Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Good morning. It is Thursday, February 19 and this is Senate Health and Welfare Committee meeting. We are looking at a bill that we've worked on bit, S-one 157 on recovery residences and Katie, we have some language changes for that bill, so why don't we go through that? Good

[Katie McLennan, Office of Legislative Counsel]: morning, Katie McLennan, Office of Legislative Counsel. Here, oops. That's okay. Here is the latest version of S157. When we last met, we walked through changes that the health departments have presented. So this incorporates those changes into a draft. So the bill that's introduced had a section that created a voluntary certification program and outlined different criteria that would be required to obtain a voluntary certification. That section of the bill has been removed. Instead, section one, you're amending an existing definition section within the Title 18 chapter on opioid use disorder, or maybe it's the substance abuse disorder chapter, and you're amending that to add a definition of recovery residence. So, residence means a shared living residence supporting individuals recovering from a substance use disorder, to provide residents with peer support, assistance accessing support services, and community resources for individuals covering a substance use disorder. And then, because we've added it in alphabetically, there is a disjumper rate that's happening for the remainder of that section. Then section two is an existing section of law that lists the responsibilities of the health department's division of substance use programs, and this list of responsibilities, as in subsection B, are being added to the list as recovery residences, generally.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, okay, I'll ask those out. So it might be helpful. I'm glad the Department of Health is here, and so I might ask you a question after we go through.

[Katie McLennan, Office of Legislative Counsel]: Section three was, when the bill is introduced, it had been section two. This is the existing exclusions language that sets out what a recovery residence has to have in a written agreement with individuals who are staying at the recovery residence and seeking those services. There were some changes. One of the responsibilities is explaining the Recovery Residences Program's rules and social standards. We like that change. There was a discussion into, use the word interferes instead of interfering, to track how it was, you know, to be grammatically correct with the rest of the subdivision. And you have that in two places. And then, a definition of recovery residence in this section. This language in the bill is introduced had been struck through, and it referenced the definition that had been in section one, which was the section creating a certification program. Because that section has been eliminated and now there's section one is an amended definition section, we're just changing the cross reference number here so that it's cross referencing the correct section where the definition is. This section four has not changed. Obviously, you've seen it in the bills introduced, but you do have a new section on rulemaking for recovery of residence certification here. So on or before 09/01/2027, the Department of Health shall file an initial proposed rule with the Secretary of State for the purposes of establishing a voluntary recovery resident certification program. At a minimum, the rule shall require that a recovery resident seeking certification from the state comply with the certification standards of VTAR or another organization approved by the department, and set forth minimum data collection and reporting requirements for certified recovery residences, including data elements and frequency. And then in subsection B, the department shall complete the rulemaking process and adopt a permanent rule pursuant to our rulemaking chapter on or before 12/01/2028. So that gives a thirteen month window between when the initial filing has to happen and when the conclusion of the rule making process is occurring. I was concerned about who's having a directive to start rulemaking and not finish it because it sounds like you could just file with the Secretary of State and we have fulfilled your obligation under the statute. That's why subsection B is added. Then we have the same effective date language. So essentially, this is a change in who is determining the details for how certification is happening. The bill is introduced, had a statutory section where the legislature was coming up with the specific parameters for what would be required of a certified recovery residence. This rule making language instead is delegating a lot of that responsibility to the health department to come up with those specific criteria for how a certification program would be operated.

[Sen. Virginia "Ginny" Lyons (Chair)]: Questions for Katie? Go ahead. Okay, I do have a question. First, I'm gonna look to the Department of Health and ask you folks, Do you wanna come up and talk about this? Good morning, good morning. Emily Pewter, Department of Health and Prevention and Sustardous and Prevention. So, maybe just a general comment about what's included here and capacity to do the rule making and oversee the certification. Sure, what I like about the rule making process is that it brings it on to a level playing field with substance or treatment services, recovery services organizations, and offers sort of a unified playing field for the service fee team. We do have the capacity in house to conduct that process, and we are well versed and have recently gone through a formal process for recovery service organizations. It's also fresh.

[Emily (Vermont Department of Health)]: So I feel confident and willing to be able to accomplish that. You've answered my other question. Do you have the capacity right now? We do. And

[Jennifer Carbee, Office of Legislative Counsel]: then a third question you may not be able to

[Sen. Virginia "Ginny" Lyons (Chair)]: answer, but I know that the World Health Transformation grant there will be RFPs going out. Will any of those relate to this work, do

[Jennifer Carbee, Office of Legislative Counsel]: you think? That is my intent. There are others about people who have

[Sen. Virginia "Ginny" Lyons (Chair)]: to approve that and we're still in the member who process that has several layers. We've never received the federal grants of this type with the type of administrative exemptions. So that's for me in my role, my goal, but obviously, you'd love me to make this. And so as long as you include Chittenden County, I'll be happy. I live there. Well, there are people in Chittenden County in great need, and somehow there's gotta be a link in this world across the states. Anyway, no, you don't have to respond on to my comment. Senator Morley.

[Sen. John Morley III (Member)]: Just for my benefit, the way we provide Rule making. So we're not gonna develop standards or how it works. You give the authority, as I recall, to

[Sen. Virginia "Ginny" Lyons (Chair)]: the Department of Health. Through the administrative Rules Committee? Act. Is it Title III? Yeah, Title III. We give them the authority to make the rules. We have certain conditions that are lined up in the bill and we can add or subtract. They write the rules with a public comment period that people from enemy share what they think would work for this process. The rules are developed over usually a long period of time, but anyway then it goes to ICAR which is the administration's rules committee and they go to ICAR and I think John Brown's still with care, don't know, but they go to that committee, that committee from the full administration looks at the rules and says, This looks good. The Secretary of State, ICAR, then it goes to the legislative committee on administrative rules. I was on that for many years. And that committee then looks at the rules. They ask committees of jurisdiction, do these rules meet underlying statute? That's okay. Signs awe on that. Yes or no? Ask questions. Then LCOG reviews the rules, looks at them, and will approve, disapprove, or say get back to going more than usual, it's true by the time they get there, happy apocalyptic Very

[Sen. John Morley III (Member)]: So that's what's giving it its legislative Authority. Right.

[Sen. Virginia "Ginny" Lyons (Chair)]: If it's done through rule making, implementation done through rule making. So would have the choice of saying just this will just happen. No rules, I think. We have the choice of saying that whatever happens specifically for certification, we have to write the legislation that will oversee that. That will take that. Or we put rules in place that allow for the administration to oversee it, and it sounds like they're obviously doing this for other studies. No, no,

[Sen. John Morley III (Member)]: I thank you for that.

[Sen. Virginia "Ginny" Lyons (Chair)]: No. That's okay. You know, that's quick and dirty, and I know I probably said a thousand things that other people are gonna start collecting.

[Sen. John Morley III (Member)]: Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: May I add one thing to that? Sure. I think it has a more comprehensive stakeholder engagement piece. I think that is really effective. We Oh, do, at least in my experience, I've found that the substance use and substance use disorder continuum participates, so I would expect a large swath of individuals to participate on that concept, which I have their GP. And we report that the chair of many things contains all that Information. Input. It contains the response from the compartment to that input. It's a big packet. Sometimes three and four of them come at a time frequently in July, when these communities are Right. When it's sunny out. No. No. No. It's good reading. Honestly, Virginia, come sit down. I read the public comments first and the response deck. That's one of the first questions. I'm glad you brought that up because that's one of the first questions that we ask in Did you hear from enough people? Did you have enough public hearing?

[Sen. John Morley III (Member)]: That was

[Sen. Virginia "Ginny" Lyons (Chair)]: it. That's a good question. Anything else? Anything else for Emily? So your sense is the department has the capacity to do this work and follow through with other folks in the group. Absolutely. So, yes, we're looking around the room. Is there anyone else who would like to comment at this point? Anything we left out? It goes to the other other chamber, I'm sure there will be other things added in. So why did they leave this out? Sorry,

[Jennifer Carbee, Office of Legislative Counsel]: Candice Ginny. Please. Yeah. From Vermont Foundation of Recovery. We had sent in an email from Jeff Moreau from VTAR about or it was from Susie Walker from Recovery Partners of Vermont about a couple of small changes that are in the bill.

[Sen. Virginia "Ginny" Lyons (Chair)]: Did you copy, Calista? Yes.

[Jennifer Carbee, Office of Legislative Counsel]: And you did? And the committee. Yeah. Katie.

[Sen. Virginia "Ginny" Lyons (Chair)]: Let's can we do have that? Do you have comments that you can make right now that we could look at? Sure. Sometimes those emails get lost. Yeah. It's okay. I do remember that. Have it? Okay.

[Jennifer Carbee, Office of Legislative Counsel]: I have it. Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: You have it? Do you wanna put it?

[Jennifer Carbee, Office of Legislative Counsel]: How should we do this?

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. I know. I'm like

[Jennifer Carbee, Office of Legislative Counsel]: I have it too. I don't know.

[Sen. Virginia "Ginny" Lyons (Chair)]: Then you just Melissa. Okay. Right. So I'm gonna take a look at Yep. It Okay.

[Jennifer Carbee, Office of Legislative Counsel]: Chair, my folks action circles. If you want, Candice, to

[Sen. Virginia "Ginny" Lyons (Chair)]: just bring this up and Yeah. Can you throw it up on the screen? We could share that. Will say just thinking about LPARD, what was the the last big read was with Medicaid eligibility. Maybe mute Michelle.

[Jennifer Carbee, Office of Legislative Counsel]: I I'm doing Sorry.

[Sen. Virginia "Ginny" Lyons (Chair)]: It was so big. We'll we'll get there. I'm getting there. I'm here. Oh, look at you. It's great. Okay.

[Jennifer Carbee, Office of Legislative Counsel]: Alright.

[Sen. Virginia "Ginny" Lyons (Chair)]: Can't be with that.

[Jennifer Carbee, Office of Legislative Counsel]: I will read it. Yeah. Thank you for the hard and thoughtful work you're doing on behalf of Vermonters. I'm ready today to express RPV support for S 157. The Department of Health suggested changes to achieve a medium option in providing guidelines to certified recovery residence operators without imposing undue burdens. We believe the changes will protect both residents and operators and enable the scaling of Vermont's recovery residence systems to meet the goal of 400 beds by 2030. Ensuring that the bill takes effect on 07/01/2026 when the landlord tenant exemption sunsets avoids disruption and positions the resident operators to continue their success in providing safe, supportive recovery housing with accountability, distinguishing these residents from typical rental properties. Rule making would take effect on 09/01/2027, as the bill states. The recovery of Vermont supports the previously provided department language with these revisions. Exempting recovery residences from section four four six zero and four four six four of landlord tenant law in nine b s a four four five two b one. Adding volunteers to language in nine BSA four four five two b one a b and nine BSA four four five two b one c, and removing a reaffirmed after seven days or modifying the language to reaffirming verbally or with signage in nine BSA four four five two b one b.

[Candice Gale, Director of Community Relations, Vermont Foundation of Recovery]: Okay, and for the record, your name is? Candice Gale, Director of Community Relations. This is great. Katie, do you have this language? Yep. Okay, So what can what we'll do is we're gonna swap places and let Katie come up and then we can understand exactly what it is you're asking and how it's fit within the business. Sure. Should I stop sharing? Yeah. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Perfect. Thank you for raising your question. Okay.

[Jennifer Carbee, Office of Legislative Counsel]: So the first bullet point is to have two new exemptions

[Sen. Virginia "Ginny" Lyons (Chair)]: for We go to the bill to look at where they would stand.

[Jennifer Carbee, Office of Legislative Counsel]: Yeah, I was gonna bring you to the language that would be exempted. Okay, let's do that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay,

[Jennifer Carbee, Office of Legislative Counsel]: so right now there are a few exemptions for recovery residences from landlord tenant law. You remember Cameron was here and he walked you through them. So, what's being proposed is adding two more exemptions from landlord tenant law. The first one would be exemption from this 4460, meaning that the recovery residences would not have to follow this law. It says that a landlord may enter the dwelling unit with the tenant's consent, which shall not be unreasonably withheld. A landlord may also enter the dwelling unit for the following purposes in the hours 9AM and 9PM on no less than forty eight hours notice, when necessary to inspect the premises, to make necessary or feed repairs, alterations or improvements to supply green services, or to exhibit the dwelling unit's perspective or actual purchasers, mortgagees, tenants, workers or contractors. A landlord may only enter the dwelling unit without consent or notice from the landlord telling reasonable belief that there is an imminent danger to

[Sen. Virginia "Ginny" Lyons (Chair)]: a person or to property. So you're asking for an exemption from all of that? Okay.

[Jennifer Carbee, Office of Legislative Counsel]: So that's the first one. Let me stop sharing and I'll pull up the second exemption.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, forty four sixty four. Here we go. Okay. Any

[Jennifer Carbee, Office of Legislative Counsel]: tenant who sustains damage or injury as a result of an illegal eviction may bring an action for injunctive relief, damages, costs, and reasonable attorney's fees. A court may award reasonable attorney's fees to the landlord if upon motion and hearing it is determined that the action was not brought in good faith and was frivolous or intended for harassment only. So this would not apply to the tenants of our recovery residents if this was listed as an exemption. Okay. So those are the two exemptions. The other changes being requested. Let me flip back to the bill.

[Sen. John Morley III (Member)]: Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: So

[Jennifer Carbee, Office of Legislative Counsel]: right now, this is the correct paragraph. The proposal would be, I think, it doesn't say where, but I'm assuming it would be to say, or volunteers, right before this semi colon. So, this is the signed document and this is listing everything that's in the document. So, indicating that by signing an agreement, the resident acknowledges the recovery residence may cause the resident to be immediately exited or transferred on alternative housing if the resident violates recovery residents of substance use policy, regularly refuses to engage in services or programming, commits a crime, engages in theft, interferes with the recovery of other residents, or engages in acts of violence that threaten the health or safety of other residents or recovery residents, staff, or volunteers. Yes. And then the last piece,

[Sen. Virginia "Ginny" Lyons (Chair)]: what about the last piece?

[Jennifer Carbee, Office of Legislative Counsel]: The reaffirming after the seven days. Oh, right. Can pivot. Is that? It's right here. Seven and a Okay. Also part of the agreement, this is existing law that the recovery residence has obtained to a resident's right consent to its residential agreement, reaffirmed after seven days. The conversation, when this was adopted two years ago, was that sometimes when individuals come into the recovery residence, there's a lot going on for them, moving locations, so there's a conversation about requiring reaffirmments and going through the written agreement again after seven days after somebody was settled. There may be reasons not to do that, but that was the discussion in the two committees a couple years ago. So what's the suggestion? Either strike it or not have it be in writing, I believe, yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Question? Yeah, no, go ahead, ask you. Yeah, why?

[Candice Gale, Director of Community Relations, Vermont Foundation of Recovery]: Yeah. Candace Gaddle, Director of Community Relations for V4. So basically, we go over we have the printed out material in their rooms. We do go over this after seven days. Right now, there's an attestation attestation that is sent after that seven day period, and that is really cumbersome, especially for new operators to have to do the attestation when they're first going over all the paperwork and then reaffirming with another written attestation seven days later, and then having to send that to VTAR to make sure that it's then like put in their file. We write it in the notes in our like, you know, systems, the word we track everything. It's posted on the walls, all of the policies and procedures. So this is basically just say, can we just say that we're reaffirming? We are reaffirming after seven days, but we are doing it verbally or with signage within the house without having to like go through a thorough process every seven weeks especially for new operators that aren't going

[Sen. Virginia "Ginny" Lyons (Chair)]: to have those systems put out. Okay, thank you. I remember this was a for the concession. Is there a question here? I'm gonna give my comments right now. We're very close to getting this bill. What you brought to us regarding those exemptions I think are something that could be carried to the House. I feel very strongly about that. If we did that now, it would probably go to at least one or two other committees, which would be concerned regarding cost. And I understand your commitment and your interest here, but we want to make sure that this goes forward. That's one. Interferes with volunteers. Interferes with That works. I mean that makes a lot of sense. And then similarly with the retina, that's a whole new place where we have to have a longer discussion. I'm sympathetic, I'm empathetic, I'm understanding. I really think that those two requests are better taken up in House Human Services. Honestly.

[Sen. John Morley III (Member)]: Senator Morley. I have called the chairs because I probably would have voted no just because it came in so late and I wouldn't have to

[Jennifer Carbee, Office of Legislative Counsel]: send I mean

[Sen. Virginia "Ginny" Lyons (Chair)]: they could send an email, there's no late notice here, there's no late notice, it's just, it's a big thing to do at this stage.

[Sen. John Morley III (Member)]: That's what I'm saying, because if you're going to go hold this out today,

[Sen. Virginia "Ginny" Lyons (Chair)]: We don't it could go to economic development and it could go to judiciary. Economic

[Jennifer Carbee, Office of Legislative Counsel]: development. Economic Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. I don't wanna go to economic development.

[Jennifer Carbee, Office of Legislative Counsel]: It's really

[Sen. Virginia "Ginny" Lyons (Chair)]: not their decision, but it does affect their jurisdiction. I'm looking at Department of Health, and, you know, listen, there's rule making in here. It could be that the house will start making decisions about alternative requirements for rule making that may affect landlord of vendor Ginny landlord member issues. There are ways of looking at this. Looking at Department of Health, these things that you want to back on the.

[Jessica Chittenden, Policy Director, Vermont Department of Health]: This is Jessica Chittenden, policy director, department of health, and I think we don't have any concerns about them, but certainly, like to mention about the process, in the warrant consideration. I do want to point out that the changes in the exhibitor and the original comments from before and I think we have a walk through with that ready so but yeah we we don't have any concerns about the changes but would be concerned with one thing from hospitals and getting her to hospitals soon. Alright. My suggestion is mull this all over given the but I'm if we mull it over, it will take more testimony, and it will take possibly another mulling it over as well.

[Sen. John Morley III (Member)]: I agree with where you are. I think change to add the volunteers. I got no problems with that. And you have concerns about opening up sort of Pandora's box on some of these other things that I feel would require a lot more discussion before I'd be comfortable saying that I can strike the note section.

[Sen. Virginia "Ginny" Lyons (Chair)]: I agree with Senator Benson and with you, and I feel, especially with this language around the added administrative burden I get after seven days, at the same time, I could foresee that someone might not take it as seriously if it isn't

[Jennifer Carbee, Office of Legislative Counsel]: signed, sealed, delivered. I

[Sen. Virginia "Ginny" Lyons (Chair)]: want to make sure that after seven days, have had a chance to settle in and absorb and do whatever's necessary to make sure that the process and the experience is a positive one. So I just worry if you don't make it, you know, caught by that.

[Sen. John Morley III (Member)]: I agree. That's a protection. Yeah. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: I think we're gonna majority of people who are agreeing to not add any denture at this time. It's not that we're we're not it's not that we're not open to its consideration. So just to let you know that Oh, that's really hard. I'm gonna suggest that

[Jennifer Carbee, Office of Legislative Counsel]: are you here tomorrow morning? Yeah. Must have just scheduled now. That felt very smart. She's on it.

[Sen. Virginia "Ginny" Lyons (Chair)]: This might happen. So tomorrow morning, let's walk through the bill with the volunteers second and then we'll I hope we'll be ready to pass it for the full senate but really good. It's a good bill, and it's a good start. Okay? We know. It's a good start. There's a lot more that we could do. The house is all day. They're gonna. Okay. Thank you. And so now Jen is here. We have a joint assembly that so we're gonna adjourn at 10:15. We have a short interview. Thank you all. Thank you for your forbearance on our email world and also on our being positively about this bill. All right. Thank you for being here.

[Jennifer Carbee, Office of Legislative Counsel]: Good morning. Harvey from the office of legislative council. So yes, we are shifting gears. So can

[Sen. Virginia "Ginny" Lyons (Chair)]: I say one thing before we start So you know as hospitals are going through the whole transformation work with the state health plan, they're concerned about, they're working together, in particular some of the hospitals in the Northwest and Northeast Kingdom working together to find savings and efficiencies but they're very concerned about challenges related to monopoly? This bill has that information in it. Some people think we need it, some people think we don't need it, but we'll hear it from the hospital association. First, we need to know what's in the bill.

[Jennifer Carbee, Office of Legislative Counsel]: Great, all right. So yes, we are here to look at S-two 49, which is an act relating to possible collaboration in state action community. And as the chair said, there are efforts with the hospital transformation work to have hospitals work together to find opportunities to share resources or provide services on a more regional basis, but there are concerns about anti competitive behavior and antitrust liability. So that is what this bill is seeking to address. So, S-two 49, the natural leading hospital collaboration and state action community. And sort of from a broad standpoint in antitrust law, there are some exceptions to antitrust liability when the state is providing appropriate supervision. And so, the idea of state action immunity is that the state is sufficiently supervising the activity such that any outcomes are effectively the actions of the state or approved by the state, then they are accorded immunity from otherwise applicable antitrust liability. So that is what this bill is seeking to do, is to provide kind of a framework for how to achieve state action. We talk a lot, even in some existing bills or legislation, about sufficient supervision, but what does that actually look like? And that's what I've tried to kind of spell out a path on that in this bill. So it starts out with a discount. It's a new section that we go in Title 18 in the chapter on healthcare administration, which is where a lot of fairly general healthcare inpatient provisions go. Starts out with legislative intent that hospital and health system collaboration efforts that meet the requirements of this section be afforded state action immunity under applicable federal and state. There's antitrust laws of federal and state laws, so under applicable federal and state laws. And it specifies that this community is in addition to the hospital cost containment conduct that is aborted state action immunity under a particular provision. That's a provision saying if the Agreement and Care Board tells a hospital, either directs them or authorizes them to do something specific in a hospital budget order and provides appropriate supervision of how that's implemented, that is already entitled to, try and have

[Sen. Virginia "Ginny" Lyons (Chair)]: it entitled to state action immunity. Just a clarifying question to the attorney. Do we have the right to

[Sen. John Morley III (Member)]: basically give immunity for federal law?

[Jennifer Carbee, Office of Legislative Counsel]: Oh, in the sense that the concept of state action immunity actually comes, I think was originated at the federal level. And so, basically what the federal government is saying in the state action immunity doctrine is states, you're allowed to do a lot of things on your own, and if you are kind of supervising to such an extent that you are in charge of the activity that would otherwise be anti competitive, and the state, basically we're gonna defer to the states if the states are actively supervising it. So yes, we can at least attempt to give state action immunity. There's certainly the potential that the supervision would be deemed insufficiently active at the federal level, and there could still be, so there could still be, it's not a slam dunk. It has to actually be carried out in an active supervision kind of way. So yes, if all of the steps are followed for the state to say, here's what we're trying to do, we're trying to say otherwise anti competitive behavior is okay. If it is because we are actively supervising it, and then the act of supervision happens, then the courts have looked at conduct like that and said, it's okay because of the act of supervision. It's a long way of saying yes.

[Sen. John Morley III (Member)]: Hope I follow where you're at.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's saying you're not a lawyer, but she is.

[Jennifer Carbee, Office of Legislative Counsel]: Did, I went down to grab a

[Sen. Virginia "Ginny" Lyons (Chair)]: hole

[Jennifer Carbee, Office of Legislative Counsel]: on this, working on language.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, there's a, we have the, The DNAs are sort of allowed certain sections of the state. That's kind of a

[Jennifer Carbee, Office of Legislative Counsel]: Yeah, think that's a little bit Yeah, think that's a different concept, because there isn't necessarily the active state supervision requirement on the ongoing basis. But I think we have, yes, we have provided territories, regents for, I

[Sen. Virginia "Ginny" Lyons (Chair)]: think the names. Senator Morley. Senator Cummings.

[Sen. John Morley III (Member)]: I didn't know any of this. I was gonna ask the same question. Senator Benson did. What's the risk if the Feds, the federal law says, you guys really didn't do what you're supposed to do at the state level? You shouldn't have allowed hospitals to or you don't have it set up well enough or something like that. I'm guessing it's low because I think we're gonna do a really good job as far as I'm concerned.

[Jennifer Carbee, Office of Legislative Counsel]: Well, I mean, think it'll be helpful to see what the process is that's laid out in the bill. But the case law that where the, most of the case law is where, at least the case law that I'm finding, is where the feds have said it was not sufficient state supervision. And that's things like where the state says, Go for Like, we were to say, hospitals, go forth and do whatever you want because we've

[Sen. Virginia "Ginny" Lyons (Chair)]: said it's okay. That doesn't work.

[Jennifer Carbee, Office of Legislative Counsel]: That's not enough. That's not active state supervision. And even to say, let us know you're working together and whatever you're doing is fine. Still doesn't seem to be that. But for the state to have some sort of an active role, basically what they're saying in the case law is if the state makes the anti competitive behavior its own, so whatever the outcomes are, the state puts its imprimatur on it and says yes, state approves, then it's effectively the action of the state, even though it's private entities who are doing the actual duties there. So the liability would be on, I think, the hospitals. If our system was not sufficiently set up or we didn't actually do the active state supervision, I mean, it's the hospitals whom the federal government would be going after Oh, staying thought it was

[Sen. John Morley III (Member)]: paid down care report then.

[Jennifer Carbee, Office of Legislative Counsel]: So do you disagree with that? No, agree. So

[Sen. John Morley III (Member)]: it's the law school tax.

[Jennifer Carbee, Office of Legislative Counsel]: So the way I've set this up, it's a whole process with the AHS doing the supervision with some additional reporting going to the attorney general's office. But if there were to be an antitrust violation, it would be, the people being sued would be the hospitals. Because the feds would be saying, You have engaged in anti competitive behavior, and then the hospitals would say, No, no, we were following this state process, and we were being actively so it should have been okay. And then it would be up to the court to decide whether our active supervision scheme that is set up and the execution of it was sufficient.

[Sen. John Morley III (Member)]: Legislation should be absent.

[Jennifer Carbee, Office of Legislative Counsel]: I don't wanna stop saying what I was doing.

[Sen. Virginia "Ginny" Lyons (Chair)]: No. I was just saying, I think the last time we did this was the write up. Was it home care providers or child care workers to unionize? And they were individuals, and they couldn't I think it was the home care providers

[Jennifer Carbee, Office of Legislative Counsel]: where you get to hire your own.

[Sen. Virginia "Ginny" Lyons (Chair)]: And but they they want to unionize to negotiate with the state, and it was very controversial. It was a child care provider at one point for child care workers and the state had to state we will supervise this because, yeah, which is what we need to consider. Do you want to

[Jennifer Carbee, Office of Legislative Counsel]: look at the language? Yes, go ahead. I understood there would need to be some sort of level setting on what we're talking about. Right. So, that's helpful. All right, so we're starting out with our intent. The intent statement here is we're trying to do state action immunity, basically what we're saying. And here's how. So the qualifying conduct. Conduct undertaken by, some of this was language given to me, so we may need to work with hospital association on terms, but undertaken by rural hospitals, community hospitals, health systems, or a combination or, and then these are the purposes, so this is part of what's important in state and actual communities having specific purposes. For the purposes of cost containment, improved access to care, quality improvement, preservation of rural or community hospitals, advancement of the state healthcare delivery strategic plan, once that's established, or enhancement of any existing healthcare initiative in a matter that is consistent with the principles expressed in ATBSA 09/1971, sometimes called the Act 48 Principles. So conduct undertaken by hospitals or health systems for these purposes shall be afforded state action immunity from, and they don't know who we need to specify, but under applicable federal and state antitrust laws,

[Sen. Virginia "Ginny" Lyons (Chair)]: if the conduct meets all of the following conditions. Can I, yep? So it says once the plan is established, so I'm modifying that because right now the hospitals are changing within the plan process. I'm talking about how we add the plan process to them.

[Jennifer Carbee, Office of Legislative Counsel]: Well, think that, I mean, the transfer, I think just saying as part of hospital transformation isn't specific enough. I think the purpose, so I was trying to list out the purposes of I agree, I understand, but

[Sen. Virginia "Ginny" Lyons (Chair)]: having something about, this is a word, that's that we can talk about another time, that's sliding in.

[Jennifer Carbee, Office of Legislative Counsel]: Alright, so here's the conditions that have to be met. The Secretary of Human Services authorizes the parties to explore opportunities to collaborate to achieve one or more of those purposes, and the Secretary of Human Services deems any initiatives proposed by the collaborating parties as a result of that authorized collaboration to be consistent with the state's healthcare policy goals, and the Secretary of Human Services approves each initiative proposed by the parties prior to its implementation, and the agency actively supervises the parties' conduct throughout the collaboration and implementation, and that is spelled out more in subsection D. So that's qualifying conduct. Conduct that is undertaken by some combination of hospitals and health systems for any of these purposes, get state action immunity, if all of these steps are met. You can go to some of these in more detail. But then there's specifically authorizing information sharing. It says hospitals and health systems that are participating in discussions and collaborations that are approved under this section may share cost utilization, workforce, and quality data as needed to achieve the purposes of the collaboration. That information sharing shall not be due to violation of federal or state antitrust law. Let me get to the process for approval and what state supervision looks like. Subdivision 1, here's just sort of our overall construct. A hospital seeking to collaborate with another hospital or health system in a manner that the hospital determines may violate state or federal antitrust law shall seek approval from the Secretary of Human Services prior to engaging in that collaboration. And separate approval is required for the parties to discuss and explore opportunities to work together to further the state's health policy goals, using the process we'll see set up, and for implementation of any initiatives developed pursuant to those discussions. So separate approval for the conversation and then for the implementation. So first we get to the conversation group. A hospital that's interested in exploring potential collaboration with one or more hospitals or health systems must submit an application to the Secretary of Human Services describing the proposed collaboration and specifying the manner in which the proposed activity would further the state's health policy goals and achieve one or more of those purposes that were at the beginning of Subsection B. Then the Secretary reviews the proposed collaboration and can ask for additional information or an informal hearing or both. And within thirty days following receipt of the proposal, the Secretary can approve, approve with conditions, or reject the proposed collaboration. Approval or approval with conditions constitutes the Secretary's determination that the proposed collaboration is consistent with the state's health policy goals and likely to achieve one or more of those specified purposes. If the Secretary rejects the proposal, the Secretary's decision has to include the basis for the rejection and the ways that the proposed collaboration fails to align with or further the State's Health policy goals or achieve any of those purposes. It also allows the Secretary to order a hospital or health system that's doing a collaboration to obtain the services of a third party aggregator or facilitator as a condition of approval at the hospital or health system's own expense. And then there's a reporting requirement. If the secretary approves the collaboration with or without conditions, the collaborators have to report to the agency human services at least quarterly, or more frequently as required, describing material developments related to the collaboration, and including any third party reports if an aggregator or facilitator was required. So that's getting approval for what the collaboration process looks like. And then if the parties, during the collaboration, come up with initiatives that they want to implement that would further the state's health policy goals and achieve one or more of the specified purposes, then they submit a joint application describing those initiatives to the Secretary of HS for approval. The application would include the names of the parties to the proposed initiative, how each proposed initiative would further the state's health policy goals and achieve, and then it lists those purposes again, or enhance an existing initiative, or a combination, the expected impact of each proposed initiative on patients, providers, payers, and the state, and a timeline for implementation. Then again, the secretary reviews the application and can ask for additional information or request an in full hearing, or both. This one has sixty days, these are just numbers, you can change timeframes, change any bit. But within sixty days following receipt of that application, the Secretary would approve, approve with conditions, or reject proposed initiative or initiatives. Approval of conditions constitutes the Secretary's determination that the initiatives are consistent with the state's health policy goals, and that they can achieve one or more of the specified purposes. The Secretary rejects it. Again, the decision has to set forth the basis for the rejection, and the ways that the proposal fails to align with or further the state's policy goals, or achieve any of the specified purposes. And again, the Secretary can order the parties to retain the services of a third party aggregator or facilitator. Then the quarterly reporting would continue, or more frequently required, throughout the course of any approved initiatives. And this allows the Secretary to revoke approval, or require submission of additional materials at any time Secretary finds that the collaborative conduct is inconsistent with state's health policy goals, is not on track to achieve any of those specified purposes, or materially deviates from the original application, so they start going a different direction. And this allows actions taken in furtherance of a collaboration, either the conversation or the implementation, to occur without the presence or involvement of any state employee. They don't have to have AHS in the room at all times, As long as the parties report their activities to the agency as required, submit any additional materials reasonably requested by the agency during the collaboration, get additional approval from the Secretary before engaging in any collaborative activities that exceed or deviate from those approved, and ensure that their efforts continue to be aligned with and in furtherance of the State's policy goals. For the most part, except as specified in subdivision two, everything submitted, all applications, reports, analyses, and other materials submitted to or generated by the Agency of Human Services in connection with a proposed, approved, or rejected collaboration are exempt from public inspection and copying under the Public Records Act, are presumed to contain proprietary or competitively sensitive information and shall be kept confidential unless a hospital or health system specifies that any of them does not need to be, and should not be considered exempt or does not need to be kept confidential. Notwithstanding subdivision one, the AHS can make publicly available the fact of an approval and the general nature and purpose of an approved collaboration, as well as any finding that's necessary to demonstrate compliance with state policy objectives, so long as the agency tries to strike a reasonable balance between confidentiality of sensitive information and public interest in transparency. Also requires the Agency of Human Services to provide annual written notice to the Office of the Attorney General about hospitals and health systems whose collaborations were approved, approved of conditions rejected or revoked during the previous calendar year, along with a description of the general nature, and it says that notice shall not disclose proprietary or competitively sensitive information as protected under Section E. Sections two and three, I'm putting in assertive belts and suspenders, although there may be reasons to take out. These are just specifically carving these arrangements out of the existing state laws on antitrust and anti competitive behavior in the Consumer Protection Act, but there may be reasons not to because it is so specific, and it does say in here, at least specifically under section three, where a sexual illusion is crime, and then it says, but that doesn't apply to existing law, That subsection does not apply when people are authorized, or approved, or required to work together by state or federal statutes or regulations. So that really should cover it, but there may be reasons to include it or not. And then finally the act of take back to us.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I know this is a brand new concept that's come up. It's a long bill and a lot of oversight and a lot of stuff in it. So questions we want to first ask is, is this absolutely necessary to allow for hospitals to work together? And we'll have to get that answer from the hospitals, from the AHS, from AG. The other question we had this agency had capacity to oversee this program. How will it affect hospitals work? Will slow down what's now happening? I mean they've already saved $170 right? They're say, oh, I've heard that. And then there's the exemption from the Public Records Act which Gulick would want to look at it. So there's a lot in this bill and but we've heard from hospitals that some hospitals at least that this is really necessary for their continued collaboration. So what I'm going to suggest is we let this one sit for a little while, come back to it, we'll try to understand it more And let me know what your thoughts are, and we can talk about it. We'll talk about the bill. We might have some time to talk about it tomorrow, just our conversation. I know you can't be here. Are you here? Yes, you are. So Care for something. We may have time. Well, we may and we may not. So we'll see how it goes. But we'll we'll try to work it in. We'll wanna hear from us about this. Senator Collimore did introduce it and it was kind of last minute for me to get it up on the agenda. So he wasn't, in fact, invited. I was just saying then did he wasn't invited to testify, but I will I'll talk to him in meantime. Quick question because we have

[Sen. John Morley III (Member)]: This is for you, actually.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, gosh. I'm

[Sen. John Morley III (Member)]: getting crossed with my brain here. The regulatory authority and oversight between AHS and Green Health Care Board. Oh, good. One of them. Because this is all AHS.

[Jennifer Carbee, Office of Legislative Counsel]: The way this is set up is AHS because AHS has been tasked with the transformation work and is working with the hospitals on their transformation activities. So I put it in AHS, But it doesn't have to be AHS.

[Sen. John Morley III (Member)]: Yeah, but that

[Sen. Virginia "Ginny" Lyons (Chair)]: isn't work all strict. Yes, could put it somewhere else. We'll have that discussion. Yeah, no. Good question. It's a good question. No question about Yeah. So any other questions for Jed? Uh-oh. Now is I understand possible this need because you're the comfort level. Maybe, maybe not. But hospital transformation. There's our hospital transformation film, and there is the rural health We're gonna ask that question. We're gonna ask the questions. The problem will be solved. Right. So I'm gonna bring closure to this. We I have a lot to talk about here. Send this. You did she Why don't we just send this? Did she just give me? Oh, no. We're not giving them our hospital transportation. Okay. Thank you, Jen. I know it's a heavy lift all of a sudden because a lot in here and we have to sort it out. And we have Carolyn Sheridan here, the National Organization of Rare Disorders. And Carolyn, we have about twelve minutes. Okay. I can do that. Alright, good. That will introduce ourselves. Well, good morning,

[Carolyn Sheridan, National Organization for Rare Disorders (NORD)]: Chair Lyons. Good morning, Senators. This is over here.

[Sen. John Morley III (Member)]: Senator John Morley. John Benson from Orange.

[Sen. Virginia "Ginny" Lyons (Chair)]: Ginny Lyons, Chittenden Southeast. Martine Larocque Gulick, Chittenden Central. Ann Cummings, Washington District.

[Carolyn Sheridan, National Organization for Rare Disorders (NORD)]: Morning. My name is Carolyn Sheridan. I'm here from the National Organization for Rare Disorders, or NORD. I am joined by my colleague, Jake Saltensdahl. He serves as our community engagement manager, so he is deeply connected to the community. And we're also joined by NORDY, our zebra, which I'll tell you a little bit more about. I did send in some written materials to Vanessa ahead of the meeting, so you can, you know, kind of dive in in your own pace. But I just wanna say I really am grateful for the opportunity to come and introduce NORD and rare disease day and everything that we're working on in Vermont. The rare disease world, rare disease is defined federally under the Orphan Drug Act, as any condition that is prevalent within 200,000 or fewer individuals. That brings us to about ten thousand known rare diseases right now, and we're talking about thirty million Americans. NIH has statistic where we kind of cite a one in ten numbers, that comes out to a few thousand Vermonters. NORD was founded in 1983, and it came out of being the group of advocates, patients, caregivers that fought for the passage of the Country Drug Act. And so now we are a national nonprofit, we have a federation of membership, an umbrella style organization, we have about three fifty patient organizations that are disease specific, and NORD represents the rare disease community as a whole. We like to say that our work is disease agnostic, and that alone we are rare, but together, our numbers are strong, therefore we are strong. There's kind of like four main programs that state lawmakers really like to be most familiar with, especially if you have constituents that call in looking for resources. So NORD runs one of the largest patient assistance programs for rare diseases in the country. This provides direct financial support for patients for their medications and travel assistance. That's kind of one of our origin programs. That was actually run out of a garage of our founder back in the 80s in a little garage in Connecticut, and we're still doing that to this day. We also have an education team, which maintains a growing list of medically reviewed rare disease database. It provides information for patients and caregivers of a good couple thousand of the 10,000 rare diseases, and that's still growing. Also have a clinical network. We have some, it's pretty much like an accreditation program called the Rare Disease Centers of Excellence. And we have healthcare facilities. We're up to about 40 in that network now. And they're just designed to really elevate best practices for rare disease treatment, diagnosis, and multidisciplinary care. And then we also have our public policy team, which is where I serve on. Going back to our origins, we're fighting for the Orphan Drug Act, continue to really try to drive policy to improve care and access for various patients. And we are now operating with a fully remote workforce. So I'm based out of Albany, New York. My colleague, Jamie, came in from Massachusetts, and we have staff all around the country, which really allows us to kind of be really responsive to kind of state specific needs and work. Vermont is always my favorite state to come to, for sure, and I'm not even joking. We're always looking for people to live here. I actually just purchased my first home with my fiance in November, and we really almost came into Vermont because we skied Mount Snow and El Jimo, but we did find one in there. Oh, wow. We were so close. Woah.

[Sen. Virginia "Ginny" Lyons (Chair)]: To

[Carolyn Sheridan, National Organization for Rare Disorders (NORD)]: give a little I am here about Rare Disease Day, though, and I'm actually gonna be joined by a number of Vermont based advocates later today. We'll be up in the cafeteria from four to six for an ice cream social. Yes. Rare Disease Day is observed annually on the February, and the February was chosen for rare disease day because February 29, the leap year, is the rarest day of the year, so it aligns very well. Yes, and the observance of that day began actually in Europe, and it became a global movement in 2009, when NORD became The US sponsor for that awareness day. The purpose of RAISE these days is to provide awareness, and promote equity and representation and policy. Landmarks, you'll often see them lit up in the colors of rare disease day, which is pink, purple, green, and blue. There's patients and families that share their stories. We gather at state houses for awareness days, and you will also see a lot of what we call the Show Your Stripes campaign, and that is because the zebra is the symbol of rare disease, and that goes back to the 1930s. There's a saying in the medical community, when you hear a hoof beats, think forcids, not think, don't think of zebras. Try to find the more common situation of what could be causing this person's symptoms. But in the rare disease community, we are the zebras, and we do need to be remembered. So, zebra becomes our nazcat, and our these are awesome. I will leave naughty with all of you, so that you can Oh, that's terrific. So, Mary Steve Day is a moment of visibility, but really what we're fighting for in Vermont, we've been fighting for with representative Stone for the last two years or so, is kind of a vehicle for Vermonters to have year round structural attention as well. Vermont is considering right now H46, which the house passed last session.

[Sen. Virginia "Ginny" Lyons (Chair)]: Which is right up there.

[Carolyn Sheridan, National Organization for Rare Disorders (NORD)]: Yes, yes, it is. And that would establish the Rare Disease Advisory Council, which would be housed throughout, within the Department of Health. I do look forward, I'm gonna be coming back in April, again, with another group of advocates, and we are hopeful that by that time, age 46 might be up for discussion, and then you can meet some of these rare monitors and folks with rare diseases yourself, and then we can explore, right, how we might be able

[Sen. Virginia "Ginny" Lyons (Chair)]: to continue strengthening the around support program. Good, thank you for that, and we probably will take that bill then. Thank you, Chairwine. So do you have a list of the rare diseases that we can look at? I mean, as we pick the bill up, we're gonna wanna know what diseases are there and then what's here in the state of Vermont. I know I've talked with a few people about some of the rare diseases, you know, maybe others, and then what's not included. I mean, now we have long COVID, long Lyme, know that how is it defined?

[Carolyn Sheridan, National Organization for Rare Disorders (NORD)]: Yeah, so many infectious diseases like that are not necessarily counted in that definition, but the known list of 10,000, there is a database through the NIH, there is a database through GARD, G A R T, and then NORD has a database as well, which has about 1,000 of the 10,000, but it is a very large number, and many are growing. The majority of many rare disease conditions are genetic in nature, for sure. All pediatric cancers are considered rare as well, and many rare diseases are prevalent in children, so there'll be a lot of pediatric diseases.

[Sen. Virginia "Ginny" Lyons (Chair)]: Good, thank you. Thanks for this.

[Sen. John Morley III (Member)]: It was

[Sen. Virginia "Ginny" Lyons (Chair)]: a good introduction. And I know we'll probably see you back after we can take a look at that.

[Carolyn Sheridan, National Organization for Rare Disorders (NORD)]: I hope so. Thank you so much, senators. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Thanks for coming here. Appreciate it. All right, committee, we have