 Just a heads up for us. We're on the record. We are now on the record and the the clinics for the uninsured are not here today so our agenda has been attenuated and Jan Carby is going to be on the telephone because she was smart. Brinn is also smart. Brinn is brilliant. I know we know that. So here we are and you why don't you introduce yourself for the record and let us know what you have for us. Sure thing. So for the record Brinn here from Legislative Council here with I draft 1.1 of a Senate Health and Welfare Committee Amendment to each 83 and I can talk to you about this amendment. I drafted it as a strike call. I could just as easily draft it as an instances amendment if you prefer. There are four changes to this and they're all essentially making the same change which is changing female genital cutting to female genital mutilation or cutting. I understand that you heard some testing yesterday from a clinician who indicated that in practice this is commonly referred to as female genital mutilation slash cutting. I did a little research and see that the federal government and its documents on the World Health Organization and other websites refers to female this practice is female genital mutilation or cutting and when it's reduced to an acronym it's FGM slash C. So our drafting operations office does not like to use a slash for a few reasons one of which is that it's awkward to read on the floor. So I've changed a female genital cutting to female genital mutilation or cutting in the chapter title on line 8 in the section title on line 9 in subdivision B prohibiting the practice on line 16 and then the final change is on page 3 that we've retitled the bill to read an act relating to prohibiting a female genital mutilation or cutting. So I added the word prohibiting there to make it a little bit more clear what the bill does. So again this could easily be done as an instances of amendment if you prefer but I drafted it this way just for the sake of clarity to go through it. I actually have a question not about the changes that you've made but going to the penalty section is that are those penalties consistent with other violations of medical practice or what? So violations of medical practice I'm not sure I have to look into what the non-medical practice violation it's a crime. Yes so the House Judiciary Committee took possession of this bill when it was in the house and they reviewed the penalties to make sure that they were consistent with other sort of similar crimes and so yes I would say they are. I'm just looking for my notes to see what the I believe it was it's consistent with the penalty for cruelty to a child. Oh okay child abuse. Not more than 20,000. I've got one in my committee that is a $25,000 fine. No ifs ands or buts for failing to report a power outage to the 9-1-1 board. It's got everyone's attention as presented I don't think it's going to leave the committee that way but if I look at the severity between not reporting that you've got 25 people who can't reach to cutting. Okay so I haven't talked with Senator Sears about this one I did talk with him about the other one the PA bill and so but I I feel like we're ready to act on this bill. Yeah and I know that so I think whoever reports it and I will individually and then maybe you could help us out and talking with judiciary about the penalties aligned precisely with the cruelty to it the cruelty to a child statute also has two distinct penalties based on the severity of the crime and that aligns precisely with the yeah but we they need to know what they need to know that it's in here otherwise we'll have a problem on the floor and we don't want that to happen so okay so would you want to wait? I had it ready to pull out. I grew draft 1.1 of age 83. Senator Cummings? Yes. Senator Moravitz? Yes. Senator McCormick? Yes. Senator Westman? Yes. Senator Lyons? Yes. Well done. And so we would like to report this. I generally would take most anything but I'd like to pass on this. Yeah okay. We'll get you next time. I'm not asking Senator McCormick he's only doing his job. I'm telling another disturbing bill. No you're doing a good job. Senator Cummings you're not interested in reporting this or are you? My candidate is Senator who wants to do it. That's fine. We're good. Hello? Hello? Is that Jen Carby? Thank you for being on the telephone Jen. Yeah no problem. All right so and I know that you've got your daughter there and your not your your head is there probably more than is here but we really appreciate the time you're taking. Yeah no problem. All right that's good. So there were two things that we are going to do the I think we'll keep in the order on the agenda. We're going to go through S290 probably in less detail than I had thought because we are remote but then and then go through S2888 and I understand we and I told the committee that we had two suggestions from cannabis folks and then from others on definitions and so on so we'll get to that second. Okay. All right so why don't you just walk us through everybody's here by the way we're all we're all brave soldiers. I guess so. All right. All right so we are looking at S290 and activating the health care reform implementation and so I've broken it out with the what we call reader assistance heading just to kind of orient you to where we are and what we're talking about. So section one is the it's the statute where the Green Mountain Care Board has oversight of accountable care organizations and this would add a few elements that statute itself has the first half of it is really what the Green Mountain Care Board has to ensure an ACO meets the criteria the ACO has to meet in order to be certified to operate in the state and then the second part is what they look at the Green Mountain Care Board looks at when they do the ACO's budget review. So as far as the certification piece this would add some things the Green Mountain Care Board needs to find in order to certify an ACO. So the first on page three is that the ACO consults with the agency's human services and departments regarding public health and population health issues and coordinates its services and initiatives in these areas with the agents with agency and departmental programming. Okay so I can you help us understand exactly what we're saying here so. Sure so this would require the Green Mountain Care Board to verify that the ACO is working with the agency human services and the departments in it. When the ACO does things around public health and population health and services an initiative that the ACO is implementing coordinated and consistent with what the agency of human services and its department are also doing so keeping these areas aligned between what's happening in the ACO and what's happening elsewhere as a result of efforts by state government. Okay so as an example of this what we could and I know because we've had discussions about RISE both in this committee and in appropriations. So this would suggest that before would this include DSR spending so before before a program is initiated like a RISE program that there would be some connection evaluation assessment look at by AHS. Right so this I mean what you would be having with this language in the bill if you'd be having the Green Mountain Care Board looking to make sure that this that kind of consultation happens and doesn't for purposes of the bill and the Green Mountain Care Board work it really wouldn't matter what the funding source was whether it was DSR investment funding or other type of funding that is what was supporting the ACO's work it's really looking at the initiatives themselves and those are coordinated. Okay and then the the next question I have is we know that there are three goals or things that the ACO is being measured on. For the all-payer model. For the all-payer model. Right. So with this link and with that I'm thinking of the one of the goals being um related to public health. Um but I don't have the okay don't we'll sort that one out later but I'm just trying to figure out uh whether or not um this work that's going on with Lincoln with an outcomes assessment so there's some consistency go ahead. What problem are we trying to solve? We're trying to solve a communications problem here between the agency and the ACO to ensure that there's coordination when state monies are used. Okay is this got to do with RISE and did the ACO this got just right. It's okay it could be I mean I brought it might be I mean we also think about designated agencies and designated agency work in mental health and also if you start an initiative on suicide prevention which is one of the outcome measures for the all-payer model. We want to make sure that the ACO is not starting programs that may duplicate or not work in coordination existing programs. Perfect thank you. No thank you well said. That's good. Just trying to figure out once I know the problem then I can figure out if it's okay that's why we're going through it so this is great. The two of you sound like Rachel Marks and Margaret Tumor. Thank you. Which one is which? I'm not sure. You're going to want to be very translate later. There's a little type. Okay Jen so Senator Westman. Can I just ask that the coordination of human services is absolutely where in that coordination but we have a lot of non-profit organizations some of which get state grants to do stuff in that that when we I'm going through this right now in the DCF budget. There's a whole. Jen can you hear Senator Westman okay? Yes I put you guys back on speaker. Yes okay good thank you. When we're talking about home visits and the coordination with how that relates into early childhood and so the kids that are acting up the kid that was biting in all this you've got expelled from daycare that gets expelled from daycare getting well child visits that we're working towards I've got five people in well county mental health which is not a state agency doing work I've got people in now one care that's beginning to fund programs that are there when we say state organizations does that also include the other non-profit agencies that would be doing taking a piece of all of this. So I ask Jen I have my own answer on that level. I'm throwing that out on the table to make sure that we're there. Jen does that does the language with agency and departmental programming covers some some of what Senator Westman is talking about all of what he's talking about in terms of I think it would I mean it would include it to the extent that those that the DA's and others were also coordinated with agency and departmental programming. I think there are other places there may be other places and it might make sense to go through and and take a step back and look at the the overall statute that this would all be going into there's a lot that's already in the law about coordinating with community partners about not duplicating existing programs so while this new language doesn't speak specifically to to the community partners I think there's a fair amount in existing law that's already in there. I just it is a concern of mine that we look at the whole picture as it comes to this and at some point in this upfront might want to just say that. Okay okay and I'm just making a note so I think maybe it would be good for us to to look at the whole existing statute because if there's language in there that is that doesn't quite do what you wanted to do we can tighten those pieces up as well. Okay that'll be that's actually a good homework assignment for us to go through and identify places in the current statute where we have questions whether or not we make changes is another thing because I don't. This section is 18 DSA 93 82. 93 82. Yeah it's a pretty long one. But yeah there are things that you that any of you think need to change in the existing law in addition to or instead of what's here in S290 we can certainly look at those. Okay. Thank you. Thank you. Okay. Okay so in further on toward the bottom of page three we have the next new language so this is in as far as having healthcare providers participate and this is this one's new language would say the ACO fosters collaboration among its participating providers including hospitals and community providers and has established appropriate mechanisms for evaluating the extent to which these providers collaborate effectively. So let's just let's just digest this one a minute so this doesn't say how it happens it doesn't say you have to have care management it doesn't say you have to have somebody walking across the hall I mean it just it's an opportunity for to ensure that the hospitals and community providers are all connected and the ACO has some responsibility in making that happen so that it becomes a point of responsibility. Okay then the question we would have to ask is how the evaluation takes place and that's that's a question for the ACO. Right and I think it's also a question for the Green Mountain Care Board because they'll be the ones who would have to actually be carrying out this you know certifying that these things are okay questions on this one well my kind of general concern is just that every time we ask any of these entities to do more reviewing or more reporting we're adding we're adding costs to the system and we're adding complexity and we're already being criticized for having you know too much government in in the in this whole process and it's still early on in in you know this all this trying to take place and I mean my inclination is just let it play out the way it's already set up I mean I think we did a good job setting it up to begin with and I just worry that we're adding we're adding things on top that we don't we don't really I think that's what I'm yeah I feel like I'm monkey was I know at one point this committee almost used the Green Mountain Care Board is its private research arm yeah we don't want that and I'm still yeah I want to know what this is going to do to the the personnel the the ability the ACO to do all this to know what the costs are and then what the benefits are having you done so thinking about this and then thinking about the governance structure of the ACO where you have so many different organizations sitting around the table I think that it provides an opportunity for that group in particular to talk about how folks are working together I don't see it as I see it as an important principle now whether it's redundant with another principle that we have in the whole thing I think we have I agree we need to be sensitive to that we can we can't keep piling on we don't want to keep piling on and yet we've heard like when we went to Gifford we've heard that there's a need to pull things together and have that communication so whether this is something we want to add on or whether it improves what currently happens well you know this is a good question and you just probably also the Green Mountain Care Board is already doing a lot of work in this area you know largely because you have directed them to in this statute but I think their execution of it may also help inform what you think may need to be added or not so here's my thinking on that I mean here it's a Green Mountain Care Board for me is a regulatory organization and looking at whether or not the outcomes the goals are being achieved and measuring the outcomes right so that's why I look at it and the ACO has become an autonomous organization that that is building a system of care that includes community services and community folks and links in with our AHS programs okay so we got that so so if we give the Green Mountain Care Board the role of of linking community services then they not only become they're not only regulatory but they're carrying out I mean so I'm this is this is a confusion I really want to avoid but but go ahead the integrated within the ACO is measuring outcomes because they're they're payment structures exactly dependent upon exactly so I don't know why we need to and that's why I just well let's find out adding more on to it let's find out if it's an add-on or if it is something that improves the work that's going on I'm fairly totally open to that senator I attended Gifford as well and I did not hear that they wanted more coordination they spoke of coordinating they were talking about that that was something they were doing and that was a good thing well I heard them said that they needed was substantially more psychiatric nurses and beds and they needed places to send violent patients right so the question real what this your I was not your immediate predecessor but several predecessors back Doug Rossin when he was chair of this committee he's worn always he said I hate bills that say go forth and do good and that I worry that this doesn't pass the test well it's just telling go out and do the right thing no but this doesn't say go out and do the right thing this says make connections between community providers and and others in hospitals and so what we don't have another policy for years I don't know I want to we'll have to look look at the 18 vsa 93 82 I'm not going to decide yes or no right now until we hear some more testimony but it's a very good question that's been raised and we've got it on the you've got it down right I got you okay I'm wondering if the world how the world's going to be different if we've asked this bill or if we don't well let's just find out what's that rest is in the bill okay all right it this is just this one section that you guys have questions with and so make sure you highlight it and Jen's got it highlighted and when we go through and read the statute on the ACO we'll keep that one in mind okay okay so the next adding to language in existing law that the ACO has established mechanisms and care models to promote evidence based health care patient engagement coordination of care use of EHR and other things this would add the ACO engages in ongoing and multi-year relationships with its participating providers and encourages the development of sustainable programs and initiatives so that one that one is really we could say you'd be looking instead of at a one-year contract with folks you're looking at a multi-year contract with folks right now providers line on for a year yeah so it can't sign on for more than a year I don't know can they sign on for more than a year I don't think I don't think that's happening right now so this would tell it's new so I think I understand the providers are risking their financial security yeah exactly think one years so we'll hear testimony on that and whether or not the fact is if you have an ongoing relationship it might reduce risk or it might not and it might give some reassurance I would think if they can't sign up for more than a year that's too prescribed because you know some of these changes keep years to unfold and why would we conclude them from going on with that yeah yeah we might so Jen in the current statute is do you have an understanding of whether or not it can be for more than a year I don't think it I don't think it speaks to the length of the contract I don't think there's anything that stops it from from contract being longer than a year rather than the interest among the participants on either side making it longer than a year okay so Lucy so Lucy Garen uh want to hear from on I would just uh Vicki can address this next week but I would okay caution um getting into the contracts because if a program is not successful you don't want it okay and we'll hear from her next week okay okay uh-huh so next we get into the second half of the statute which is really focused more on the budget pieces the ACO budget review and so this would add language that would specify that the Green Mountain Care Board would only be able to approve an ACO's budget that has salary increases in it for ACO employees if the ACO has met uh it's saving the preceding ACO budget year and there may be some timing issues with that about when we know when they're passing and it would say that the board shall not approve an ACO's budget with salary increases ACO has failed to achieve its savings or quality targets or go for the preceding ACO budget year okay I'm sure we'll he'll testimony on that okay this and then I just know is one care though right one care okay it's not the participating though okay it's one care the ACO's ACO budget right and I did run this by them so we'll hear from them okay at one point okay also says that the Green Mountain Care Board shall not approve an ACO budget if the total proposed administrative expenses which is something the board would doesn't would define comprise more than 15 percent of the ACO's overall budget I think the reality is that they're far below that 100 percent it's like one or two or something like that yeah yeah so maybe we'll yeah so that that percentage is was a was thrown in there as a placeholder so whether we need to have that or not we'll see right okay well what's the percentage you use when you're looking at a charity about that 13 or 15 I thought it was more like 12 to 13 yes okay all right so that is the end of that particular section and then it's the second section would add a new annual reporting requirement that would have the ACO submitting a copy of the ACO's most recent audited financial statements prepared in accordance with generally accepted accounting principles the evidence basis on which on which each of the ACO's programs and initiatives was established and is being evaluated benchmark data including the numbers of attributed lives by type of insurance or other coverage quality metrics and health health outcomes the ACO's outreach efforts to educate public about the ACO's financial its impact to date on population health and other outcome measures ACO's administrative costs including salaries by category and the source of funds that covers those costs and the amount is achieved by the ACO during the previous reporting year how those savings were distributed and the criteria the distribution of shared savings and then it must include an assessment of the services patients receive across the continuum of care including primary care services ongoing care management appropriate counseling services trauma informed support services provided in the community and other services that help patients to achieve positive clinical outcomes are these new things so this we will hear from the acl and the gremountain care board um and as to whether or not it's an improvement because it's put it at the same time but it also answers a lot of the questions that we hear all the time about information so we'll I think before we we all we all would have questions about this obviously but I think it's important that we take testimony all right section three would direct the agency of human services in consultation with the gremountain care board who look at the pros and cons of moving the acl budget review process and those reporting requirements from a one year to a two year cycle um and then so this one it seems to me uh might offer some some freedom to the acl in accomplishing its goals instead of constantly preparing reports um they'd be able to get some of the work done if it were a two-year rotation but I don't know I don't know whether it's I don't know whether we can you can do that or not and that's why it's a study in there we'll hear from the gremountain care we'll hear from gremountain care board we hear from acl we'll hear from aahs on this one because it involves some other other dollars ready to do it so that is the end of the acl the acl part for the month part um so just so just so we know that we've come to the end of the acl section but we have our homework is to go back and look at 18 bsa and a 382 and we each of us has questions about each of those sections and then as we come to get to our testimony um we'll be able to put those questions into context okay okay so then we move into hospital um rates and information that the hospital would be providing to the gremountain care board so this is um the first part is in the context of their um the hospital budget review the hospitals provide information on the three specific healthcare services that were subject to the largest increase in commercial rates and three service services that has the largest decrease in commercial rates during the previous fiscal year so looking at gremountain care board within 30 days following an increase of a half a percent or more to the commercial rate for any healthcare service at the hospital um and i so and i have talked with the gremountain care board and i think they will be and the hospitals obviously will be um weighing in on these sections and what what value is there looking at um utilization for specific services you know yeah i would just like again my concern is are we you know every time we make hospitals do more reporting we're also adding to the cost so yeah we need to look at that whether there's enough value added and if they have the data and but then the thing is if utilization is going up in specialty services and then we're trying to move toward primary care what's the relationship there and and then how do we how do we see that data so yeah good yeah okay okay then we move into some sections that um the old gremountain care board and others um so the first one sections five would add a new duty for the gremountain care board to review the budget of annually of the specialized service agencies and preferred provider organizations so the dh and fsa they provide the health department to provide substance use disorder treatment in the community setting so this would direct um the gremountain care board in consultation with a hs and its departments to do an annual budget review entity and then it's i face the language largely on the hospital budget review that sort of modified to um suit the context of the dh ssa's and preferred provider organization um which in some cases is different um so it goes through the process i don't know how detailed you want to look at for them to provide their financial uh of the entity dh ssa and for our provider organization to follow certain file certain information with the board and costs of operation revenues assets liabilities fund balances other income rates charges units of service service information include outpatient community rehabilitation and treatment substance use disorder treatment developmental disabilities children and family emergency and aspects the impure services utilization information any new services or programs that they're proposed appreciation schedules on existing buildings and other facilities and equipment and then anything else that the board would require in conjunction with these budget reviews the board would review the utilization information consider the h-rap the health resource allocation plan as it pertains to the services provided by the entities considering reports from professional review organizations solicits public comment meet with each of the entities to review and discuss their budget then we have the board in consultation with a hs and its department establish a budget for each of the dh ssa's and preferred provider organizations annually honored before june 15 followed by a written decision honor before july 1st and and then each of the entities would need to operate within the budget established um by the board to allow us the board to adjust a budget um if an entity requests it upon attaining circumstances um and then it allows the board to request and requires information the board needs to determine whether they are operating within the budget that was established for them and allows the board to adopt rule so right now the board and the dhs and the ssa's don't have a relationship and this is a this is a lot in here and the so the board and as i understand it the nermont care partners um are looking at this section this was like this was just thrown together not thrown together but thoughtfully put together as a placeholder and um so we will be hearing from the green mountain care board and we will be hearing from da's and ssa's so you're visiting nurses their da right no no no no okay home health agencies yes well they were talking to me yes i'm kidding no i'm sorry how much are we increasing their budget so they can hire an accountant to put all this so senator this is exactly why we're going to hear from the green mountain care board and the da's and ssa's as to what is possible i think it is there's some value in having the budgets evaluated at the board level as you know we did this a few years ago and then that helped us to adjust salaries and then how can we do that because there's there's a lot of state money federal money and private money involved in some of the decisions that so there's also a point at which we cost more than we're worth and you might want to think about going private and it's a balance here and the more time you spend recording to us there you go the less time you have to deliver service or the less money you have the last i heard all the home health people were operating were not did not have enough budget money to cover their costs they were all operating on fundraising right every one of them right that and then and we don't have home health in here but it's an area yeah it's an area of concern well the mental health agency well we have mental health in here they last i heard they weren't doing any too well either exactly that's why they're in here so the question is you know how how can we look at what the budgetary needs are what are the financial needs and what is the current financial status of these organizations they do a great deal of work for the state and um there's state money involved so it's really an assessment at this point and i can't wait to hear from the green mountain care board and the ramon family partner for my care partners what do we what do we ask hospitals what do we ask for their when radiation schedules on all the buildings stay on yeah so this most of this comes out of the hospital that comes out of the hospital dude all right that's that's how it got there right it's a it was a placeholder it's probably more than it's necessary all right but i think it's important to have that conversation i think i'd have that conversation if i thought you could get the more money but i'm i'm not seeing the carrot at the end of the stick that's that's senator westman and senator reform extra and you can end it and you go to take a stick and not to stay here appropriations not going to stick you would are all taxing yeah all right jen thank you for you take carefully walking us through that really i know i think we're all so everyone here at the table is all set with that section and ready to go right now we'll hear testimony on that section do you see us in this room i know i can see where we will be taking testimony on this and we have asked we have a long list of people testifying next week and we'll be collecting others to testify as we go along we do want to improve whatever we can in here and we're only halfway through the bill jen we are on page 12 my favorite bill all right okay are we on page 12 jen page 12 section six we're ready to look at section six section six is language that should be familiar to the committee this is language that would require at least one member of the green man care board to be a health care professional so a mechanic physician and physician assistant or a necessarily just call an accident while somebody is currently on the board who's not a health care professional from serving another term or more terms if they were reappointed but the next new person on the board you know who else we don't have in the board an insurance professional i mean when we started out we set up the board to make health care decisions they're now basically making a lot of health insurance decisions and there is no representative of the insurance industry well we didn't set the green health care board up in the beginning to be the regular that's right and more and more they're moving towards being the regulator so from that point of view what would we want on the board and at a stage where we're theoretically our goal is to transform to uh within the aco model and so there's a lot of changes that are going yeah the green man care board was supposed to operate in a post insurance world yes that's right you're right you're right yeah that's what we started out to do okay so this section that's a good point though senator that you've made and but this section really is reflects the bill that we passed out here last year not to say this has been brought to my attention sure that's that's another place where we are missing okay so now we're moving on to the board section seven Jen can we do that yep the section seven starts the first of a few kind of related sections this is in the list of the duties of the green mountain care board and it would add to the duties proposed health care contract between health plans or other contracting entities and health care providers that's not something the board's currently involved in okay and I've heard comments that there are just hundreds and thousands of these contracts and it would be impossible but there might be some benefit to having um some model contracts going forward I can't I look forward to hearing from from the board on this and I've heard from a number of health care providers uh at the hospital level at the individual provider level and other levels that are extremely concerned about um the types of contracts are being handed from carriers so I'll we'll leave it at that and we'll hear testimony from folks okay okay and then the next section um is kind of an expansion of an existing authority that the board has but has not used which has to do with setting the amounts uh the payment amounts for health care services uh under existing law the board has the authority to set the maximum amount that a provider could accept for services but it has not what we've referred to in the past this rate setting um the board's rate setting authority they have not exercised that authority it's my understanding uh additional staff to do so um section eight first starts by expanding the intent statement under existing law we have it's being the intent to health care professionals in quality of care and will permit them to provide on a solid basis effective and efficient health services that are in the public interest and then it goes off between payers paid to health care professionals it's sufficient to enlist enough providers to ensure the health services are available to setting or hospital affiliation while also allowing for facility fees if appropriate so this is adding that concept of site neutral reimbursement where the reimbursement is not based on hospital affiliation and then in statute it directs the board to set not only reasonable rates but reasonable site neutral rates regardless of setting or hospital affiliation um questions here well aren't we this is this fee for service aren't we trying to get away from this so this this specifies we're about to get to some language that says this should apply in both the fee for service and the uh and amounts provided through the LPR ACO model because uh because there is still payment that goes on to providers it's not necessarily on a fee for safe service basis but there is still reimbursement um it just happens through a different mechanism different methodology right so i mean right now we're in a transition stage and for the next several years we're in year going into year three of the all payer model and and there's still fee for service and there's fee for service for specialty care which is maybe inequitable depending on the site so this this covers both both of those things and it's hard to write something for a transition but moving forward is this dealing in any way with the fact that the private practice physical therapists get paid a small percentage of what the hospital affiliated that's what this would this would look at that but it would include an assessment of facility fees because obviously you have a big yeah you'd have to look at overhead it's a lot of work i don't know you know and this is this would be this would be happening at the board level and uh it costs some money to do this which we will have to talk about and i know the board will be responding to this section as well others as well perhaps our director of health care reform so i haven't looked at all the language but it's all pretty consistent with with what we've been talking about board wouldn't be the board would be allowed as under existing law to consider legitimate differences and costs among health care professionals but it would specify that the board shall not create reimbursement disparities for the same services based on health care setting in which the services are delivered or the health care professional affiliation or line affiliation with the hospital and then about establishing uh an approving payment methodology the payment methodology consistent with payment reform and evidence-based practices um and then i specified shall apply to the reimbursement amount provided to health care professionals through the all-payer ACO model and then include fee-for-service payment to the extent appropriate so again this this really moves the board into that regulatory role in the given where we are with our um payment reform right and this rate setting authority is around site neutral for section nine any questions around the table that this one this one is a huge this is like slightly a heavy lift yeah minor minor detail so but i think that this is this is a significant issue out there in the health care world and it is one of the things that is driving a loss of health care providers in the state especially in rural areas so i think we need to be very aware of it and how do we how do we solve it i mean this is one way of solving this problem how do we do it we can put more money into Medicaid that would also help but we don't have it right now okay all right then that um now we're going back to this idea of the contract between the payers and the providers and having the Green Mountain Care Board review those so this would specify that a health care contract between a health plan or other contracting entity and health care provider will not be effective until it's been reviewed and approved by the Green Mountain Care Board for fairness adherence to those rate parameters and the rate settings done by the board and consistency with the with provisions of existing law in chapter 22 i'm sorry chapter 221 sub chapter 2 of title 18 which deals a lot with the relationship between payers and providers i think we better all read title 18 thoroughly yes i'm sorry i think we all here sitting at the table are going to have to read title 18 pretty thoroughly at least some of us will yeah you may want to focus on certain areas yes i'm thinking that the health insurance rate review that the section 10 can we just stick with section nine for a second to see if there are comments or questions concerns more a little bit more on that topic a little bit further on okay then let's go okay so right now we're taking a little break here and going into health insurance directly to health insurance and health insurance rates um under existing laws health insurance rates must go through as you know with the green mountain care board um and the board must determine whether a rate is most quality care most access care protects insurer solvency and is not unjust unfair inequitable misleading or contrary to the laws of the state this would add sub language specifying that proposed rate increase shall be judged uh if the and i think i was i think this is the error on my part in the drafting i think it was supposed to be if the um proportion of the rate increase attributable to exceed the cumulative consumer price index rate of inflation for the applicable period basically if the administrative expenses are going up faster than uh the rate of inflation and we didn't specify medical inflation we specified not specified medical inflation medical inflation um goes up at a much faster rate than right so we've put in a cpi for right you could put in inflation rate this is a one option for an index okay uh benchmark all right then section 11 now we're back to the contract between the pair extract standard there's a lot of requirements for what has to be in the contract and be part of the contracting process so this is a couple of things the first is to remove the language on confidentiality under existing law um on page 19 you'll see crossed out but contracting entity may require healthcare providers to execute written confidentiality agreements with respect to fee schedule and claim edit information received from the contracting entity this would eliminate that um 20 um under existing law and the contracting entity proposes presents a proposed healthcare contract for consideration by a provider the contracting entity has to provide or make reasonably available certain information this would specify that the contracting entity must provide at least 120 days for the provider to consider the proposed contract and for negotiation of contract terms including reimbursement amounts it would also specify that healthcare contracts must be for a minimum of two years and include reimbursement amounts that are consistent with the rate parameter set out by the green mountain care board contract taking effect it must be reviewed and approved by the green mountain care board for fairness adherence to the rate parameters set by the board and consistency with provisions of this sub chapter um and other applicable laws and then it would also again take out language saying that um the requirements don't prohibit a contracting entity from requiring a reasonable confidentiality agreement between the provider and the contracting entity about the term of the proposed contract so this is doing a couple of things it's giving best time the amount of time minimum amount of time for the provider to consider the proposed contract and to do negotiations it's eliminating some confidentiality provisions around what's in the proposed contract and it's requiring green mountain care board approval of the contract there's a lot here we're going to hear from the board um and uh it it does change uh or the relationship between providers and contracting entities such as an insurance carrier but um there is a lot of information out there I don't know if anybody else has been contacted from folks but I have and I have received some anonymous uh uh envelopes and large envelopes looking at contracts that have been forced foisted foisted on providers without negotiation uh it seems to me it's not a fair process so that's why I asked to have this put in we'll see what happens but I certainly want to hear from the board we're going to have to hear from carriers we're going to have to hear from everybody about this and what the applications are okay we're almost done with the walkthrough the effects well um would direct the agency of human services in consultation with the green mountain care board the department of human resources and the unions for state employees and public school employees to determine the likely effects of attributing and not attributing state and public school employees who are getting insurance through the state or the schools and their dependence to an accountable care organization specifically the agency is directed to consider the expected impacts of attribution and non attribution on the employees access to health care the employees health outcomes the employees experience of the health care system the relative value of the employees uh employer response or health benefits if they both are or are not attributed to an ACO and the state's likelihood of meeting the scale targets contemplated by the all-payer model and the related effects on health care reform efforts in Vermont so looking at you know what's what's involved in attributing the public employees teachers and other school employees to the ACO what does that look like from their standpoint what does that look like from the state standpoint and it would have a ahs report its findings and recommendations about attribution by october 15th so so this this is really comes out of the concerns that we've heard about a loss of benefits if there if folks went to the ACO and uh we can we'll have testimony on this because i think there already is information but we'll we'll see what we get and that's basically it then we get into the effective state all payer models sorry go go ahead different for different different for different yeah different dates for different things which we can go through but may make more sense to go through as we individually consider different parts of the bill wow look at all those sections thank you gen boy there's a lot of work in here but just for the dates i don't know if we can all keep that straight questions for gen yeah there's some things in here that we we feel uncomfortable about i think as a committee there's things in here that we feel that are important to resolve in one way or another there are things in here that um no one will have fun on a fiscal note with and trying to sort that out uh and so we'll be taking testimony i think we have a day next week dory is it wednesday we have folks that will be on 290 yes yeah and so that'll be the beginning of testimony i think we'll be taking a couple of days of testimony we need to hear from people if you have not yet signed up with dory this is the time to do it this is a great day to do it and any questions do you have any comments no one do you want to do you want to give us some comments right now sure all right come out we don't have a fiscal note no at least you'll be identifying it's 17 pages of colors but and as it is now knowing that there's no fiscal note for the record no online which i just don't know uh mine's more of just a overlying comment of just to be mindful of there's a lot of stuff in here that we're telling agreement and care board to do and um much of it would require staff contracts etc and several moments ago we just talked about how the agreement on care board was created in a different world in a different time and so and then on top of that i was also recently hurt their budget and you know how they're you know how they're what they're doing to keep their budget level funding and how they have increases in their health insurance costs and their offsetting with contracting costs etc so the point is is that uh you know just think about be mindful of what it is you want to cream out the care board to do and how you pay for for instance uh you know right now with the budgeting process for the hospital we build back the hospitals right i don't think i don't i think i could speak by saying i don't think anyone that's having it didn't have a desire to build back the da's right to do the budgets right look at their budget there's a lot of complexity in this so and so and a good chunk of agreement care report budgets come from build back right but they can build back the indies in which they're regulating so the extent that we put more work on them that is not a regulatory function that comes a general fund if it is a regulatory function we're going to start building back even the hospitals and the insurance and the aso even more which comes back another way so i'm just it's more of like uh helping you think about as you work walk through this think about what what it is you want them to be doing what is it you know maybe that's that's all i was yeah very helpful i'm in fact i have up on my little one of my what do you call those little things you have up there with your contacts yeah i have the agreement care board statute right there and i've been reading it going through it trying to sort out the things that we can shift over to director of health care or things that we can shift other places and and and so that we can move forward with a more of a regulatory and entity and i you know i don't know so that's a big that's a big job to follow up with what doleman said yeah they were developed with a certain vision that vision never really happened exactly the way that rolled out the way we thought it was going to and now we're moving them into a regulatory place what is our real vision of where we see the aco and the green mountain care board in the overall and what are the pieces to that for me it's really the aco is doing the payment reform and we want the green mountain care board to oversee that in a regulatory fashion but we want the aco to do the payment reform piece the as i heard testimony we see the aco moving into the public health area and we're worried about the coordination when all of the other groups including the agency of human services doing one thing i see as a lack in what they're all doing is we're all kind of in a higgledy-piggledy way that might um going into the recruitment of the people to do the work and like that can we put a higgledy-piggledy in i don't care it's a category but in those pieces so in the overall what's our view of where the green mountain care board fits in that and how is our view of what we want them to do different than it was before and so you remember the last time we looked at this bill and and i think you and i agree on this we all agreed that we try to lay out our vision for what we see as moving forward health care reform and and and for the board and knowing you really you know you actually hit the nail on the head we're fast to do things that are we're no longer doing well and i think um the whole idea about um work you know workforce is i mean that's what i think we really ought to be focused on because that's where we can actually help how you know what are the measures that we can do to and i don't really see with the aco if they're in the front on payment reform to keep people in the thing they also need to be a piece of the recruitment because there's a hand in hand if you're going to do the payment with them so let's let's hold that thought and then just yeah no i understand and i understand we understand we thoroughly understand the need for workforce that's why we've looked at p a's that's why we're looking at the nurse compact that's why we're going to continue working collaboratively with the appropriations committee and where we put our money in for workforce development and expanding nursing programs as much as we can but that's not in this bill but we know that is a very important issue and we we know we all agree on that but this is another there are a lot of big issues that we face here and this is one of them so if there's something we can do to modify the bill that would help the green mountain care board we need to help them they're they're overwhelmed with everything that goes on we've given them a lot of work over the years absolutely we haven't taken anything away from them but they don't want to give anything up either they're enjoying the work you know this is another issue so we'll have to talk about what's our vision yeah i think that's yeah and is the funding mechanism we set up yes and enough yes you know so you so right now they do health care reform and they do regulatory oversight so maybe health care reform move somewhere else i don't know uh oh big question okay anus looking like she could take on health care reform that is okay she she left the board to get away from it okay thank you no one yeah stimulate a good conversation we're okay so uh you know i was thinking uh we're at a point where we could move on to our next bill i there's everybody in the room well i has something to say i know that and we would love to hear from you but let's do it in a more formal way because this is a huge bill and i know in in meeting with the green mountain care board and with uh the Vermont care partners in the hospitals and others that there are suggestions that will be coming in for improvement to the bill and not the least of which is our health care reform director so we have everybody coming in with some improvements to the bill we need to listen and to to the testimony and we've got all of our own ideas and i think they're listening to richie improving the bill is we're kind of starting in the middle and maybe we need to go back yeah at the beginning and say this is what we need to have happened right and it's very different than what we wanted or needed to have happened when we thought we were going to be single payer so what do we need to have happened now and what's the best way yes to make sure that it happens and so a lot of what you're seeing in here are things that i guess we heard on h rock that need that maybe we need to have happened and then some of my ideas about what would help and so we'll have to we'll have to talk through maybe some things need to go back to financial regulation which is where well they used to be well that's a conversation well you said it back to dfr let's let's have that conversation if you send rate setting back to dfr health care rate setting what is left at the green mountain care board and how do you ensure coordination between insurance companies and providers and so if we're moving toward an aco we're an all payer model then what is it that the dfr is going to be doing so that's a that's a question we all need to think and i think that going to an all payer model again is an experiment for us you know if not health care reform in the sense of going to single payer i mean that was post insurance it was overturning the entire system this is kind of realigning the system yes but it's not the complete overhaul you know i always talked about the ocean liner that we were trying to strip down and rebuild in the middle of the ocean and not lose anyone or any of the other smaller craft attached this is kind of reorganizing the death or well but it is it is the next best hope it is an excellent hope but the question is i think it's the tugboat i i really i think this is more than reorganizing it may be but i think that's it is a very it's a challenge this bill is so challenging to so many different people and entities that i think it it does challenge us to to do things differently and so it offers transparency for how rate setting is made right now there is no transparency on that when a when a carrier goes into the green mountain care board with an increase in rates whatever it is 10 20 8 percent and the negotiation begins with that request it doesn't begin with all the actuarial data and analysis so i'm you know i think anyway that's right okay did you want to say sorry senator mean no okay we have a lot to we have a lot to deal with in here and i think it begins with the testimony from folks and we can then begin to sort it out and i know there'll be suggestions for language change so our assignment is if we accept it i like the suggestion what's our vision going forward for the green mountain care board what's our vision going forward for health care reform and um read through those sections of title 18 and title 18 that relate to the bill itself jen thank you for taking the time to educate us yet again well all right so i think what we should do and since you're on the phone let's just dive into 288 and look at uh the language that other people have brought so we're finished with s290 for the day but we'll be back and if you have if any of you uh haven't signed up please do sign up and i'm also happy to meet with people okay and then jen we have uh draft 1.3 from you right the same one we went over the other day okay then what about the requests that we had from janitor jennifer costa and gales that's um have they i they haven't did they they sent something to me did they send something to you um yeah uh well yeah why don't we just talk about what it is that they sent and then your comments back to me and your analysis back to me on those very helpful okay um and so put us into the section of bill where they were making suggestions and pick your make your choice okay what s288 i found at draft 1.3 yes okay that's under tuesday it's on today's two and yes i think oh it did not pop up a mic today yeah i'm just you have to refresh all right well i got two stays in there the same so there was a request from gales that who represents cannabis to um to exempt medical uh thc and then there was a request from jennifer costa to change some definitions so jen why don't why don't you put us in the section of the bill and start with either one whichever one you would like i think we're probably more familiar with the definitions so start with jennifer costa okay so um she sends various versions i think she actually has two issues one of them is definitions and one of them is possession um so for definitions uh she has sent me various iterations of um requests to change the definitions either around getting rid of e-liquids putting something about substances in the definition of echo substitute um and she sent a list of um new definitions that she wanted to change things to based on some other organizations or definitions that have been vetted by some organizations and i guess my overall response to all of this is i'm not sure what problem it's looking to solve um so i um i'm not sure that the definitions that are being proposed make anything clearer and in some cases i think create potential inconsistencies throughout our other tobacco and smoking statutes oh that would be good and changes language that seems to be working now so i'm not really sure you know what the what the gain is i think if there are specific concerns that they have with the existing statutes or language that's in the bill i'm happy to address those directly but taking on a new replacing our existing set of definitions and terminologies throughout the statutes is a new set of definitions that aren't familiar to the people who administer and enforce the laws doesn't seem like it's like it's a game um so we've gone and you know i've gone back and forth with her a number of times on various parts of the language but but really my uh and and frankly i tried to take a step back to say am i just you know being attached to my language because i drafted it somebody else's language but i don't think that's it i just don't know how it fits with what we currently have the fact that it would add things like tobacco substitutes and e-liquids into our definition of tobacco products and then elsewhere in our smoking statutes we talk about use of lighted tobacco products um or use of tobacco substitutes if you put tobacco substitute in the definition of um tobacco products you at least have to take it out of other parts of the statute but then you still got the issue of whether it's actually lighted or not i just don't know what the what the purpose would be of changing our existing definitions unless we really want to kind of take a step back and and start over and redo our tobacco statute which uh does anyone want to do that no no okay i do have a question really well so my will let someone else do that another day okay i do have a question yeah we uh senator agreement has a question um so Jen um these disposable pods um that i've been reading about are they included in our definition in this 288 with abe band also flavored ones i believe so because of the way it um because of the way it's written which has e-liquids being the solution substance or other material used in or with a tobacco substitute that is heated or otherwise acted upon to produce an aerosol vapor i think that is broad enough that it it includes liquids it includes solutions that include substances with other materials that get heated okay yeah so it's meant to really be as broad as possible right that our definition right i'm trying to keep it so i think that some of the challenge here and some of what we were going back and forth with jennifer on yesterday is you want to be broad enough to anticipate what may be coming out like there are now gels that are used to describing something specifically as a liquid i think is a problem because it wouldn't include gels and who else knows what else comes out but going so far that you're not putting it in any context having to do with e-cigarette we could be banning orange juice because it's flavor you know because it has a flavor i mean i you know you have to i think you have to put it in some sort of context that is related yeah okay thank you okay so i have a little personal item here i would be willing to do a trailer wait okay okay we're not finished yet all right i'm sorry guys we'll talk all right this time it's great idea i want to share hold on uh so we jenn there was also another two other suggestions that we have to go through what was the other one right so they so there's a couple of others from the um tobacco uh the you know the cancer association and others um one of them has to do with possession so we had specifically taken out of uh on this latest draft taken out the possession language uh the ban on possessing and just saying or attempting to purchase um flavored tobacco products flavor the a like which is like what's do you know what section you're in now we are in i think we're pretty far into so it's in 16 and it's processed okay so they as you may remember from last year are interested in um eliminating penalties for possession generally um which you declined to do last year but in in the new draft that i brought to you i had adding possession ban which may not be what you want because again it goes to the issue of possession so i think there's a couple of questions for you in here one of them is do you do you want to maintain any penalties for possession under age and so right now uh the on page 17 we have the person violating does that include people under age and for possession well no no because you took out the possession it's really this uh it's the sale offer for sale give provide transport manufacturer or other why distribute these products that is subject to the penalty on page 72 okay so uh the part that's crossed out would eliminate the um fine the traffic ticket for possession for under age and i say that correctly on page 16 so yes and no because of language elsewhere that i'm now going to i think it's in section 1000 uh let me just get there yes so section one says a person under purchase or attempt to purchase tobacco products tobacco substitutes that i had added in the draft e-liquids which we had added everywhere or tobacco is working you know it has them in the course of their job unless they work for you know convenience store or something so um so in this section if you add an e-liquids then even though you had said possession of flavored e-liquids was not of e-liquids whether flavored the traffic ticket no so um because i think the first question here is what you want to do with respect to possession and then we should look separately at the purchase or attempt to purchase because you may have a different feeling on that so the possession is now the traffic fine yes so under existing law possession is a traffic a traffic fine what has not been specifically spelled out is whether possession of the liquid desperate from the e-cigarette itself is a is a traffic violation uh so we've never really broken out this idea of the e-liquids the substance that goes with it goes with the tobacco substitute because when i wrote the tobacco substitute statute they were generally all one day um or you know all one product um so you've never really looked at the issue of possession of the pod the liquid separately from um possession of the tobacco so i'm i've sort of keyed up this question by adding uh and i think the what was uh the point that the and because they do not support a penalty for possession i would say no at all what do you need um and you had agreed to take the possession penalty out of section 1013 for flavored liquid and other flavored products um it did not seem consistent to them to put up to to maintain or add a penalty for possession of liquid flavored liquid for people under 21 am i making sense uh huh yeah yeah okay so if kids possess them they're going to smoke them but there's just a base problem with starting a young person out we tried it with the possession of alcohol and we got all these people driving around 10 years later with a suspended license because they got caught walking around with a can of beer when they were 17 um right but in general my experience people get irate over parking tickets i can't tell you how many people used to call me about their parking tickets um in my former life because people don't perceive parking 10 minutes over the limit is a crime i've never had anyone scream because they got a ticket for running a red light or for speeding or because there's a general perception that there's danger to yourself and others there but to make something a criminal offense that out of criminal offense no but i mean to make it you get a ticket you go to court that that's if you're selling it you're an adult you know you're doing what you're not supposed to do then fine we nail you to start nailing kids because somebody finds them with a thing in their pocket you know uh oh such as mine that those things suddenly start talking to you it's the newest scam ads suddenly start talking i don't know even though the sound's off no it's happening to me in here but it's a high tech business it's a high tech business yeah but anyway i i just you can't sell them you can't buy them how far do we want to go to stop kids from going to new hampshire which they will we even new hampshire is not going to be able to sell them because the feds have banned flavoring so how you know you don't want to create a basic disrespect for the law because you're making you're punishing somebody for something they don't see is wrong and i just i just have a problem doing that okay so suggestion then is to keep that section crossed out yeah yeah right so i don't think it's a question of whether to keep that section crossed out whether to put some whether to make a change in section 1005 which starts on the toward the bottom of page eight around possession the section 1005 around possession prohibit possession purchase or attempt to purchase by people under 21 it prohibit all the prohibits misrepresenting age to purchase or attempt to purchase and then it has the the penalties for someone who possesses so if you were interested in removing penalties for possession we could meet penalties for purchasing an advantage but get rid of how's that go so i mean what do people think about so that would be for just people under 21 yeah right because you had already taken out the language the possession purchase or attempt to purchase by people generally on the flavor stuff so i mean one thing that may be useful is just to separate the concept of possession and purchase it yes yeah yeah yeah okay that makes sense yeah makes a whole lot of sense i can see a whole lot of problems arising otherwise and so we could you know even in the flavored side we could ban purchase or attempt to purchase although they should not be also should not be being sold so maybe that's moot so that could get your sting people in trouble they send in underage people economic development is going to be going through whatever we finish with this to ensure that it fits with their jurisdiction and i'd like to know we're saying you get a traffic ticket yeah well it's in the manner of a traffic ticket okay because it goes through the judicial bureau all right it's not the traffic ticket that we've put five hundred dollars worth of fees on that i think it's 200 that people can't pay and are driving around without a license i didn't want to setting kids up for future right i don't believe so but let me look um let me just look at the judicial bureau doesn't see how that works so help me a little bit here so i get the purchase here in in the um but it's the possession piece in the transferring that if you're an adult so you're in berry you take the bus to aqua sausney you buy a um um menthol cigarettes and to bring them back with your friends what happens to you if you take them back and you do what with them you share them with people you sell them to people you smoke them smoke them if you smoke them personally if there's no ban on possession then it's not a then you haven't violated anything and but if you're um on an 80-year-old that goes over and buys them and gives a brings back a uh a pack and gives it to the other folk in the old age home well then you have given or provided or otherwise distributed them so you may have violated the new statute and when i walk by someone can an enforcement officer tell if they're menthol or straight tobacco strawberry yeah but can is there mid let me you are asking the wrong person i'm okay but i'm i'm just thinking we've not done other things here and we've been talking about minorities but i mean but you have you have not banned possession so we have any bans and i'll cigarette not would not be breaking the law we're not banning possession right yeah does anybody here who wants to any smoke in force have an enforcement action on possession nobody wants that around the table that's what i'm hearing right okay take possession out everybody yeah um and and do you okay so possession we we have decided under 21 over 21 no ban on possession right okay um so the second question that is uh purchase or attempt to purchase do you want all state of law okay i i just cancel out can jen hold on a second we have we have a question so um public safety is like say all the people that can do the budget are going home at noon because the governors and our protest said it's up to the committee chairs that we are for monitors and we should be able to talk i am a broader and i've driven 1973 and never made it you know made it when we've had more snow maybe than this so um i can't see any point in meeting if we don't have any witnesses and i can't tell them my staff when their bosses said they can go home they've got a state for me so um um we're canceled you've canceled already i canceled because my witness couldn't go over the bill because he was at home okay so that's what it is what it is i think you're in a spot you might as well yeah well i could sit down at the end of the table we'll come testify we have we have ledge council on the phone but we're yeah because they're not in all right all right well center ash is not officially it's up to the chairs i know so so what is this you're canceling this afternoon i didn't hear an answer because i don't have uh i don't have anybody i don't have any witnesses yeah but if you want to sit around and chat with me i'll be there you and i'll be there well i've got a hold on jen thank you for uh what's that being the patient okay so so so where are we then purchase or attempt to purchase attempt to purchase or attempt to purchase right so then you have do you want to uh do you want to maintain a prohibition on people under age purchasing or attempting to purchase now would that in would that involve a um a traffic fine or the larger fine yeah no well it depends so i i sort of have a separate question on under 21 and then uh and then under over and under 21 21 and over and under all people with labored products right um which you know shouldn't be getting sold if you're banning the sale of them so maybe you don't need to address attempting to purchase or purchasing labored products well what if they go over to the guy that was in last week that's moved to smoke stop across the river well they can go to the hand like a purchase is it there they can but they've got but well if they're yeah i'm not sure so you can't stop you can't regulate behavior that happens outside the state yeah right even if you can with sales tax right so for the most part it depends kind of where the transaction occurs and the nexus with Vermont that the business has for tax purposes there may be different relationships with the state but uh but somebody going across the border and purchasing something in New Hampshire that is legal for purchasing New Hampshire i do not believe you can sense that you could attempt to prevent them from bringing you back into the state but you're not banning possession that's hard to do yeah that's true that's a similar argument for not getting possession because if they get it somewhere else i can bring it back over we can't ban everything okay so there's still a traffic ticket however four under twenty one right so not traffic tickets per day but in the manner of a traffic ticket right right and how much is that it's twenty five dollars for a twenty five dollars okay first i think for first let me just go uh twenty it's twenty five dollars and then if someone misrepresents their age by using false identification to purchase um then it's fifty fifty dollars or up to ten hours of community service or go and that's just a fine that one doesn't specifically say traffic same manner as the traffic value okay okay so the but your question is about over twenty one right over twenty one or generally it's you so right now the language i know i can be keep popping back and forth between sections one thousand five and section ten thirteen um the section ten thirteen the language that we had struck through uh was that a person not only shall not possess but shall not purchase or attempt to purchase flavored products flavored tobacco that's over twenty one that's anyone i better go back down to one but if they're legal to sell right they're legal to sell they should not be getting purchased okay so maybe that's the guy with the overcoat with the maybe a simplest to just uh continue to take that language out in section ten thirteen and then take out possession in yes five yes okay all right and so that would just leave see on page seventeen right that's the news that we put in it says anyone who sells it or distributes it or um otherwise yes anyone who sells offers for sale gives provides transport manufacturers or other manufacturers or otherwise distributes these products in this state a subject to a civil penalty uh of up to a hundred dollars for a first defense and up to five hundred dollars for a subsequent offense also brought in the same manner of the traffic values so that's the current penalty that we have for uh sales to someone underage okay it's the penalty for someone over twenty one also this would be a penalty for selling these products or distributing these products regardless of the age of the purchaser and i'll just say that the only place that i have trouble is um we have tons of people from around here that go over to uh particularly aquasazi and uh and the casino and they bring stuff back to their friends and i have a problem with um um putting somebody like that in a position where um um they're breaking the law well so jen i suppose and i have no problem with any of the vaping product products um being um um if they come back and bring baking products i'm not it it really is about somebody that's older with with a sequence okay so and i know that the state police has always had fun you know inspecting cars coming back with tons of cigarettes and stuff avoiding the tax um jen yeah so if um i give senator westman fifty about dollars when he goes up to aquasazi and he comes back with some cartons of cigarettes maybe two uh it's any amount for it for me uh and i say you know just get me something i don't say i don't specify but he brings it back and he gives them to me as a gift well if it's flavored then it would ban it would violate the ban on giving or selling or otherwise that's your meeting with somebody to have to find out that he actually did it right yeah so he's breaking the law we'd be breaking the law together yep okay but that is that is currently what happens with contraband tobacco products at a lower cost and it's right i mean i mean you know under our existing law in order to and i'm just going up um to the sale part but i mean you have to have a license to sell yeah um you didn't sell you bought four generally a gift yeah they go over on the bus all the time oh we get the senior center yep the senior center all right we'll mull that one we'll we're gonna mull that one that language you think about it it just about the existing law does talk about retail sales oh it does so it's a retail sale it's in the retail sale so you're coming home with a car load yeah that's different so that's that's different than going over on the bus and yeah and having one of your friends at the seniors and bring it back in your backpacks on your way okay right okay and i'm just checking nobody can engage in the retail sale a person who sells these products without obtaining a tobacco license i mean this one doesn't specify retail sale but the rest of the section is about retail sales and to me it's different between the menthol cigarettes and the the baking products well they've been banned yeah everything yeah right they're banned okay so it sounds like we're comfortable with a language that is in that 1.3 um that section on page 17 and the and the previous section crossed out on page 16 right so i think the question for you is for people over 21 is there any sort of exemption language or section language you want for people who are doing work you know to to address the issue that senator wasn't bringing up well is it all but in current statute there's no exception language for that there's not but if you're not engaged in the retail sale it's not clear that you have violated by giving something to someone i mean unless the person you're giving it to is underage so we should just i think we should go with what is current statute on that i mean be consistent i think um doesn't isn't that what page 17 does if it keeps it consistent well page 17 page 17 no i'm not confused on that sorry um that's really page 17 are you talking about that's the retail sales i'm sorry that's the retail sales penalty well it's not a retail sales penalty it's a penalty for any person who gives offers for sale gives provides transport manufacturers or otherwise distributes and that's consistent with that's not the same as the retail just the retail sale but is that consistent with current statutory language on tobacco only so under current law on tobacco oh it says no person shall engage in the retail sale of tobacco products tobacco substitutes or tobacco paraphernalia in his or her place of business without a tobacco license no person shall no person shall engage in the retail sale of tobacco so why would you tell me how the gifts will provide why don't we just go with that language for everything else because i think that um economic development can also struggle with us and and that gets rid of the give or provide yeah that gets rid of the give or provide and it goes along with retail sales which is what we're really trying to let us get rid of sales yeah let's you would limit you would change it from a person shall not do all of those things on page 16 to a person shall not engage in the retail sale of um where are you yeah on page 18 16 line 16 yeah okay yeah i think i think we're trying to stick with what is current statue okay and because i think it makes a lot more sense this this could become overly prescriptive and difficult to enforce and we may find that it's another we have another iteration of something down the line and maybe economic development will look at that a lot a lesson specifically for that i think it solves some concerns that people have okay okay so that is we're taking out possession from the under 21 we are changing the language for what is prohibited to be the retail sale and continuing to take out the language on possession and purchase um page 15 all right um where else will we then they have one more oh um the uh the advocates also wanted to make it clear that um that the penalties are assessed on the retailer and not the individual clerk so they would want to the 16 year old kid yeah that's the point right that's the point um so they would want to add a definition of tobacco retailer and then impose the penalty on tobacco on the tobacco retailer yes okay the retailer will lose their license sorry that's you look at this retailer lose their license if they're caught selling they can if there are multiple violations they can okay for a certain period of time okay and then so that's all of the advocates piece and then the the concern for the issue from the cannabis folks tend to do with uh the dispensary but again i'm not entirely i understand why they would have concerns but i'm not entirely clear which part they have concerns with and they are suggesting um adding language to the definition of a tobacco substitute having to do with substances sold by a dispensary to register patients and register caregivers not being tobacco substitutes no um and i i'm not sure oh i got that that makes sense i think that so i went back and looked last year in um similar issue had come up with economic development and i attracted language that didn't end up going in the bill um but they could add language in the no person uh shall engage in the retail sale it would say notwithstanding that a dispensary may engage in the retail sale of tobacco substitutes and tobacco paraphernalia to register patients and register caregivers we could do the same thing on the flavored eliquid eliquid their flavored eliquid i guess my concern is uh that if you start putting things out at the definition level then something can be purchased at a dispensary but used for whatever yeah i think that's my concern we accepted them at their request from the tax the tobacco tax that we put on babes last year because people that's how people consume their medical marijuana i'm not sure i'm prepared to go to say you could have strawberry shortcake medical marijuana i don't know yeah i know that virginia renford was here to talk about that briefly uh and and we'll let you do that but the the concern i have is this opens up a whole new conversation and also knowing that the house is just passing or in the process of looking at cannabis generally yes and that this is really part of the dispensary conversation right i mean i you know i thought i think there's concern maybe in part that that there not be conflict between what you pass in this bill and what gets passed and that could be cool yeah what you know and it well it doesn't matter i mean whichever bill passes last that's the one that's going to stand all right honestly why have we defined cannabis as a different tobacco product we don't have anything yet on that okay now so what we're doing here shouldn't touch cannabis that's another they're not going to be tax like tobacco products i don't think right i think the issue is when you have uh when when they're banned on use of um tobacco substitutes or where you can purchase them um they get concerned about the accessibility for the patient yeah it is a medication and it is my medication it is by so i can um it is not a tobacco substitute well our definition of tobacco substitute is really aimed at the device and so the device i my understanding is used it is i think filled out and used by patients to base marijuana so Jen yeah hold your hold on a sec um Virginia Redfrew is here and she's gonna she's gonna testify for just a couple of minutes and then we'll go back to our discussion around the table okay aimed or designed to develop nicotine or other substances into the body through them and then if you skip down it says products have been approved by the U.S. Food and Drug Administration or other medical purposes shall not be considered to be tobacco substitutes so the U.S. food has not obviously approved of medical because the federal government doesn't recognize it so that's the and i know that in s54 um i believe Jen might know this better but there's language in there which bans flavored um uh thc vape pens already um so our just we there are a number of patients who have no longer are actually smoking the flour they prefer using the um the vape pens um which are made at the dispensaries and the Department of Health is already and so they're they're a separate prescription process through the Department of Health no they're not through nothing no but i mean when the whole vape scare came yeah the Department of Health reached out to the dispensaries to ask them where they were getting their cartridges and the oil that was being put in to make sure that they didn't have vitamin E and so they gave them all of that information so um so i mean that's just i know that my business partner gales that's has been in contact with janin we're just a little concerned over this other substance so that means existing law um so my concern about taking things out of the definition stage as i said is that it hasn't impact on a lot of other statutes so we have bans on uses the use of a tobacco substitute on school grounds if you start saying but it's not a tobacco substitute if it has um thc in it so i mean jan what we the amendment that we sent to senator lyons uh gales sent last night and uh i'm not sure if the committee got that or not well we just had the line other substances shall not include substances sold by dispensary registered under 18 bsda chapter 86 for registered patients and registered caregivers as those i those terms are defined in 18 bsda right but i think that it doesn't if you're picking it out you're taking things sold by dispensary out of the definition of tobacco substitute at the definition on the level you can't like kid who has it who shouldn't have it yeah so if there's a particular concern that you have like which retailer can tell or it's because i mean they would that guard each side of possession is not going to be banned so i guess i'm not sure it is what the purpose remains for having some sort of carve out what is the problem that you are concerned will happen i mean i think the concern is is that you know someone read this and then turns around and says to the dispensaries we don't feel that you should be selling under this a new law that just passed that you should be selling vape pens do you sell the the little pens or is this more the big tanks no they're a little they're a little they're very slight they're and battery they charge patients can charge them so they buy it once so it's a closer to jewel it's not the big yes thing yes it's like yes it has a little cartridge so that's what when that runs out then the patient just has to get a new cartridge and so i mean i just i wanted to raise this issue i know that there's been discussion in the committee that the legislative intent is that it does not include the thc but i just wanted to so i mean one thing we could do uh i'm wondering if it makes more sense either in the definition of e liquid which is a solution substance or other material used in or with a tobacco substitute that is heated or otherwise acted upon to produce an aerosol vapor or emissions to be inhaled by the user regardless of whether the liquid contains nicotine um you know it could there could potentially be a better carve out i'm just i'm i'm trying to understand other than potentially somebody understanding the law and and misinterpreting it or i just don't understand what the problem is i don't think this is a good solution so what is the problem so we can address it okay so we got it yep so we're gonna have to digest this again and then and we'll just talk about it a little bit before we have to go up on the floor um i'm inclined i'm inclined to think that because we we have a fairly robust medical dispensary uh statute uh that it's good that that's where this question should be resolved i i do i think us i'm not with standing language in that section huh they work we could potentially put something in title in that chapter entitled 18 yes we could and you know and we do have we do have a bill we have a bill in s uh in uh house human services s 117 so maybe that's when i'm thinking that it might best be resolved and and maybe that bill or or the other cannabis bill and so just some not with standing language so we don't have to get into it in this bill but at least we were cognizant of it when questions come come up that work i think that should work okay we'll and we can support that process okay thank you for doing i'm happy to help take that through okay all right terrific okay we knew it was there we knew it was there it is it is difficult this is that stuff all right so now we have gen yep can we look at a clean draft weather permitting uh we're going to come back to this sometime next week uh and then we can and then we can have our clean draft and i'm hoping that we'll be able to get this bill out so when you say clean draft i can certainly take out all of the things we have decided to you know clean up from what we did today do you want to see the additional changes from today in you know all the highlight and stuff that you can yeah we should see that we should see that i will bring you a version that incorporates everything that is currently highlighted um the way it is described and that makes the additional changes that we talked about excellent okay thank you for being with us this morning thank you for accommodating oh no problem i hope you're in a comfortable chair by the fireplace oh it's good yeah okay we're with you that's where we want to be yeah so uh okay thank you and senator ingram and i might be in touch with you about putting together some kind of a chart or something that's more explanatory on some of that nuance within the bill and with the fda so we can talk about that okay all right we're going to a senator coming so you're going to hanging up in my head the red i have the red little red bye good grief yes you all that that was good i mean it was actually good it wasn't bad having her um i i do like having here but we actually accomplished something how about that so enjoy your weekend