Vermont Legislature SmartTranscripts:

[Theresa Wood (Chair)]: Welcome back, folks. For this next thirty five minutes or so, we're going to spend some time having a discussion about H. Five forty five, the act relating to issuing immunization recommendations. And I started to say, I don't know if I just had this in my head and didn't say it out loud, but I think I did say it out loud. In any event, Zon is going to be doing the floor report on this. Did I say that yesterday?

[Anne B. Donahue (Ranking Member)]: Yes. Okay.

[Theresa Wood (Chair)]: All right. Yesterday seems like a blur already. It's only the second day of the session.

[Zon Eastes (Member)]: It's the third week. That's your reaction.

[Jessica, Policy Director (Vermont Department of Health)]: It's the third week of the session?

[Theresa Wood (Chair)]: Don't confuse me.

[Esme Cole (Member)]: It feels like the

[Zon Eastes (Member)]: phone is I'm letting off.

[Anne B. Donahue (Ranking Member)]: Okay.

[Theresa Wood (Chair)]: We let's let's it's relatively short, Bill. Why don't you pull up the bill on your on your devices and pull up the 1.1 version? And Katie's already working on an amendment. But let's let's talk about what we heard yesterday. And, Lori, have have we heard back from the any of the witnesses, the additional witnesses that don't that like those two folks? No. Not yet. Okay. So I I want to make sure that people saw in the documents under yesterday public comments from

[Jessica, Policy Director (Vermont Department of Health)]: and

[Theresa Wood (Chair)]: Susan Bowen, in particular. Those are people who we did have not heard from in person. We extended our invitation to them. And Stephanie Winters, who was here yesterday, her written testimony has now been posted. When looking at the language, one of the things we didn't ask, but I did talk to Katie about, is the change in the language in vaccines to immunizations and was there a specific reason? And what Katie said this morning was it's actually throughout this part of law, it's used interchangeably. And so it's not a big deal. And I said, well, is this making it more consistent or less consistent? And she said more consistent. So that's really all that that means. So I thought that was So on page one, right at the bottom, the first comments that we had, both here and then from witnesses, and the use of the term domiciled in the state. So there was a request to remove domiciled. And there was a suggestion, not remembering who from, but to use who received care in the state or something like that. What are folks' thoughts about

[Zon Eastes (Member)]: that?

[Esme Cole (Member)]: I just offered that suggestion because they initially, Department of Health initially suggested just going back to the language, which says Vermonters, which I didn't see as really addressing their concern.

[Theresa Wood (Chair)]: It's not any different than this. Right.

[Esme Cole (Member)]: Cross border care that's received on New Hampshire, Vermont, New York, Vermont borders. So I had offered receiving care.

[Theresa Wood (Chair)]: Yeah, and I think the problem with that is there are a

[Anne B. Donahue (Ranking Member)]: lot of people who don't receive care routinely, but we want them to be immunized and that could be misinterpreted as meaning, well, if you're not seeing a doctor, include

[Zon Eastes (Member)]: it. I don't know.

[Esme Cole (Member)]: And I don't know what receiving care, sorry. Receiving care, whether that requires being under the care of a physician versus going into CVS and getting, so maybe it's to someone seeking immunization.

[Theresa Wood (Chair)]: Hey, why don't you join us?

[Esme Cole (Member)]: From New York who's getting treatment.

[Theresa Wood (Chair)]: Yeah, right.

[Esme Cole (Member)]: Right, for Markov.

[Theresa Wood (Chair)]: We're not really, we're sort of doing pre markup.

[Anne B. Donahue (Ranking Member)]: We're chatting.

[Theresa Wood (Chair)]: We're chatting. Oh, no. So the first thing we're chatting about is the language request from the department to go back to Vermonters at the bottom of page one. And I think Doug pointed out that doesn't really change the language that they're asking to strike, because Vermonter would mean that they're living here, I think the plain language version of that. So we're just trying to come up with language that doesn't exclude anybody who is seeking a vaccine in the state.

[Katie, Legislative Counsel (Office of Legislative Counsel)]: Yesterday, somebody used individuals who received care in Vermont.

[Theresa Wood (Chair)]: Yeah, we just decided that wasn't good. So, I mean, it was just suggested that individuals seeking vaccinations or immunizations

[Anne B. Donahue (Ranking Member)]: Yeah, ensuring universal access basically to anybody

[Theresa Wood (Chair)]: who to. For all individuals seeking immunizations. Right.

[Jessica, Policy Director (Vermont Department of Health)]: Oh, yeah. I have some questions

[Zon Eastes (Member)]: about the notion of your first notion, immunization and vaccination? It strikes me that there could be a subtle difference in, I mean, get that they're interchangeable. I think they probably are in a lot of ways, but the notion that a public could be concerned about immunizing people or about the notion of immunization is very different than the notion of vaccination. Vaccination is what you get, the very thing, but immunization is what a public is providing to a people, to a state or a population.

[Theresa Wood (Chair)]: It's almost an outcome of a vaccine.

[Zon Eastes (Member)]: Yes, exactly. It strikes me that the state has an interest in immunization of its people. But people get, individuals get to make the choice about vaccination I think that that could be useful as we go forward in this conversation because we're not, as I heard you say yesterday, we're not intending to mandate that everyone be vaccinated which might answer some of Todd's questions for instance. But the notion of immunization is a reasonable thing for a state to have and hold.

[Anne B. Donahue (Ranking Member)]: And support and have as a goal. But on the other hand, as you're saying, the universal access is to a vaccine as an individual. The goal of the state is immunization by encouraging people to have follow-up vaccine.

[Zon Eastes (Member)]: That's what I'm thinking about. I don't know if that would at all be useful in sort of teasing that out if it's too pale.

[Theresa Wood (Chair)]: I'm not sure that it is. I mean, it's why I asked the question this morning when I was meeting with Katie, and it was a question I had on my list, and I didn't ask it. I just forgot. But I think it warrants a further question back to the department, I guess.

[Jessica, Policy Director (Vermont Department of Health)]: Because I to estimate this.

[Theresa Wood (Chair)]: Well, is a plus about But whether we change, we want to inform- We want to understand better what their thinking was, because I think you make an important point that immunization is a result of having received vaccine. So, in some cases, it's interchangeable and in other cases, it's not. I think that's a good point. It feels like that we should probably have that on the record, that come that point on the record. So I'm just wondering if we could have Megan back. I wonder if she's able to come back tomorrow or the next day. Meredith Plumpton, the Immunization Program Manager, or Jessica. We can reach out to Jessica, the policy director, and Meredith to see She's here. Where? Is she in the room? Oh, I didn't see you, Jessica. I just looked all around the room looking

[Jessica, Policy Director (Vermont Department of Health)]: at the room. I'm Scott. Jessica Schmonekau, the

[Zon Eastes (Member)]: Director of the Department

[Jessica, Policy Director (Vermont Department of Health)]: of Health, and I have Meredith on my chat, she's given me the answer.

[Theresa Wood (Chair)]: That would be great. That'd be great. And are you sufficiently clear about the distinction we're making and the question? Yeah, okay.

[Jessica, Policy Director (Vermont Department of Health)]: Yes, we are. Okay.

[Theresa Wood (Chair)]: So we wanna be generic about those people requesting vaccines and get rid of the domiciled or Vermonter kind of thing. More to come on the use of the term immunization. Thank you, Jessica. I'm sure they saw it on the agenda. I thought that somebody would be here. Then we move down to line 17. All the other things are about essentially that substitution of that term. The department shall determine which recommended immunization shall be purchased under the program. So I think it's important to notice the difference between the funding program. So there's two things. There's two advisory panels here. There's the funding advisory panel, which we'll talk more about in terms of removing the requirement to meet. Seems And then the vaccine advisory panel that is made up of the medical professionals in the field. So just wanna make sure that people understand that there's two distinctions between the two panels that are referenced in here. So do people have any questions or comments about line seventeen and eighteen down there? And also in that little section down there, it says to be able to purchase it from the CDC or another vendor. What

[Anne B. Donahue (Ranking Member)]: page are we on? Page two. Oh, okay. We're on two. Thank you. Yep. Because I was looking at 17 on page one. I did that at Chris.

[Esme Cole (Member)]: Yesterday, a point was raised that the language talks about purchasing from the CDC or another vendor at the lowest available cost identified by the department. So would the department, I think plain language, they would be required to get the lowest price. The point raised yesterday was what if the CDC's comes with strings attached? Like, we'll sell it to you cheaper, but you must do A, B, and C, and those are not consistent with Vermont's goals. We would then perhaps not be buying from the lowest price.

[Anne B. Donahue (Ranking Member)]: Yeah. When you brought that up yesterday, I thought that was Yeah. The

[Theresa Wood (Chair)]: commissioner responded in a way that didn't actually specifically address that particular issue. His response, we're looking for very specific drugs that are by name and reference and all that kind of stuff. That's price quality. Right. They're not going

[Anne B. Donahue (Ranking Member)]: sacrifice No, it might, the strings might be around dosing or things like that.

[Zon Eastes (Member)]: Or even which vaccines are you can have, we'll sell you this one at this price if you take this one off the list or something based on that.

[Theresa Wood (Chair)]: Or demographics that would be. So I think the one thing that we know is that it is a moving target at the federal level. Things are coming out on a daily basis, multiple times a day about lots of different things. And it's not really up to us to predict what may or may not come out. But I think that we could tweak this language somewhat, Katie.

[Anne B. Donahue (Ranking Member)]: Unless there is whatever reason to.

[Theresa Wood (Chair)]: I'm not even sure we have to say where we're purchasing them from. Guess I'm that out as a question. Do people feel specific about us identifying. So we don't identify what the other vendor might be. Because we know how big Because we don't know.

[Esme Cole (Member)]: But it's the lowest available price where What I've borrowed

[Theresa Wood (Chair)]: I'm saying is that, do we need to reference any federal service?

[Zon Eastes (Member)]: They're just purchasing vaccines.

[Anne B. Donahue (Ranking Member)]: We just need to talk about the purchase. And not even say anything about cost. I

[Theresa Wood (Chair)]: think that's a question. A question of

[Anne B. Donahue (Ranking Member)]: have appropriate quality at the lowest cost or something like that, maybe.

[Theresa Wood (Chair)]: Meets the I like when somebody was going, meets the intent of the state's program or whatever they're calling it.

[Esme Cole (Member)]: Personally, I like having the reference to trying to get the best price. Think that's working out for volunteers and money. But with a clause or another of the lowest variable costs identified by the department, does not require or conflict with the intent of the Vermont immunization schedule or something like that?

[Theresa Wood (Chair)]: Or even the recommendations. Yeah.

[Esme Cole (Member)]: The committees.

[Zon Eastes (Member)]: So I have a question. It's not clear to me that we're actually spending Vermonters money. I've understood that this is

[Esme Cole (Member)]: all to be paid for by insurance companies. Well, I

[Theresa Wood (Chair)]: taxpayer dollars. I said no. I said Insurance insurance companies will be paying for it. But I told them. The way I understand it, Jessica can correct me if I'm wrong, because I asked this question yesterday because I some of the wording here was confusing to me. The department, the state obtains the lowest possible cost. The vaccine is obtained from the physician's office and then is billed to the insurance companies. And the department has a per member per month kind of thing that then funds the program. So yes,

[Zon Eastes (Member)]: think

[Theresa Wood (Chair)]: the wording is okay.

[Anne B. Donahue (Ranking Member)]: And the advantage of having said this whole program is that it's possible we get a much lower price if you're buying in bulk rather than different places buying it separately. But no, that's fair dollar.

[Jessica, Policy Director (Vermont Department of Health)]: Told them that. We

[Theresa Wood (Chair)]: agree to some kind of language to say that we want the lowest price consistent with our

[Anne B. Donahue (Ranking Member)]: goals the state. Goals of the program,

[Theresa Wood (Chair)]: Vermont's immunization program, for example, with

[Anne B. Donahue (Ranking Member)]: states. Yeah.

[Jessica, Policy Director (Vermont Department of Health)]: Jessica Shefano, I'm to partner of health. And on this purchasing thing, just one clarification for the committee. So the department would only purchase the vaccines outside of the CDC contract if they're no longer available or if there were strings attached. And the lowest cost piece would be if we needed to maintain access to the vaccines by purchasing outside of the CDC. Because I think our experience is that CDC will always provide the lowest cost if they do opt for the vaccines without strings, so we would default to that as the purchasing.

[Theresa Wood (Chair)]: You're saying that that qualifier, lowest available cost, is only applying to the other vendor?

[Jessica, Policy Director (Vermont Department of Health)]: I think it could apply to everything because CDC is always, like in our experience, it would always be the lowest cost. Yeah. Do offer it without strings, but it would be

[Theresa Wood (Chair)]: more So I think that with the suggestion, just to summarize, we want to keep lowest available cost. We want to keep another vendor. People are wanting to keep CDC, but we want to stay consistent with the goals of Vermont's immunization program or recommendations. Is that what I summarized what people said? Okay. Okay. This has sort of turned into a little bit of markup, sorry Katie. Okay, again the rectum, do you have immunization?

[Jessica, Policy Director (Vermont Department of Health)]: Do. Clarification to hear that speech. Yeah. It is a bit of a technical one. Immunization allows us to encompass both vaccines and some of these other new products, like the RSV monoclonal antibody that's approved for use, that's not technically a vaccine, so immunization is a little bit of a better term that would allow us access to these newer types of protections.

[Theresa Wood (Chair)]: Okay, so that's not something I was anticipating? No, me neither.

[Anne B. Donahue (Ranking Member)]: It just means you could buy it and make it available, in other Right, exactly. So it's really talking about the product. But in terms of where it's used elsewhere without scanning through, would that open it that the advisory committee could say, well we think this one should be on a recommended list? There's still the definition of immunization in there that has specifics about what the product would be, but

[Jessica, Policy Director (Vermont Department of Health)]: it is, you know, may be other sorts of new technologies that provide that sort of protection that wouldn't typically be considered test.

[Theresa Wood (Chair)]: What I hear you saying is that the science is evolving as science does, and you're trying to have this language be flexible enough to accommodate all of that. Okay, does that satisfy people? Yeah, it

[Anne B. Donahue (Ranking Member)]: does for now when we get to other sections of the bill, my mind might recycle that. Okay,

[Theresa Wood (Chair)]: so I'm at the top of page three now, this is where I got confused. On line six, Health insurance shall remit the department the cost of Bless you. Recommended immunizations as that cost is established by the commissioner. So are we saying that the health insurance I'm still confused by this. I don't know. Am I the only one who's confused by it?

[Jessica, Policy Director (Vermont Department of Health)]: Because I'm trying to figure out I

[Theresa Wood (Chair)]: get what it's saying, but it is. Are we saying that health insurers can only bill the department for the cost that the department has established? Is that what that's saying, Jessica?

[Anne B. Donahue (Ranking Member)]: Well,

[Theresa Wood (Chair)]: no, the term that cost is, yeah.

[Jessica, Policy Director (Vermont Department of Health)]: Page three, six through eight. Yeah, and I think our suggestion there to add that a cost is established was just to be clear about the reference back to what is being established by the commissioner, but there's concern or It

[Theresa Wood (Chair)]: doesn't make it clearer.

[Jessica, Policy Director (Vermont Department of Health)]: It's not making it clear, then I don't think it's an essential change.

[Theresa Wood (Chair)]: So let's delete that cost is. The other thing for folks to know is that with the help of Jen and Katie this morning, they did identify the part of the Office of Professional Regulation miscellaneous bill that had a reference to the pharmacist that the department referenced yesterday. And because these had to both have two different implementation dates, we're going to pull that language from there and put it into here. And we are working on getting AR to testify, just saying that that's okay, essentially. Because it is likely that these will have two different effective dates, and that will leave pharmacy in an odd space in between. Okay. So moving on to page four. Anybody have anything on page the rest of page three? It seemed like it was okay. On page four is the makeup of Which one is this?

[Anne B. Donahue (Ranking Member)]: There's no changes at all to anything on page four other than the vaccine.

[Theresa Wood (Chair)]: No, that's the funding advisory committee. Okay, I'm looking for removal of the date. Okay.

[Katie, Legislative Counsel (Office of Legislative Counsel)]: Ratio of designee was raised yesterday and all of Yeah, it I

[Anne B. Donahue (Ranking Member)]: was on A and B where it requires the executive officer of the board of pharmacy and it requires the executive director of the Green Mountain Care Board and anywhere else where we have a person that says designee. And usually I think that sometimes drafting implies or designee but if we're saying or designee in the same statute, it's true. We've got to go one or the other.

[Jessica, Policy Director (Vermont Department of Health)]: Well, can't you do a mix? I mean, I Yeah, sometimes you want that one.

[Theresa Wood (Chair)]: You might input it. Well, that's

[Jessica, Policy Director (Vermont Department of Health)]: the question. That's right. Is the question there. Is there an intent for it

[Anne B. Donahue (Ranking Member)]: to be that person and only that person. We've had statutory tasks that said that person and only that person. And then the departments have gone and had a substitute person. It's like, no.

[Esme Cole (Member)]: But you also might find that the executive director of the board of pharmacies has someone who is like an expert in this So

[Theresa Wood (Chair)]: is there an injection for A and B inserting or designee? Okay.

[Esme Cole (Member)]: It's the patient that's fit. Jessica, do you think

[Theresa Wood (Chair)]: the department's okay with that? Okay. I think it's a good point that there are probably people The executive director of Green Mountain Care Bear is probably not the most well versed person on this.

[Katie, Legislative Counsel (Office of Legislative Counsel)]: And then

[Theresa Wood (Chair)]: this is something that I hadn't personally seen in a lot of other things, but it probably exists. It's very specific about saying that the Commissioner of Health appoints these people. So does that mean that recommendations go to the Commissioner of Health from these organizations and then they're appointed? So that theoretically means the Commissioner of Health could say, no, I want somebody different. I'm wondering why it has to be appointed by the Commissioner of Health. See

[Anne B. Donahue (Ranking Member)]: through on C G. Yeah.

[Theresa Wood (Chair)]: I know it's current language, but once you start amending a bill. Right. I

[Anne B. Donahue (Ranking Member)]: think that there's some distinction in that some of the groups are, they're not a group who can appoint their own member. They have to choose And then somebody else has to appoint them, but some of them, they are they're ungrouped.

[Theresa Wood (Chair)]: Right, like three representatives of health insurers. One from each,

[Anne B. Donahue (Ranking Member)]: those health insurance would normally choose who they represent.

[Theresa Wood (Chair)]: What's the third largest health insurer in

[Anne B. Donahue (Ranking Member)]: the That's Cigna. By a lot less than? Yeah, they've always been near the three.

[Esme Cole (Member)]: Maybe.

[Jessica, Policy Director (Vermont Department of Health)]: Gee,

[Anne B. Donahue (Ranking Member)]: is no group. That would have to be somebody.

[Theresa Wood (Chair)]: I'm just raising it because it just seemed a little unusual.

[Jessica, Policy Director (Vermont Department of Health)]: Yeah, like for E and F, if

[Katie, Legislative Counsel (Office of Legislative Counsel)]: I were to draft this now, I'd say a representative appointed by the Vermont Chapter of the American Academy of Pediatrics. Yeah.

[Theresa Wood (Chair)]: Well, each of the health insurance would, because it says one from each, they would need to appoint their own.

[Anne B. Donahue (Ranking Member)]: Right. I and F ought to be

[Theresa Wood (Chair)]: I'm in favor of just having the groups appoint their own member rather than

[Anne B. Donahue (Ranking Member)]: than G.

[Theresa Wood (Chair)]: Oh, they probably have an association, I don't know. They Well, maybe. But we'll leave it like that one, yeah. So in places where it's not necessary to have the Exactly what you were just speaking of, Katie.

[Jessica, Policy Director (Vermont Department of Health)]: So for D, you

[Katie, Legislative Counsel (Office of Legislative Counsel)]: want the three insurers to do it?

[Theresa Wood (Chair)]: Yeah. And same with E and the same with F.

[Katie, Legislative Counsel (Office of Legislative Counsel)]: And c, this is interesting, nominated and then appointed. We just got appointed by the director?

[Theresa Wood (Chair)]: Yeah, the director of the blueprint. Yeah. Selecting a member from members at the first meeting of each calendar year, and then you don't have to meet. Sorry, I didn't have money.

[Anne B. Donahue (Ranking Member)]: We fixed that. Yeah, fixing that. Okay,

[Theresa Wood (Chair)]: I don't think there's anything else on that page, unless anybody else has anything.

[Katie, Legislative Counsel (Office of Legislative Counsel)]: Can I flag something? Yeah, of course. Okay, this is to existing law, but there's a change in the other committee. So the change in this on lines fourteen and fifteen, page four, says the committee will receive administrative support from the Department of Health. The other committee currently has administrative, technical and legal support from the Department of Health and legal technical support. There could be lots of reasons for that, but especially the legal support. I have heard over the past year or two that when that language about legal support is left out, that there's a gap in who answers questions like open meeting law, like who would answer that question. So I'm just flagging it because I don't know in the absence of saying that one entity is gonna provide legal support, who is answering those types of questions. Well,

[Theresa Wood (Chair)]: is I don't know, Jessica, if you can provide any insight into why the department's suggesting removing that in the other committee.

[Jessica, Policy Director (Vermont Department of Health)]: I think we have run into some challenges with Brigitte's team with how much legal support and what legal support is offered by the Department of Societies committees. And so I think that from our perspective, was trying

[Anne B. Donahue (Ranking Member)]: to alleviate that potential burden and confusion, but if

[Jessica, Policy Director (Vermont Department of Health)]: there are potential gaps that

[Anne B. Donahue (Ranking Member)]: are raised, I can certainly take that back and have more discussion with the subpoena.

[Theresa Wood (Chair)]: I sort of understand the sort of inherent, maybe potential conflict of interest, because it's supposed to be a group that's providing advice to the recommendations to the department, and the department's then now providing legal assistance too. So I get that. I also understand how it could be really demanding, because the request might be over and above what the department might have to, you know, just a capacity issue. Yeah, I'm not sure there'd be a capacity issue on this particular topic, I think, I guess I'm just going to ask Jessica if you can bring that back. And we would be making both of them consistent. I think we could probably remove technical or maybe we leave technical in and then the primary could decide who provides technical assistance. Like, that could be a technical question, I guess, on open meeting law. But we just have questions about why it's removed and they both should be consistent. And I see that they were actually moving in the opposite direction of probably where we would move in terms of making the department was making it consistent with what exists for this panel. But we would probably seek to add the other to this panel. It's probably the direction we would go. Okay, so we'll leave that one open, Katie. Thanks.

[Anne B. Donahue (Ranking Member)]: Yeah, go ahead. I have

[Zon Eastes (Member)]: a question on line 16. There was a request yesterday that rather than wait, that this might take effect on July 1, that it might take effect immediately. We'll consider that at some other point. But if January, if it were to take effect soon, then it's really essentially a whole year before line 16 report comes into it. And I don't know if it's useful, the information is just information needed to keep track of things or if it's actually information that's gonna be required to actually move ahead. Should we change that date in the first year?

[Anne B. Donahue (Ranking Member)]: I don't

[Theresa Wood (Chair)]: think we need to. This says by. By. Okay. It can be done before then. Okay.

[Zon Eastes (Member)]: Would just So be a request from the commissioner to have the report Yes, that's correct. One second. Okay.

[Theresa Wood (Chair)]: We're at the top of page five. We're leaving open the committee shall receive what type of support from the Department of Health. So we're asking for more clarification. Okay. And so at the top of page five, have, again, this is looking at the state recommendations. So I'll remove the word federal purchase requirements. Okay. So this is also getting at the issue that people were raising before. If the federal recommendations don't further the goal of ensuring universal access. It's

[Anne B. Donahue (Ranking Member)]: another paragraph referencing that. Which does that. Yeah.

[Theresa Wood (Chair)]: That we're going to follow our state's recommendations. Okay. Is it weirdly placed that it only needs got to it. I'm not sure why it wasn't there. Okay.

[Katie, Legislative Counsel (Office of Legislative Counsel)]: So,

[Theresa Wood (Chair)]: so this is a new section. So I'm going to stop us now because

[Jessica, Policy Director (Vermont Department of Health)]: we have to think

[Anne B. Donahue (Ranking Member)]: of them. Okay, So this is where I question that now that we know the medical, whether this should be recommended immunizations versus vaccines, because that then potentially opens up to recommendations on all sorts of other things. Maybe I'm just not sure. That's where I'm not

[Theresa Wood (Chair)]: familiar with the broader because it's a broader definition. So I need to understand better that. Okay. I'm thinking, Laurie and Jessica, that we should have Doctor. Hildebrandt maybe just zoom in for a couple of extra questions. But we'll wait until we get all the way through so he doesn't have to go more than once. Okay. All right. Thanks, Laurie. We're all set.