Now, CFR in their charge, their purview, aren't they supposed to be doing this anyways with insurance? Isn't that part of their regulation? Is to examine actuarial pricing and things like that?

[Nolan Langweil (Joint Fiscal Office)]: So what they do, and I would defer to Kyle, but as part of the regulatory process, sure, they have actuaries that review rates, they use bill back, I believe this is sort of outside of that. You're asking them to do a study that I'm not sure they can bill back for. Maybe if they can, maybe they can't. This is something that I would defer to them in terms of that process.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: Which study are you talking about, both

[Nolan Langweil (Joint Fiscal Office)]: I've things on the only been half of those things. So I'm thinking about a review of the facilities and help with Yeah,

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: so I would say, the initial one you're talking about, about the impact on premiums for plans in the market is gonna be an actuarial analysis that will require the use of their contracted actuaries. And I think, Noel, you would need to hear from them about what is within their existing contract and what they would need additional resources for.

[Alyssa Black (Chair)]: Don't we have an expectation if VFR is coming to us with a proposal that they actually have information to back

[Karen Lueders (Member)]: up the proposal? You have

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: not asked them to do an actuarial analysis of the impact on premiums in the individual and small group market until a few minutes ago, so I don't expect that they would have budgeted for that.

[Nolan Langweil (Joint Fiscal Office)]: To follow-up, I'll just say, I'll look into it, but I'm flagging it as a potential cost. I'm saying you're absolutely fast, but I think there is definitely a potential cost to be more good.

[Alyssa Black (Chair)]: Good to know. Have Leslie, hold on, Leslie Topper. Leslie Wendy Topper. Leslie, go ahead.

[Leslie Goldman (Member)]: I'm listening to the conversation, it's really complicated to try and understand. But it's going to be hard for me to support guess we're talking about section five without with a date in there for implementation. Because I think we need the information before I

[Alyssa Black (Chair)]: can imagine supporting a date.

[Leslie Goldman (Member)]: So that's what's hard for me. I understand it's going to cost money, but how else do you do it? I think we really need the analysis, and then at some point we decide about going in a future with the implementation date. But I can't support it with a date already.

[Alyssa Black (Chair)]: Can I ask a follow-up to your question, and Lori as well? And what I'm hearing from both of you is that you would support if the language was struck from the original bill and it was just basically the report back next year to say here's the information and then we essentially copy and paste this language from this year and put it into next year. Is that what I'm hearing or are you

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: okay with language as is, I just want the additional data in the report to come back next year for whoever's sitting in these seats to

[Leslie Goldman (Member)]: renew And I guess I'm not that because the effective date implies that regardless of what information we get, it would be implemented. And I'm having a hard time with that.

[Brian Cina (Member)]: It's like a reverse sunset.

[Leslie Goldman (Member)]: Yeah, it's about protecting the QHPs for me. And until we know that status, I can't support it because you're implementing it.

[Alyssa Black (Chair)]: Is there a way to sort of write in that this only goes into effect pending legislative approval?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: There isn't. I mean, your way of approving means to pass a bill.

[Alyssa Black (Chair)]: Okay. I have Karen.

[Karen Lueders (Member)]: So I think of the way this statute is operating as sort of like a springing mechanism, like you might have another trust or something. And so until we have the condition precedent of the federal government changing something we don't know if they're going to change yet, it doesn't even exist. It's all theoretical construct. And I really love the idea of expanding options and reducing the cost of health care and making it more accessible for more people and for everybody. But as we know, because of the federal reductions already, people that used to be able to afford their health plans better are now less able to, or they've got rid of their insurance, there's already, with the subsidies going away, a real impact on those folks. And if we have a mechanism that pulls even more people off, I think I've heard some other folks say this, and they go, well, what happens to that tiny, tinier pool that's left, and how does that impact them? So I think we do need to understand the impact. I always want to not have unintended consequences on thoughtful legislation, but still loving the role of options and cost reduction and all that. It seems too soon before we even know if the federal government will allow it, but if we have the information, that's a good thing, we can say, yes, we've got the language, let's implement. So I think, I don't want to be ignorant, I want to make an informed decision.

[Alyssa Black (Chair)]: Thank you. I got Topper. I have Brian. I have our healthcare advocate who's done. I've got Allen. And then I wanted to make a comment

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: afterwards. I may have to Yes. Leave you in a few

[Alyssa Black (Chair)]: I think we'll be okay.

[Karen Lueders (Member)]: Topper?

[Francis "Topper" McFaun (Vice Chair)]: Is the health care advocate going to be with us?

[Alyssa Black (Chair)]: Not on this.

[Francis "Topper" McFaun (Vice Chair)]: Like by yourself,

[Alyssa Black (Chair)]: health Well, care no, he had raised his hand earlier in the side, and I shushed him.

[Francis "Topper" McFaun (Vice Chair)]: I think I tried to answer that question that you just brought up by talking about subsidizing whatever is left, if the price is going up for them. So anyway, I think I'm done for right now. I love the camera. I want everybody to know that as this thing is setting right now, I can't support it. This particular section?

[Nolan Langweil (Joint Fiscal Office)]: Can

[Alyssa Black (Chair)]: you clarify for me, can you not support it because of the report fact or can you not support it? I can't support it because the way it

[Francis "Topper" McFaun (Vice Chair)]: was originally written is to have everything ready and and and then apply, see if we can get the waiver from the government.

[Leslie Goldman (Member)]: And to why

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I want waiver on this to to move forward.

[Alyssa Black (Chair)]: The wrong the

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: It's okay. Just wanna make sure people know. It's just if the federal government changes the law, our law would be ready to go.

[Francis "Topper" McFaun (Vice Chair)]: We'd be ready to go. And right now, we're gonna do a study, and then we're gonna chairman of world, we're gonna be ready to go. So

[Alyssa Black (Chair)]: Brian, I mean, Allen.

[Michael Fisher (Chief Health Care Advocate)]: Yeah. I guess Exactly. Heard too.

[Brian Cina (Member)]: Yep. I I I thought of another possible way that I could see myself compromising on this section, which would be the analysis and putting the language passing the language with a sunset. Because if there's a sunset, then it goes it goes out of existence, but the legislature doesn't do anything. So it kind of puts the put it puts it would put the committee in the future in the position of having to decide, do we remove the sunset and let this go into law, or do we or do we let it go away? And so it's kinda like we create something, and it and it sits there. And it's on the shelf, and it's ready to go. And then if it's possible, we just quickly we we pass a bill that removes the sunset. It's a very simple action, and then it goes into effect. If we or we modify it a little in that bill. Like, you know, we have something to work with. We we fix it up, and we remove sunset. But I would be uncomfortable putting something there that just sits on the books forever.

[Alyssa Black (Chair)]: Can I ask you on a question really quick, based on yours and

[Brian Cina (Member)]: your Yeah?

[Alyssa Black (Chair)]: Because I know I only have it for another minute or so. Is there something that would allow DFR to proceed with just rulemaking but not going to effect so that they could Because I think that's one of their concerns is that they wanted to start the rule making process so that it would be ready to go. Is there a way that we could write it in that they could just do the rule making but then have to come back to us if they were gonna implement it in '28.

[Francis "Topper" McFaun (Vice Chair)]: What would you do in the rule making on?

[Alyssa Black (Chair)]: Well, DFR wanted to start rule making in If

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: you wanna hear from from that, I mean,

[Leslie Goldman (Member)]: there's there's

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: cost and time Mhmm. Staff time, a considerable amount involved in rule making. I think it would be unusual to have rules sort of I just didn't know if we could write that in. Contingent upon a contingency that's upon a contingency. It starts to give a lack of notice to

[Alyssa Black (Chair)]: the public about what the law is. I'm sorry, I've got to go to Allen here first.

[Allen "Penny" Demar (Member)]: Okay, I'm confused again. Okay, so what do we study if we don't know the status of the federal law? What are we we're saying we're to have a study?

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: So the study in the version I brought to you today isn't really a study. It's just look at what the federal law says. The language that was just talked about that I've been working on potential language for is studying the projected impact on our health insurance markets of expanding access to the association plans, including the likely impacts on premiums in the individual and small group markets.

[Allen "Penny" Demar (Member)]: So you answered part of my second question is, is the intent here, and what are we trying to accomplish?

[Karen Lueders (Member)]: You worked at the other people.

[Allen "Penny" Demar (Member)]: The chair probably.

[Alyssa Black (Chair)]: I'm sorry, I've missed your question.

[Allen "Penny" Demar (Member)]: I want to know what our intent is. I think I do because we just answered some of that. But what are we actually trying to accomplish here?

[Alyssa Black (Chair)]: I think that kind of leads me a little bit to the statement I wanted to make. Cause I've been listening to this whole discussion and we keep discussing what's going to happen to the individual market, what's going to happen to the small group market. I mean, the intention of putting this in here, just to answer your question, is because we haven't actually done any analysis of what this is going to do to our market. And before we proceed with possibly upsetting and destabilizing our healthcare marketplace, we probably should have a little bit more information. That's what I think this is about.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: Be thankful this afternoon. Yes.

[Alyssa Black (Chair)]: Well, thank you. But I guess what I keep thinking about as I'm listening to this whole conversation is, you know, I always talk about how it just seems like in all we ever get to do is we nipple around the edges. And we're sitting here talking about, well, maybe we can subsidize this market. Maybe we can What can we do for this? Maybe Here's something that can maybe lower rates for a small group of people, but it might increase rates for others if they do that. I keep coming back to just moving deck chairs around. It's not about the market, it's about the cost of care. And I just feel like we need to be putting our efforts into reducing the cost of care for everyone so that we don't have to sit here and have hour long conversations around expanding to AHP plans. That's all I guess what my statement was. I want to work on things that reduce costs for the small group market, the individual market, even the large group market, maybe even Orissa plans, although I'd love if the qualified health plan and the market that we have control over to some extent, I would love for that to be the place that everybody wants to be because it has lower costs and I just see this thing on association health plans as people fleeing because the costs are so high. Let's do something about the costs, because that helps everybody.

[Nolan Langweil (Joint Fiscal Office)]: When you do something about

[Allen "Penny" Demar (Member)]: the costs, those people will come back.

[Alyssa Black (Chair)]: That's what, that's kind of

[Allen "Penny" Demar (Member)]: But in the meantime, I'm going to go where I can feel is the best for me financially and my family.

[Alyssa Black (Chair)]: And I'm concerned that by going with the best that people can find that they're actually raising costs for other families who are left behind or who don't have a trade or an association where they can pool. I mean, how does this help my guys and their families at an automotive repair business? It doesn't, it raises it for them too. I've got Val and then I got Lori and Leslie and Brian. And then I think we're going to table this because we've got some other things to discuss. Oh my God, got Should I just go around the table?

[Karen Lueders (Member)]: I'm with Val. Yeah, this might be for you. It might be a little more theoretical. So if we did subsidize, say, individual's individual plan, market. We do. To what do we do now?

[Francis "Topper" McFaun (Vice Chair)]: Might have to substitute them. Subsidize them. If if

[Karen Lueders (Member)]: So then it would not eventually level out. If we're already subsidizing, we're going to subsidize more. Then we would know now that maybe in the next year, we wouldn't have to subsidize that. But we do, and now we're thinking of increasing that.

[Alyssa Black (Chair)]: Happy to know. How will I sub some of it?

[Debra Powers (Member)]: Think the

[Michael Fisher (Chief Health Care Advocate)]: question here is not about the individual market. We're doing what we're doing for that and the lines between the individual market and the group market are what they are, that have some limitations on people being able to go between. So I think the question here, the committee was asking itself already about what is it that would need to be done to protect the rest of the market if you allow people to leave. And I think that's the idea of subsidizing the smaller and I'll just add, we opted out of being a shop state a while ago. Many states do have mechanism for the small group that was allowed in the Affordable Care Act. And some states do a tax credit for those small businesses. And so what I was gonna say earlier is if you are wanting to study marketplace stability options, not only is there an actuarial questions involved, but there may also be policy questions involved about other options too. Do you want me to get into waivers?

[Alyssa Black (Chair)]: You want to tell us what a shop state is?

[Francis "Topper" McFaun (Vice Chair)]: No, because

[Karen Lueders (Member)]: Again, another thing I had to learn.

[Michael Fisher (Chief Health Care Advocate)]: Yeah, we opted out of it. We originally planned to do it, and then we opted out of it. This is a lot of years ago, and I can't now remember why it was that we opted out of it, but I'm just suggesting in the context of things to study about ways to support the small group, I would add that to the mix. And I can't say much more about it, but

[Karen Lueders (Member)]: Waivers, how we subsidize now?

[Michael Fisher (Chief Health Care Advocate)]: There's no subsidy in the small group.

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: Just individual.

[Alyssa Black (Chair)]: Up to 400%. So there's a federal subsidy under 400% on the individual market and then Vermont has elected to have what's called Vermont Premium Assistance, which then comes in and adds a little bit more based And I believe in the market report that there was a recommendation to possibly increase that. We're talking about the individual market though, not the other one. But there was And that maybe we're not subsidizing it up to the amount that we could without a waiver. I think. Maybe. Not true? Okay. There was a recommendation in there. Okay, I have no recollection of who was in order.

[Karen Lueders (Member)]: Quick move along to Chopper. Okay, really quick. Yeah, it's just a question. When I think about all of this is contingent upon the federal government changing the waiver and saying, yes, you can do this now. My question is, is it not possible to get the impact in the meantime so that if that happens, we are ready to launch. We have the information, we understand it, and we've also had a chance to think about or implement your other suggestion about what to do about folks that might be left behind. I don't know if you have an answer for it, but it's just kind of a suggestion as to, they could be simultaneous, while the federal government's figuring things out, we are also finding information.

[Francis "Topper" McFaun (Vice Chair)]: That's exactly what I thought the association plan was doing. We were gonna remove restrictions to develop a plan to be ready if the government did do it. We're not gonna do it, can't do it. Can't do it, yes. Until the federal restriction is lifted. So I just thought it was a way to get ready.

[Alyssa Black (Chair)]: Now

[Francis "Topper" McFaun (Vice Chair)]: what I'm getting a little bit concerned about now is if we're talking about studying and it's going to cost money, that's going hold this whole thing up.

[Alyssa Black (Chair)]: I'm not willing to spend money studying, but I'm also not willing to do it without a study. So

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: I just want to be really clear, because we've gone in a lot of different directions just pertaining to the association health plans. We do not know the effect that this will have on businesses or individuals at this point in time because no data was presented. I would like to ask us to go back to DFR and see if they have the capability within the funding they already have within their budget to do an analysis, which I would hope they would do anyway, to determine what their recommendation will do to the markets. I want to know that we're saying, if it comes back and we're only helping businesses by 1% or 2%, but we're raising individuals by 20%, that's a big deal. Maybe it's the other way, right?

[Lori Houghton (Member)]: Maybe 4% here will mean only two percent here. And then that's great. Let's help the businesses. But we just don't know. So outside of subsidies and anything else, I really can only support this if we put in or at least we talk to DFR about doing an analysis. That's all I'm asking.

[Francis "Topper" McFaun (Vice Chair)]: So Lori, y'all suggesting that we have DFR come in right now?

[Brian Cina (Member)]: I don't know

[Alyssa Black (Chair)]: if we need something. That's the question.

[Lori Houghton (Member)]: Right now, but I would like to know that if it's in their it is within their budget to do an announcement. Well, we

[Alyssa Black (Chair)]: did ask them questions. When they testified originally on this, we asked the question, what about this? What about that? And they said, we don't know. Right. So did we ask

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: the question? I apologize if I missed it.

[Daisy Berbeco (Ranking Member)]: Do you have

[Jennifer "Jen" Kirby (Office of Legislative Counsel)]: the money in your budget today? We didn't. We did not. And? You did the same. Let us know on five.

[Alyssa Black (Chair)]: Thank you, Nolan. Can I ask around the room, and I'm sorry because maybe I don't, is DFAR represented at all in the room today? Okay. Thank you. Brian?

[Brian Cina (Member)]: I don't know what the order is, you've been going this way. I just wanted to say that this raises a philosophical thing that I just want to put out there, that we're talking about creating more choice in a marketplace, which is a mindset of competition. It's this idea that pitting different options against each other is somehow gonna generate a better outcome for everyone because they're gonna have choice, and they're gonna be able to pick the best thing. But as we have learned, it it there's winners and losers, and it doesn't always shake out that way for everyone. And I just wanna point out that, like, we are the health care committee that if we look at humanity and then we look at human development and evolutionary biology, humans did not survive on Earth through competition. We are a social species who survive as a group. Like, we survive when we band together and we take care of each other. We don't when you we see when people are cut off, when they're isolated, they don't do well. Have a

[Alyssa Black (Chair)]: And the bands come back. Right.

[Brian Cina (Member)]: So then there's groups, and when the groups fight with each other, we don't think one wins, one loses, but when groups come together and solve problems together, then we progress. And as a species, we've progressed through collaboration more than our competition. And so our competition teaches us something, there's a place for it. But I think in the healthcare system, having competition between the healthcare plans isn't really the place to put our energy. And I just wanted to illustrate that. We're talking about this assumption that competition is somehow going to generate a better outcome. I think we've learned that that's not always the case. And then the other thing I wanted to say is when it comes to subsidies, my landlord told me advice his father told my business landlord once told me advice that his father told him that comes to mind today. He said, Listen kid, it's never really a business expense. It either comes out of this pocket or that pocket. What he meant by that is that when I'm thinking about it with the subsidies, it's like, so we create this market and then we're like, oh, it's going to hurt this piece instead of this piece, we're so gonna throw money into this piece to make up for the harm that's coming where's that money coming from? Well, if it's coming from the general fund, then it's coming from taxes, then people are paying someone's paying that anyway. So in the end, it's like what Alyssa said about moving deck chairs around. I think you said that.

[Alyssa Black (Chair)]: Yeah.

[Brian Cina (Member)]: Yeah. So I feel like I get I appreciate the idea, like, we wanna help one piece because we're causing harm to it by creating this other piece. But in the end, it just further illustrates the point that there there's all these variables, and I'm really concerned about further splitting people and creating competition without any proof that that competition is gonna make things better for the overall system. And I don't think the answer necessarily is to then spend a lot more time and money looking at all the different ways we can, like, plug the holes, you know, with money because it's just moving money around and moving deck chairs around. So I don't know. I just wanted to say that because I'm hoping we could think more more about how collaboration may be a better approach than competition in the healthcare system.

[Alyssa Black (Chair)]: So let's go Leslie, and then I think we're going to take a break. This has been a fantastic discussion, by the way, really. I mean that sincerely. Oftentimes I don't, but I mean that sincerely. I think it's been a great discussion.

[Leslie Goldman (Member)]: This discussion has really been focused on the impact of association health plans on cost of individual small group market, etcetera. Qualified health plans are really regulated by the Green Mountain Care Board. We really understand their rules. There's a lot of statute about what they can do. We don't have that structure around associated health plans. We don't know how they operate. And so there's a whole piece that worries me is the interaction of these plans with hospitals and providers of care. So I think it's important for me to know that impact included in this study. So it is beyond the actual insurance world, but it's about the whole system and the implications of adding a unregulated insurer to our system. And I feel worried about that. So I would want to include some information or study that the impact of adding this to the system. And I know you all spend money.

[Alyssa Black (Chair)]: No, I mean, I was trying to make that point. I know that we received some written testimony from a physical therapy profession and their support for the AHP plans. And I'm also thinking about some of the underwriters for the AHP plans. There was one in particular that I spent a year working back and forth with DFR and the Attorney General's Office because of unfair contract negotiations with physical therapy. And so I'm really concerned about that. We don't know the impact.

[Leslie Goldman (Member)]: I don't understand how association health plans pay the bills. What is their process? When do they pay? When do they not pay? Just saying I understand it. I'm not commenting on it. Just saying

[Alyssa Black (Chair)]: I don't understand it. Alright, so I think we should take a break until 10:30 and then we're going to move on. We're going to take some testimony on the section in the bill as it relates to what used to be, well it still is, H102 that was inserted in it. It's around just the reporting from sharing plans and we're gonna