Journal of the Senate

________________

Wednesday, May 18, 2005

The Senate was called to order by the President.

Devotional Exercises

A moment of silence was observed in lieu of devotions.

Bills Referred

House bills of the following titles were severally read the first time and referred:

H. 533.

An act relating to compensation for certain state employees.

To the Committee on Government Operations.

H. 541.

An act relating to appointment of a sergeant major and a chief master sergeant in the Vermont National Guard.

To the Committee on Government Operations.

Joint Resolution Placed on Calendar

J.R.H. 46.

Joint resolution originating in the House of the following title was read the first time and is as follows:

Joint resolution supporting the mission of First Day of School America.

Whereas, the mission of the First Day Foundation is to promote annual first day of school celebrations for families in all schools, and

Whereas, in 1997, the late Hemmings Motor News publisher, Terry Ehrich of Bennington, created the First Day of School America campaign in order to make the opening day of school a shared and special experience for children, parents, and parents’ employers, and

Whereas, this special enterprise is an effective method for encouraging parental involvement in their children’s educational odyssey starting on the opening morning of the new academic year, and

Whereas, the program encourages employers to grant time off to their employees in order to facilitate parental attendance at a child’s first day of school, and

Whereas, the project is now known as First Day of School America and is operated through the First Day Foundation, a nonprofit organization that provides technical assistance to local schools and publishes both the First Day Handbook and the First Day Newsletter, and

Whereas, in 1998, 62 Vermont schools and 17 schools beyond the state’s borders hosted First Day events, and

Whereas, in 2004, every state had First Day programs involving over 10,000 schools, and

Whereas, Michigan, Rhode Island, and Maine have statewide First Day programs, and

Whereas, in 2005, 80 percent of Vermont schools are projected to have First Day programs, and

Whereas, First Day builds bridges between parents and teachers, and

Whereas, the state board of education encourages schools in Vermont to participate in First Day activities, and

Whereas, the Vermont Children’s Forum, the Vermont Council of Special Education Administrators, the Vermont-NEA, the Vermont Parent Teacher Association, the Vermont Principals’ Association, the Vermont School Boards Association, and the Vermont Superintendents Association are extremely supportive of parental and community involvement, including that reflected by participation in First Day activities and associated events, and

Whereas, U.S. Senator Patrick Leahy, U.S. Senator James Jeffords, and U.S. Representative Bernie Sanders support the foundation’s initiative in the holding of annual First Day festivities, and

Whereas, Governor James H. Douglas supports the early and ongoing involvement by parents in their children’s education assuring educational success, now therefore be it

Resolved by the Senate and House of Representatives:

That the General Assembly expresses its strong support for the educational mission of First Day of School America and urges communities throughout Vermont to promote this outstanding program, and be it further

Resolved:  That the secretary of state be directed to send a copy of this resolution to First Day of School America in Bennington and to Commissioner of Education Richard Cate.

Thereupon, in the discretion of the President, under Rule 51, the joint resolution was placed on the Calendar for action tomorrow.

Proposals of Amendment; Point of Order; Consideration Interrupted by Recess

H. 524.

House bill entitled:

An act relating to universal access to health care in Vermont.

Was taken up.

Thereupon, pending third reading of the bill, Senator Illuzzi moved to amend the Senate proposal of amendment as follows:

FirstIn Sec. 4, by adding a new subsection (h) to read as follows:

(h)  Beginning on and after July 1, 2006, it is the intention of the General Assembly to use the revenue raised by this act, and match those state funds with federal Medicaid funds authorized under the global commitment waiver negotiated with the federal government, to support the following health care reform initiatives during the five year period of the global commitment waiver:

(1)  Approximately $105 million for premium and cost sharing assistance to low and moderate income uninsured Vermonters, so that they can afford a choice of health care coverage: Green Mountain Health coverage, or a comprehensive health benefit plan.

(2)  $20 million to increase Medicaid reimbursements to physicians and other health care practitioners, beginning with primary and preventive medical and dental services, and subsequently including specialty practitioners.

(3)  Approximately $10 million to fund expansions of primary and preventive health care in medically-underserved areas.

(4)  The remainder of available funds, anticipated to be around $100 million, to be invested in health care system change investments including, but not limited to, technology matching grants to hospitals and physicians offices, pharmacies, and mental health agencies, which agree to abide by rigorous technology and practice standards to achieve world class chronic disease management, definitively better outcomes, medical cost control, and to support “pay for performance”.

Second:  In Sec. 24, in 33 V.S.A., by striking out § 2026 and inserting in lieu thereof a new § 2026 to read as follows:

§ 2026.  ADMINISTRATION; INDIVIDUAL CHOICE OF COVERAGE

     (a)  Any uninsured Vermont resident may enroll in:

          (1)  the Green Mountain Health plan approved under section 2022 of this title; or

          (2) a comprehensive health benefit plan approved by the commissioner of banking, insurance, securities and health care administration with a deductible amount, and with a benefit design which covers preventive care notwithstanding any deductible amount.

     (b)  The commissioner of banking, insurance, securities and health care administration may permit or require health insurance companies, health maintenance organizations, and hospital or medical service corporations to offer the plans described in subsection (a) of this subsection, in accordance with such terms and conditions as the commissioner may prescribe.

     (c)  Any uninsured Vermont resident with household income greater than 300 percent of the federal poverty level may enroll in either of the health benefit plans described in subsection (a) of this section, subject to the payment of a premium sufficient to support the per member costs of the plan, and subject to applicable cost sharing requirements. 

     (d)  Any uninsured Vermont resident with household income over 150 percent of the federal poverty level and less than or equal to 300 percent of the federal poverty level may enroll in either of the health benefit plans described in subsection (a) of this section, subject to any applicable premiums and cost sharing requirements.  Upon enrollment, the resident shall be eligible to receive income-sensitive assistance with any applicable premiums, deductibles and other cost sharing, in accordance with rules adopted by the office in consultation with the commissioner of banking, insurance, securities and health care administration.  The public cost of such assistance shall be substantially the same regardless of the coverage plan the individual chooses.

     (e)  The office of Vermont health access shall conduct an outreach and education program designed to enroll all eligible Vermont residents in Medicaid, VHAP and any other public health benefit plan.

     (f)  The director of the office of Vermont health access and the commissioner of banking, insurance, securities and health care administration may adopt such rules as are necessary to carry out the purposes of this section.  The commissioner may exercise his or her authority under Title 8 and Title 18 to carry out the purposes of this section.

     (g)  The office of Vermont health access may use Medicaid funds authorized under a Medicaid waiver negotiated with the federal government, including the global commitment waiver, to support all or a portion of the program authorized by this section.

     (h)  Between January 1, 2006 and December 31, 2008, the commissioner of banking, insurance, securities, and health care administration shall ensure that:

          (1)  hospital budgets approved under subchapter 7 of chapter 221 of Title 18 reflect, in their contracts with health benefit plans, each hospital’s decrease in uncompensated care attributable to the uninsured resulting from the programs established by this section; and

          (2)  health insurance premiums approved under 8 V.S.A. § 4062 account for lower health care facility and provider charges reflecting less uncompensated care attributable to the uninsured, and reduced per member costs reflecting the improved demographic characteristics of newly insured subscribers.

     Third: By striking out Secs. 25 and 26 in their entirety and inserting in lieu thereof new Secs. 25 and 26 to read as follows:

Sec. 25.  32 V.S.A. § 8551 is amended to read:

§ 8551.  IMPOSITION; RATE AND BASIS OF TAX

     (a)  A domestic or foreign insurance company, association or society, other than life, or a surety or guaranty company, doing business in this state, shall pay a tax to the state, which is hereby assessed at the rate of two percent per annum on the gross amount of premiums and assessments written on its business in this state, but not including premiums received for reinsurance.  A domestic or foreign life insurance company, doing business in this state, shall pay a tax to the state, which is hereby assessed at the rate of two percent per annum on the gross amount of premiums and assessments collected on its business in this state, but not including premiums received for reinsurance.

     (b)  Notwithstanding the provisions of subsection (a), a domestic or foreign insurance company, association or society doing health insurance business in this state, and carriers for any health benefit plan stop loss and excess coverage insurance doing business in this state, shall pay a tax to the state, which is hereby assessed at the rate of three percent per annum on the gross amount of premiums and assessments written on its business in this state, but not including premiums received for reinsurance.

     (c)  Beginning with taxes paid in calendar year 2006, all of the revenues raised by the tax imposed by subsection (b) of this section shall be deposited into the Green Mountain Health trust fund established under section 2028 of Title 33.

     (d)  As used in this section, and in sections 8552 through 8556 of this title, “insurance company” includes a hospital or medical service corporation, and a health maintenance organization.

Sec. 26.  8 V.S.A. § 4518 is amended to read:

§ 4518.  TAX EXEMPTION

A hospital service corporation shall be exempt from all forms of taxation, except as provided under subchapter 7 of chapter 211 of Title 32.

Sec. 26a.  8 V.S.A. § 4590 is amended to read:

§ 4590.  TAX EXEMPTION

A medical service corporation shall be exempt from all forms of taxation, except as provided under subchapter 7 of chapter 211 of Title 32.

Thereupon, pending the question, Shall the Senate proposal of amendment be amended as recommended by Senator Illuzzi?, Senator MacDonald raised a point of order that the third amendment offered by Senator Illuzzi, violated Chapter II, section 6 of the Vermont Constitution by imposing a tax, thereby making the bill a “Revenue bill” which can only be started in the House.

Thereupon, the President sustained the point of order.

Thereupon, Senator Welch immediately appealed the ruling of the Chair.

Thereupon, the question, Shall the ruling of the Chair be sustained?, was decided in the negative on a roll call, Yeas 7, Nays 22.

Senator Dunne having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Leddy, Maynard, Mullin, Sears, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Doyle, Dunne, Flanagan, Giard, Illuzzi, Kitchel, Kittell, Lyons, MacDonald, Mazza, Miller, Scott, Snelling, Starr, Welch, White.

The Senator absent and not voting was: Gander.

Thereupon, without objection, on motion of Senator Illuzzi, the second amendment as offered by Senator Illuzzi was amended in 33 V.S.A. §2026(a)(2), before the word “deductible” where it first appears, by inserting the word high

Thereupon, pending the recurring question, Shall the Senate proposal of amendment be amended as recommended by Senator Illuzzi?, Senator Scott requested that the question be divided.

Thereupon, pending the question, Shall the Senate proposal of amendment be amended as firstly recommended by Senator Illuzzi?, Senator Illuzzi requested and was granted leave to withdraw the first proposal of amendment.

Thereupon, pending the question, Shall the Senate proposal of amendment be amended as secondly recommended by Senator Illuzzi?, on motion of Senator Welch the Senate recessed until one o’clock and thirty minutes.

Afternoon

The Senate was called to order by the President.

Consideration Resumed; Proposals of Amendment; Bill Passed in Concurrence with Proposal of Amendment

H. 524.

Consideration was resumed on House bill entitled:

An act relating to universal access to health care in Vermont.

Thereupon, pending the recurring question, Shall the Senate proposal of amendment be amended as secondly recommended by Senator Illuzzi?, Senator Campbell moved to have the third proposal of amendment of Senator Illuzzi dealt with before the second proposal of amendment.

Which was agreed to.

Thereupon, the pending question, Shall the Senate proposal of amendment be amended as thirdly recommended by Senator Illuzzi?, was disagreed to on a roll call, Yeas 6, Nays 22.

Senator Welch having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Scott, Sears, Shepard, Snelling, Welch, White.

Those Senators absent and not voting were: Gander, Starr.

Thereupon, the pending question, Shall the Senate proposal of amendment be amended as secondly recommended by Senator Illuzzi?, was disagreed to on a roll call, Yeas 9, Nays 19.

Senator Campbell having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Scott, Shepard, Snelling, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Sears, Welch, White.

Those Senators absent and not voting were: Gander, Starr.

Thereupon, pending third reading of the bill, Senator Shepard moved to amend the bill as follows:

First:  [Deleted]

Second:  [Deleted]

Third:  In Sec. 1, by inserting three new subdivision to be numbered subdivisions (10), (11), and (12) to read as follows:

(10)  Health care system quality is much better measured by survival rates from ailments that require medical treatment than by longevity of life, which research demonstrates is affected far more by factors such as genetics, lifestyle choices, and socioeconomic status.  While the United States has the highest incident rate of prostate cancer, it has the lowest mortality rate as a result of prostate cancer.  Breast cancer rates are similar.

(11)  Determining administrative cost comparisons between public‑funded health plans and private insurers is difficult and often misleading.  Not all related government tasks are counted, such as collecting taxes and lobbying for more funding, whereas private companies count collecting premiums and marketing in their administrative costs.  When these are all counted, the public system no longer offers great savings in administrative costs.

(12)  Every finite resource, which is in high demand, must be rationed.  In a purely market-based system, rationing is based on the ability to pay.  Single-payer health care systems ration by limiting the availability of health care services, resulting in long waiting periods for treatment.

Fourth:  In Sec. 1, by inserting eight new subdivision to be numbered subdivisions (13), (14), (15), (16), (17), (18), (19), and (20) to read as follows:

(13)  Over the past decade, most European countries with single-payer health care systems have introduced market-oriented reforms to reduce costs and increase efficiencies.  Canada has begun relying on services available in the United States to help meet the health care needs of Canadian citizens.

(14)  In years 2001 and 2002, five percent of patients undergoing surgery in the United States had to wait more than four months, as compared to 23 percent in Australia, 26 percent in New Zealand, 27 percent in Canada, and 36 percent in Britain, all of which have a single-payer health care system.

(15)  Single-payer health care systems promise equal access and care regardless of ability to pay.  However, studies in both Britain and Canada reveal that access, health care quality, and survival rate are far inferior in regions with lower socioeconomic conditions as compared to regions with higher socioeconomic conditions.  Low income Americans on Medicaid likely have more access to better health care than low income citizens in any other country.

(16)  Sicker people in Canada and Britain wait much longer for treatment under their single-payer system, than do sicker people in the United States.  Longer waiting periods reduce the likelihood of curing the ailment and often results in earlier death.

(17)  Single-payer systems have resulted in longer hospital stays, which result in longer waiting periods for patient beds.  Global budget caps reduce the incentive to discharge patients to make room for waiting patients.

(18)  Research indicates that under single-payer health care systems, the elderly are frequently discriminated against and have great difficulty getting access to health care services.

(19)  Research indicates that under single-payer health care systems, rural areas have many fewer doctors and less health care technology on a per capita basis as compared with urban areas.

(20)  Single-payer health care systems have struggled to meet the demand.  This can be largely attributed to politics working against increasing funding.  The vast majority of constituents does not have a great need for health care services at any particular time and therefore tends to oppose increasing taxes to fund the system.  While holding back funding reduces costs, it does so at the expense of unmet health care needs.

Fifth:  In Sec. 1, by inserting five new subdivisions to be numbered subdivisions (21), (22), (23), (24), and (25) to read as follows:

(21)  Medicare, which is government run, has struggled to adapt to advances in the health care industry and changes in the marketplace.

(22)  Fee-for-service, managed care, and single-payer health care models are not well suited for the information age, where patient access to information on a variety of treatments has increased demand.

(23)  Informed patients are more compatible with health care systems that offer more patient control over choosing treatment options.  Such systems are only sustainable when the patient has some stake in paying for treatments. 

(24)  High deductible insurance plans combined with pre-tax Health Savings Accounts (HSA) allow an informed patient more choice in selecting the best value treatment for his or her particular situation.  The patient has a firsthand sense of both the cost and the benefit of a treatment.  Premiums for these types of plans are typically about one‑half the cost of more traditional insurance plans.  In addition, high deductible HSA plans have a lower inflation rate.

(25)  Any time resources are transferred to an insurance pool (private or public), there are two negative consequences (increased cost, at least for the group as a whole, and decreased autonomy) and one positive consequence (reduced risk). 

Sixth:  In Sec. 2, by striking out the following:  , modeled after the Coalition 21 principles,

Seventh:  In Sec. 2, by inserting a new subdivision to be numbered subdivision (7) to read as follows:

(7)  In order to build a stronger and more sustainable workforce for the decades to come, health insurance premiums must closely align with the actuarial risks associated with age, so that health insurance premiums do not discourage young adults from living and working in Vermont

Eighth:  In Sec. 2, by inserting two new subdivisions to be numbered subdivisions (8) and (9) to read as follows:

(8)  Before the state of Vermont expands its role in the health care market by issuing a more affordable reduced-benefit policy, the state should permit commercial insurance companies to offer more affordable, reduced‑benefit policies.

(9)  Before the state of Vermont imposes a tax to subsidize or otherwise pay for health care for the uninsured, the state should permit commercial insurance companies to offer more affordable reduced-benefit policies.


Ninth:  In Sec. 2, by inserting a new subdivision to be numbered subdivision (10) to read as follows:

(10)  The state of Vermont must not attempt to control health care spending by rationing health care services for which a patient has sufficient resources to cover the cost.  The resources might be in the form of private insurance, enrollment in a state health plan, or the patient’s personal resources. 

Tenth:  In Sec. 3, by striking out subdivision (1) in its entirety and inserting in lieu thereof a new subdivision (1) to read as follows:

(1)  Universal Access.  Vermont will continue to offer universal access to hospital care.  However, to meet better the needs of Vermonters, Vermont shall embrace policies that give health care professionals a clearer understanding of the needs and priorities of their patients by giving patients more control over their health care treatment decisions. 

(A)  Policies shall put the patient in the driver’s seat by providing access to cost and quality information and giving the patient the ability to make choices that best fit his or her needs. 

(B)  Policies will be such that the patient is encouraged to make the best use of the available health care resources.  Such policies will help health care professionals make investment decisions that will provide the best balance between the health and financial needs of their patients.

Eleventh:  In Sec. 3, subdivision (2), by striking out subparagraphs (A) and (I) and inserting in lieu thereof a new subparagraph (A) to read as follows:

(A)  consideration of what changes in state policy would enable the commercial health care insurance market to offer Vermonters more affordable and flexible health care insurance policies;

and at the end of subparagraph (G) by adding the word “and” after the semicolon and in subparagraph (H) at the end of the subparagraph by striking out the following: “; and” and inserting in lieu thereof a period

Twelfth:  In Sec. 3, subdivision (3), by striking out the words “expansions to

Thirteenth:  By striking out Sec. 4 in its entirety and inserting in lieu thereof a new section to be numbered Sec. 4 to read as follows:

Sec. 4.  PROCESS AND SCHEDULE FOR ATTAINING HEALTH CARE GOALS

(a)  On or before July 1, 2006, at least one commercial health insurance carrier will have health insurance which costs about $1,500.00 annually.

(b)  On or before January 15, 2006, the commissioner of banking, insurance, securities, and health care administration, in consultation with private insurers, shall study and make recommendations to the general assembly regarding policy and statutory changes necessary to enable private insurance carriers to offer insurance policies priced near $1,500.00 annually.  At a minimum, one policy should incorporate catastrophic coverage.  A second option might meet the needs of people with chronic illnesses.  In addition, the commissioner shall study and recommend policy and statutory changes necessary to enable private insurance carriers to offer a broader array of policies to meet the variety of needs within Vermont.

(c)  On or before January 15, 2007, the commissioner of banking, insurance, securities, and health care administration shall provide an update of the uninsured along with the number of Vermonters who are covered under the new, more affordable insurance plan.

Fourteenth:  By striking out Secs. 5, 6, 24, 25, 26, 27, 28, 29, and 32 in their entirety and renumbering the remaining sections accordingly

Fifteenth:  By striking out the existing Secs. 9 and 10 in their entirety and inserting in lieu thereof new Secs. 9 and 10 to read as follows:

Sec. 9.  8 V.S.A. § 4080a(h) is amended to read:

(h)(1)  A registered small group carrier shall use a community rating method acceptable to the commissioner for determining premiums for small group plans.  Except as provided in subdivision (2) of this subsection, the following risk classification factors are prohibited from use in rating small groups, employees, or members of such groups, and dependents of such employees or members:

(A)  demographic rating, including age and gender rating, but excluding age;

(B)  geographic area rating;

(C)  industry rating;

(D)  medical underwriting and screening;

(E)  experience rating;

(F)  tier rating; or

(G)  durational rating.

(2)(A)  The commissioner shall, by rule, adopt standards and a process for permitting registered small group carriers to use one or more risk classifications in their community rating method, provided that the premium charged shall not deviate above or below the community rate filed by the carrier by more than 20 percent (20%), and provided further that the commissioner’s rules may not permit any medical underwriting and screening.

(B)  The commissioner’s rules shall permit a carrier, including a hospital or medical service corporation, to establish premium discounts or rebates or otherwise modify applicable co-payments or deductibles in return for adherence to programs of health promotion and disease prevention, in accordance with federal regulations relating to bona fide wellness programs.  Under the federal regulations, permissible bona fide wellness programs shall:

(i)  limit any discount, rebate, or waiver of cost sharing to not more than 15 percent of the cost of employee-only coverage;

(ii)  be designed reasonably to promote good health or prevent disease for individuals in the program, and not be used as a subterfuge for imposing higher costs on an individual based on a health factor; and

(iii)  provide that the reward under the program is available to all similarly situated individuals.

(C)  The commissioner, in consultation with the commissioner of health, shall adopt by rule:

(i)  standards for approved health promotion and disease prevention programs, based on the best scientific, evidence-based medical practices; and

(ii)  standards and procedures for evaluating an individual’s adherence to programs of health promotion and disease prevention.

(3)  The commissioner may exempt from the requirements of this section an association as defined in section subdivision 4079(2) of this title which:

(A)  offers a small group plan to a member small employer which is community rated in accordance with the provisions of subdivisions (1) and (2) of this subsection.  The plan may include risk classifications in accordance with subdivision (2) of this subsection;

(B)  offers a small group plan that guarantees acceptance of all persons within the association and their dependents; and

(C)  offers one or more of the common health care plans approved by the commissioner under subsection (e) of this section.

(4)  The commissioner may revoke or deny the exemption set forth in subdivision (3) of this subsection if the commissioner determines that:

(A)  because of the nature, size or other characteristics of the association and its members, the employees or members are in need of the protections provided by this section; or

(B)  the association exemption has or would have a substantial adverse effect on the small group market.

Sec. 10.  8 V.S.A. § 4080b(h) is amended to read:

(h)(1)  A registered nongroup carrier shall use a community rating method acceptable to the commissioner for determining premiums for nongroup plans.  Except as provided in subdivision (2) of this subsection, the following risk classification factors are prohibited from use in rating individuals and their dependents:

(A)  demographic rating, including age and gender rating, and excluding age;

(B)  geographic area rating;

(C)  industry rating;

(D)  medical underwriting and screening;

(E)  experience rating;

(F)  tier rating; or

(G)  durational rating.

(2)(A)  The commissioner shall, by rule, adopt standards and a process for permitting registered nongroup carriers to use one or more risk classifications in their community rating method.  After July 1, 1993,; provided that the premium charged shall not deviate above or below the community rate filed by the carrier by more than 40 percent (40%) for two years, and thereafter 20 percent (20%).  Such rules may not permit, and provided further that the commissioner’s rules may not permit any medical underwriting and screening and shall give due consideration to the need for affordability and accessibility of health insurance.

(B)  The commissioner’s rules shall permit a carrier, including a hospital or medical service corporation, to establish premium discounts or rebates or otherwise modify applicable co-payments or deductibles in return for adherence to programs of health promotion and disease prevention, in accordance with federal regulations relating to bona fide wellness programs.  Under the federal regulations, permissible bona fide wellness programs shall:

(i)  limit any discount, rebate, or waiver of cost sharing to not more than 15 percent of the cost of employee-only coverage;

(ii)  be designed reasonably to promote good health or prevent disease for individuals in the program, and not be used as a subterfuge for imposing higher costs on an individual based on a health factor; and

(iii)  provide that the reward under the program is available to all similarly situated individuals.

(C)  The commissioner, in consultation with the commissioner of health, shall adopt by rule:

(i)  standards for approved health promotion and disease prevention programs, based on the best scientific, evidence-based medical practices; and

(ii)  standards and procedures for evaluating an individual’s adherence to programs of health promotion and disease prevention.

Thereupon, pending the question, Shall the Senate proposal of amendment be amended as recommended by Senator Shepard?, Senator Shepard requested that the question be divided.

Thereupon, the question, Shall the Senate proposal of amendment be amended as thirdly recommended by Senator Shepard?, was disagreed to on a roll call, Yeas 9, Nays 20.

Senator Sears having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Scott, Sears, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Snelling, Starr, Welch, White.

The Senator absent and not voting was: Gander.

Thereupon, the question, Shall the Senate proposal of amendment be amended as fourthly  recommended by Senator Shepard?, was disagreed to on a roll call, Yeas 9, Nays 20.

Senator Sears having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Scott, Sears, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Snelling, Starr, Welch, White.

The Senator absent and not voting was: Gander.

Thereupon, the question, Shall the Senate proposal of amendment be amended as fifthly  recommended by Senator Shepard?, was disagreed to.

Thereupon, the question, Shall the Senate proposal of amendment be amended as sixthly and seventhly  recommended by Senator Shepard?, was disagreed to on a roll call, Yeas 8, Nays 21.

Senator Shepard having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Scott, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Sears, Snelling, Starr, Welch, White.

The Senator absent and not voting was: Gander.

Thereupon, the question, Shall the Senate proposal of amendment be amended as eighthly  recommended by Senator Shepard?, was disagreed to.

Thereupon, the question, Shall the Senate proposal of amendment be amended as ninthly  recommended by Senator Shepard?, was disagreed to on a roll call, Yeas 8, Nays 21.

Senator Shepard having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Scott, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Sears, Snelling, Starr, Welch, White.

The Senator absent and not voting was: Gander.

Thereupon, the question, Shall the Senate proposal of amendment be amended as tenthly and eleventhly  recommended by Senator Shepard?, was disagreed to.

Thereupon, the question, Shall the Senate proposal of amendment be amended as twelfthly, thirteently and fourteenthly recommended by Senator Shepard?, was disagreed to on a roll call, Yeas 8, Nays 21.

Senator Shepard having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Scott, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Sears, Snelling, Starr, Welch, White.

The Senator absent and not voting was: Gander.

Thereupon, the question, Shall the Senate proposal of amendment be amended as fifteently recommended by Senator Shepard?, was disagreed to on a roll call, Yeas 3, Nays 26.

Senator Shepard having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Maynard, Shepard.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Doyle, Dunne, Flanagan, Giard, Illuzzi, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Mullin, Scott, Sears, Snelling, Starr, Welch, White, Wilton.

The Senator absent and not voting was: Gander.

Thereupon, pending third reading of the bill, Senator Wilton moved to amend the Senate proposal of amendment by adding a new to be numbered Sec. 7b, to read as follows:

Sec. 7b.  12 V.S.A. § 5784 is added to read:

§ 5784.  PRESCRIBER IMMUNITY FROM LIABILITY

No person shall be liable to a patient or third party for injuries sustained as a result of the use of a lawfully prescribed drug or medical device, provided the drug or device was prescribed in a manner consistent with approved United State Food and Drug Administration instructions and any known indications and contraindications for the drug or device.

Thereupon, the pending question, Shall the Senate proposal of amendment be amended as recommended by Senator Wilton?, was disagreed to on a roll call, Yeas 4, Nays 24.

Senator Wilton having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Mullin, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Campbell, Collins, Condos, Cummings, Doyle, Dunne, Flanagan, Giard, Illuzzi, Kitchel, Kittell, Leddy, Lyons, MacDonald, Maynard, Mazza, Miller, Scott, Sears, Snelling, Starr, Welch, White.

Those Senators absent and not voting were: Bartlett, Gander.

Thereupon, pending third reading of the bill, Senator Cummings moved to amend the Senate proposal of amendment as follows:

First:  In Sec. 5, by striking out subsection (b) in its entirety and inserting in lieu thereof a new subsection (b) to read as follows:

(b)  On or before July 1, 2009, provided the commission determines that cost savings relative to the benchmarks established under this section are met, the commission shall recommend to the general assembly that all Vermonters have a minimum common benefit level, including hospital coverage, and be able to choose between Green Mountain Health and any commercial plan offering a common benefit level.

SecondIn Sec. 14, 18 V.S.A. § 9473(b), by striking out the second sentence in its entirety and inserting in lieu thereof the following:

The attorney general and the commissioner shall consult with each other prior to the commencement of any investigation or enforcement action with respect to any pharmacy benefit manager. 

ThirdIn Sec. 25, by striking out subsection (a) of 32 V.S.A. § 5848 and inserting in lieu thereof a new subsection (a) to read as follows:

(a)  An employer health insurance impact tax is imposed upon every person who is required under subchapter 4 of this chapter to withhold income taxes from payments of income with respect to services. 

(1)  The tax under this section shall be equal to an estimated rate of 3.0 percent of the total taxable earnings, as defined for Medicare part A taxable earnings paid to:

(A) all employees in the reporting period, if the employer did not offer paid or partially-paid health insurance for the entire preceding calendar quarter to all its employees; or

(B)  all employees in the reporting period who were not covered by health insurance for the entire calendar quarter preceding the reporting period, if the employer did offer paid or partially-paid health insurance for the entire preceding calendar quarter to all its employees.  An employee whose only health insurance coverage is through any combination of Green Mountain Health, Dr. Dynasaur, the Vermont Health Access Program, Medicaid or a Medicaid-waiver program is considered not covered by health insurance for purposes of the health impact tax under this subdivision.

          (2)  The first $25,000.00 of wages which, but for this provision would be subject to this tax, shall be exempt each year. 

Which was agreed to.

      Thereupon, pending third reading of the bill, Senator Sears, on behalf of the Committee on Judiciary, moved that the Senate proposal of amendment be amended by striking out Sec. 7a. in its entirety and inserting in lieu thereof the following:

Sec. 7a.  12 V.S.A. § 1912 is added to read:

§ 1912.  EXPRESSION OF REGRET OR APOLOGY BY HEALTH CARE PROVIDER INADMISSIBLE

(a)  An expression of regret or apology or an explanation of how a potential adverse outcome occurred made by or on behalf of a health care provider, including one that is made in writing, orally, or by conduct, that is provided within fourteen days of when the provider knew or should have known of the consequences of the potential adverse outcome, does not constitute a legal admission of liability for any purpose and shall be inadmissible in any civil or administrative proceeding against the health care provider, including any arbitration or mediation proceeding.

(b)  In any civil or administrative proceeding against a health care provider, including any arbitration or mediation proceeding, the health care provider or any other person who makes an expression of regret, apology, or explanation on behalf of the health care provider, including one that is made in writing, orally, or by conduct, that is provided within fourteen days of when the provider knew or should have known of the consequences of the potential adverse outcome, may not be examined by deposition or otherwise with respect to the expression of regret, apology, or explanation.

(c)  As used in this section, “health care provider” shall have the meaning given in subdivision 1910(e)(1)(A) of this title.

Thereupon, the pending question, Shall the Senate proposal of amendment be amended as recommended by Senator Sears on behalf of the Committee on Judiciary?, was agreed to on a roll call, Yeas 28, Nays 1.

Senator Welch having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Ayer, Bartlett, Collins, Condos, Coppenrath, Cummings, Doyle, Dunne, Flanagan, Giard, Illuzzi, Kitchel, Kittell, Leddy, Lyons, MacDonald, Maynard, Mazza, Miller, Mullin, Scott, Sears, Shepard, Snelling, Starr, Welch, White, Wilton.

The Senator who voted in the negative was: Campbell.

The Senator absent and not voting was: Gander.

      Thereupon, pending third reading of the bill, Senators Flanagan, Kittell and White moved that the Senate proposal of amendment be amended in Sec. 5, by striking out subsection (b) in its entirety and by inserting in lieu thereof a new subsection (b) to read as follows:

     (b)  Provided that the commission determines that cost savings relative to the benchmarks established under this section are met:

          (1)  On or before July 1, 2007, all Vermonters shall be able to join the Green Mountain Health plan;

          (2)  On or before July 1, 2008, the Green Mountain Health plan shall be expanded to include hospital coverage; and

(3)  On or before July 1, 2009, all Vermonters have a minimum common benefit level, including hospital coverage, and be able to choose between the Green Mountain Health plan and any commercial plan offering a common benefit level.

Which was disagreed to.

     Thereupon, pending third reading of the bill, Senator Mullin moved to amend the Senate proposal of amendment in Sec. 24 by striking out §2025(a) and inserting in lieu thereof a new §2025(a) to read as follows:

§ 2025.  PAYMENT AMOUNTS

(a)  The intent of this section is to ensure reasonable payments to health care professionals and to eliminate the shift of costs between the payers of health services. The payment amounts should reflect the fair market rate for the health services paid for by Green Mountain Health.

     Which was agreed to on a roll call, Yeas 25, Nays 4.

Senator Mullin having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Ayer, Bartlett, Campbell, Collins, Condos, Coppenrath, Cummings, Doyle, Dunne, Giard, Illuzzi, Kitchel, Kittell, Leddy, Lyons, MacDonald, Maynard, Miller, Mullin, Scott, Sears, Shepard, Snelling, Starr, Wilton.

Those Senators who voted in the negative were: Flanagan, Mazza, Welch, White.

The Senator absent and not voting was: Gander.

     Thereupon, pending third reading of the bill, Senator Mullin moved to amend the Senate proposal of amendment by requiring that Green Mountain Health initially provide catastrophic coverage rather than primary and preventive care coverage.  To accomplish the purpose of this amendment the words “primary and preventive care” shall be stricken and replaced by the word “catastrophic” throughout the bill, as appropriate and, in Sec. 24, section 2021 of Title 33, by adding a new subparagraph (2) as follows:

(2)  “Catastrophic coverage” means comprehensive health insurance with a high deductible plan, as defined by the director of the office of Vermont health access, in consultation with the commissioner of banking, insurance, securities, and health care administration..

and by renumbering the subsequent subparagraphs accordingly

     Thereupon, the question, Shall the Senate proposal of amendment be amended as recommended by Senator Mullin?, was disagreed to on a roll call, Yeas 8, Nays 21.

Senator Wilton having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Coppenrath, Doyle, Illuzzi, Maynard, Mullin, Scott, Shepard, Wilton.

Those Senators who voted in the negative were: Ayer, Bartlett, Campbell, Collins, Condos, Cummings, Dunne, Flanagan, Giard, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Sears, Snelling, Starr, Welch, White.

The Senator absent and not voting was: Gander.

Thereupon, the bill was read the third time and passed in concurrence with proposal of amendment on a roll call, Yeas 21, Nays 6.

Senator Leddy having demanded the yeas and nays, they were taken and are as follows:

Roll Call

Those Senators who voted in the affirmative were: Bartlett, Campbell, Condos, Cummings, Doyle, Dunne, Flanagan, Giard, Illuzzi, Kitchel, Kittell, Leddy, Lyons, MacDonald, Mazza, Miller, Scott, *Sears, Starr, Welch, White.

Those Senators who voted in the negative were: Coppenrath, Maynard, Mullin, Shepard, Snelling, Wilton.

Those Senators absent and not voting were: Ayer, Collins, Gander.

     *Senator Sears explained his vote as follows:

     “I support this bill because it is time to move forward.

     “It is clear to me that this is not a taxpayer-financed single-payer system no matter how hard some would like to portray it.  In my view the findings make it clear that a single-payer system will not work on the state level.”

     Senator Maynard moved that the remarks of Senators Coppenrath and Leddy during yesterday’s proceedings be journalized.  Thereupon, Senator Maynard requested and was granted leave to withdraw the motion.

Committee of Conference Appointed

H. 504.

An act relating to appraisals and education finance.

Was taken up.  Pursuant to the request of the House, the President announced the appointment of

                                         Senator Cummings

                                         Senator MacDonald

                                         Senator Maynard

as members of the Committee of Conference on the part of the Senate to consider the disagreeing votes of the two Houses.

Adjournment

On motion of Senator Welch, the Senate adjourned until nine o’clock and thirty minutes in the morning.