Sunday, April 11, 2021

April 11, 2021 Update

The House Health Care Committee is looking at the question right now about when it is right to do something to help a whole lot of people, knowing that your action will negatively impact a few. There is very little that we can do to directly influence how people must pay for health insurance, because it is so heavily regulated by federal law. A specific part of the new American Rescue Plan Act gives us a window of opportunity, however, to help ease health care premium increases for small businesses, non-profits and municipalities next year. Understanding the opportunity gives a glimpse into the complexities of our current system of paying for health care.

I should begin by saying the most important part of ARPA for many individuals is that you stand to benefit tremendously from the increase in premium tax credits. If you currently buy health insurance as an individual, rather than through work, should be checking immediately at Vermont Health Connect to see whether you should change your plan. This is most important if you are buying a plan directly from Blue Cross/Blue Shield or MVP and receiving no tax credits.

It is highly likely that you are now eligible for some help, but it requires that you buy your plan directly through Vermont Health Connect. VHC is open right now for new enrollment in part for this reason. In addition, if you are going without insurance because it was simply unaffordable to you at full price, you may now be eligible for help. Please check!

The Deeper Dive

The first background piece about our opportunity to help small business groups is these new, increased tax credits. Regardless of my angst over the huge deficits we are taking on as a nation through the economic stimulus efforts, I strongly support the aspect regarding the new investments to help people with health care.

Another “regardless”: whether moving to some sort of universal coverage system would be a wise solution in the future or not, I think our current gross disparities in the ability of people to get coverage – which means getting access to health care itself – is unconscionable. Hardworking people making the same amount of money may pay virtually nothing, or huge percentages of their income, to get insurance. If you are very poor and eligible for Medicaid, you are in great shape. If you have a job that provides excellent benefits, you are in great shape. If for reasons outside of your control you are working for an employer who offers minimal coverage, or you are self-employed, you are in a highly inequitable position.

Ever since the Affordable Care Act passed, one such moderate income group was the folks buying their own insurance who fell “off the cliff.” Tax credits go up to 400 percent of the poverty level, and up to that point, the ACA standard was that someone should not have to pay more than about 10 percent of their income for insurance. Tax credits (and at lower incomes, premium subsidies) filled in the rest. At 400 percent, the supports were cut off, and those individuals could end up having to pay 15 or 17 or even a higher percentage of their income. You fell off a cliff.

Under ARPA (the new federal rescue plan), those credits have no cutoff. It sets about 8.5 percent of income as the “affordable” standard, and as long as the basic plan exceeds that based on your income, you can get help. That puts many folks on a more equitable footing, and the cliff is eliminated.

Small Groups

The individual market is always the most expensive. The smaller the market the higher the cost, because the risk cannot be spread out over as many individuals. The next market group is the small business market, those with fewer than 100 employees. There is a large group market as well, but very few employers are in it in Vermont (about 3% of Vermonters) because at that size, they flee to the “self-insured” market, because that is regulated solely by federal law. None of Vermont’s requirements and protections apply to that category.

Since the ACA, there has been a 40% shift of large employers to becoming self-insured, and that market is now 33% of private insurance in Vermont. Dividing the other biggest pieces of pie up, Vermont has about 25% under Medicaid, 22% under Medicare, 15% in the combined small group and individual market, and about 3% uninsured. The 15% is split about 55/45 between small group and individual.

I mentioned that the individual market is the most expensive. Vermont made a controversial policy decision at the start of the ACA, requiring small business to be combined with the individual market, called a “merged market.” This helped individuals save some money because the market was bigger.

Continued in part 2

 

Continued from Part

The savings comes at the expense of the small business group, which had to pay rates that are higher. Small business is subsidizing people who have to buy as individuals. When we did an analysis from 2018, we found that this saved about 7% of the premium cost for individuals, and cost small businesses about 5% extra. The numbers may have shifted since, but that’s the ballpark we have, to work with. It has always been unfair to do this – but the dilemma was that it would strand individuals if we “unmerged” this market, and we were blocked by federal law from spreading the cost further by including larger employers.

What Changed?

The increase in federal tax credits has changed this picture. If the individual market cost increases by 7%, the vast majority of those people will be 100% shielded from that increase because of the new credits. We can unmerge the market and reduce premiums for small businesses, non-profits, and municipalities and their employees without a negative impact on the individual market.

Wow! A win-win. Well, not 100 percent.

First, this tax credit boost only lasts for two years; it can only help small business without hurting individuals for one insurance coverage year. It does seem likely that public pressure across the country will prevent Congress from repealing this, and the small business community has testified to us that even if it is only a one-year break, it is still worth it for them.

Second, not quite everyone wins. People in the individual market who have an income high enough that results in a plan costing less than 8.5% of their income would see that 7% increase. That actually represents the actual cost within that market, but it would be a change from existing cost for them. That is estimated to be fewer than 10% of folks currently in the individual market, because most folks at this income level have robust employer coverage. (Currently, about 32% in the individual market do not receive credits or subsidies; the drop would represent the impact of the ARPA increases.)

An even smaller number of people could be hurt in a more complicated scenario from something called the “family glitch.” This is an inequity that was unintentionally created by the ACA. People cannot go to the individual market and get subsidies if they are offered employer insurance, unless that insurance is deemed “unaffordable.” Unaffordable is defined as basic coverage that would cost more than about 10% of the employee’s household income.

The glitch is that the percentage is based upon full household income, but in relation to the cost of an individual (single-person) plan. The federal administration is trying to find a way to address this glitch, but it is not clear whether it will get resolved. Thus, those folks may remain not eligible for tax credits if they go to the individual market, but might still want to, if it provides better coverage than their employer plan. If we “unmerge” the markets, that market plan would cost them that estimated 7% increase in premium. This is fewer than 300 people in Vermont, but it still means we cannot say that this change would only benefit people, and cost no one.

These two sub-groups would have to pay the actual cost of the very small individual market, without the current benefit of being subsidized by small businesses. It is still the right thing to do. The estimate is that the small group and its employees could save about $17 million in this one year. But we have to have our eyes open, and acknowledge that there will be some individuals whose premiums would go up as a result.

Other Bits of Action

A bill requiring anyone who does any project valued at more than $3,500 to sign up on a new state registry as a contractor passed the House last week. The registry ties into a slew of requirements. Picture a college kid doing a summer project for a neighbor who fails to keep the records for seven years, or doesn’t provide her email change within 30 days.

The potential penalty? A $5,000 fine. It that likely to ever happen? Of course not. But we ought not to put things in statute that we do not intend to ever happen on the premise that it’s “not likely.” I can claim direct credit for one thing. I pointed out that the bill also had a cross-citation that allowed up to a one-year jail term for failure to register. As a result, the committee amended the bill to remove that penalty.

It is an honor to represent you. Please contact me (adonahue@leg.state.vt.us) or Ken (kgoslant@leg.state.vt.us) any time for questions; you can also ask to get on my direct mailing list for these updates.

Saturday, March 27, 2021

March 27, 2021

 There were many major bills on the floor in the past week and I encourage folks to contact me or Rep. Ken Goslant if you want more background on any of them. 

We have passed on to the Senate this year’s annual budget, the two-year capital construction bill, and the transportation budget. We also passed the education tax rate bill, a major economic development bill, broadband build-out, and child care support reforms. Most of these bills had my support.

There was a bombshell regarding the review of options to address the crisis in the pension for state employees and teachers. Rather than crafting a joint bill as a committee, the chair and vice-chair released a detailed proposal that uses increases in employee contributions to addresses the shortfall from past state mismanagement. 

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The Budget

I voted for the budget with a fair amount of trepidation. The base budget of revenues and programs is balanced and reasonable. It exercises fiscal restraint, which is particularly important given the uncertainties as we pull ourselves out of a pandemic. In conjunction with the amounts for the economic development and workforce and the broadband bills, it appropriates $650 million from the new federal COVID-19 “rescue” fund.These were all solid and constrained to single-time investments – not building new programs that will then require ongoing future state budget expenditures. In addition to the items in the bills above, it includes clean water, higher education, and sate IT system investments.

My concern is that we are looking at a total federal influx of about double that -- $1.3 billion -- in money that can be spent over the next three years, and are making spending decisions on half of it without establishing a big picture on overall priorities and how the full pie should be divided up. It is a bit like spending half the money to build part your house without knowing what you need for the rest of it and whether you will have enough money left.

The base budget does include $360 million from our state funds to sustain our current pension obligations ($100 million more than what was required last year) plus – by moving the new federal money to backfill state funds -- $150 million in addition to address the current shortfall. But that is only a drop in the bucket compared to what is needed...

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The Pension Dilemma

I share in a strong desire to ensure that we don't back off our obligations based on our (as a state) prior mismanagement with the various state and teacher pension funds that have resulted in the $5.7 billion hole. I also agree that we should avoid decisions with a long-term impact, precipitously. Addressing those points have more complexity than may appear. 

The shortfall has built up over many years due in significant part to the state’s failure to fund its obligations, but is also based on acceptance of misguided actuarial assumptions without regular review of actual performance of investments. The boards making those decisions included employee representatives and included increases in benefits over the years – and, incomprehensively, different boards made benefit decisions from those making investment decisions. Revision of that structure is part of the reforms needed. Delay in action even for a year would have a huge impact on the ongoing exponential growth of the current shortfall. 

This past week was the first time that I and our caucus members were told about the plan presented by legislative leaders, so we hope there will be a great deal more testimony and input before a decision is made by the Government Operations Committee and brought to the House floor. When it reaches the floor, I will need to make a decision about whether a proposed resolution is fair and responsible. Once it leaves the House it goes to the Senate which will be able to change it as they see fit and then negotiate that with the House; it then goes to the Governor for his decision. So, we are still at a beginning phase. 

If you or anyone you know would like to send written testimony to the Government Operations Committee regarding specifics you should do so here: testimony@leg.state.vt.us. The details on the current proposals for change can be found at the legislative web site, legislature.vermont.gov by going to the committee web page and looking under Documents, date tab for March 24, under Chris Rupe. Two public hearing were scheduled but both filled quickly. You can watch the hearings on the same committee page; click on livestream and then on the archived YouTube link for the dates of March 26 and 29.

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Taxes: Education Fund

We voted out the base education property tax rate (the statewide one, which can shift locally based on town budget votes), which will go down next year by about 1.5 cents on the dollar. Before celebrating, we need to remember we’ve been in this place before, when costs continued to grow but tax increases were hidden because tax rates declined. Home sales are a hot market right now. The increased prices will drive up the grand list and thus revenues will increase while the rate stays the same or goes down. If your home value goes up on paper because other homes are being sold at higher prices, your taxes will go up even if the rate decreases. Increased spending doesn’t just vanish; we still pay for it.

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More on Taxes

We also raised a tax; one that appeared to place a small burden on very wealthy folks – those buying homes worth more than $1 million -- to help out those struggling just to buy a mobile home, by expanding the current tax credit that helps them. But recall the current increases in the market. This is resulting in major increases in the existing property transfer tax revenues. The mobile home tax credit can be increased without an added tax.

The property transfer tax also applies to far more than high-end homes. It applies to purchasers of rental properties, where costs will be passed on to low income tenants. It applies to businesses, which have been hit hard by the pandemic – and those costs will be passed on to the purchasers of goods and services. This is terrible timing. I voted no. Although several moderate Democrats joined most Republicans in opposition, the tax increase passed.

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Capital Bill

The only issue in contention in the capital bill was the construction of a new mental health facility that will replace a decrepit, temporary 7-bed building in Middlesex. The original was a set of trailers intended to last only a few years, set up after Tropical Storm Irene to replace state hospital beds that were used for a small group of patients who did not actually still need hospital-level care, but still did need a locked setting due to unresolved safety concerns. No one questioned the urgent need to replace that structure. 

The concern was about the expansion of more state, institutional beds (the new program will be 16 beds) without addressing the need for residential supports in the community for other Vermonters who are also remaining in hospitals because of lack of access to the post-hospital support they need. A shortage of community services feeds on the need to increase higher levels (and higher cost) care. Over the past ten years, utilization of hospital beds has nearly doubled, while access to community support has been stagnant. We added 12 highest-needs beds two years ago, which are just now about to open. That’s backwards, and the cost of running this new facility will suck more money away from the ability to support other Vermonters’ needs. 

My Health Care Committee, which is responsible for policy, took extensive testimony on this concern. We reached a compromise with the Institutions Committee, which is responsible for meeting the need for essential new state construction. That committee has been working for years to get this new facility built, and the construction will go forward.

Language from our committee that I drafted was added, however, to ensure flexibility in design to allow for future changes to address other needs. They also accepted policy language for a directive to the Department of Mental Health to identify community projects over the next nine months that might be able to be funded with the new federal infrastructure money. Operating costs then may be able to be addressed with the new federal bridge funding for several years, and then replaced by state funds saved as hospital levels are reduced. 

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Remote Vote Crisis

We had our first mini-crisis with remote voting. A thunderstorm rolling through briefly locked out several members from a vote, and when one member got up to ask if there was a way he could vote afterwards, he was told that House rules barred it. 

We started on a new bill, and I jumped up (figuratively) to call a point of order. Given our unique status in functioning from home computers, I felt we needed to find a way to preserve members’ ability to vote. A path forward was found by voting to suspend our own rules to allow a revote on the bill. The Rules Committee will be meeting to review this issue more broadly. 

After all, thunderstorm season is upon us...

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It is an honor to represent you. Please contact me (adonahue@leg.state.vt.us) or Ken (kgoslant@leg.state.vt.us) any time for questions. Remember that you can access any of my updates from the past on my blog representativeannedonahue.blogspot.com.


Saturday, March 13, 2021

March 13, 2021 Update

 It’s been a busy week facing the deadline for bills to be voted out of committee if they are to be considered by the Senate this year, and these bills will be flooding the House floor for consideration in the next few weeks. Those that require money to implement must make a stop next in the Appropriations Committee, which much balance them against the overall needs and revenues of the state.

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Votes Last Week

Two controversial bills came up for House roll call votes this past week.

First was a Montpelier charter change to allow legal residents who are not citizens to vote on local Montpelier ballot items. Vermont law doesn’t allow towns to change their own charters without approval of the legislature. I felt this was a Montpelier voter decision about voting on Montpelier issues, which is not related to any state voting issues and sets no state precedent, so I voted yes. It passed 103-39.

The second makes it explicit in law that a judge can order a person to temporarily relinquish firearms prior to a court hearing when there is a domestic violence restraining order and it appears that there is a threat. Because there is no time for a hearing in advance, it is termed an “ex parte” order: the subject does not get to appear and give their side.

The primary opposition centered on whether a constitutional right should be suspended in this way based on the routine standard used in civil cases, which is call “preponderance of the evidence,” meaning that it is more probable than not, or weighs more than 50% on the scale of certainty. The higher standard requires a showing of “clear and convincing,” and criminal convictions require “beyond a reasonable doubt.”

There are rarely topics where I believe an issue is absolute, with no balancing of rights involved. I have opposed the overwhelming majority of bills placing restrictions on Second Amendment rights because I felt the rights were impacted in a significant way and the restriction was not something that would actually help reach the public safety goal that was articulated.

 This was an instance where I felt the balance fell towards allowing a temporary removal. The existing law permits even a child being taken from a parent “ex parte” based solely on preponderance of evidence of a claimed risk. There is urgency for these emergency orders, and the suspension of a right before the hearing can occurs is brief.

The vote on the bill was 101-41. (Everything is archived on YouTube now, so if you want to see my explanation on the House floor, you can check last Thursday’s video and go in to about the 1 hour, 46 minute spot.)

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Up Next Week

One of the bills on the calendar next week is on registration and certification of residential contractors. The purpose is to protect consumers. It applies to jobs that exceed $2,500 in cost. The registration would be mandatory; certification would be an option for those who want to be able to demonstrate to customers that they have qualifications that have been verified by the state. The registration requires a minimum level of liability coverage and the use of written contracts. 

I’m not generally in favor of the endless increase in the various occupations we put under state oversight. This bill does seem to make some sense, but it came out of the committee with a split vote, so I’ll be considering the reasons for opposition in the floor discussion.

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Health Care Bills

My committee passed four bills for the “crossover” deadline. Three were unanimous, and one was with one vote in opposition. 

Telehealth continues to be a major factor in our continuing virtual world, but providers must be licensed in Vermont to practice here, and “practice here” includes via telehealth. We had a bill proposed to approve telehealth practice by a mental health counselor who was licensed out of state but had an existing client who moved to Vermont. It turned out that there were a lot of complicating issues, plus a question about why we shouldn’t consider all medical professionals. We rewrote the bill to create a work group that will review all the issues and recommend legislation next year.

Sometimes it seems like we punt on a lot of subjects by setting up work groups. The reality is that if we were to do reasonable due diligence on every issue, we could easily take up half a session on one bill – or need to be a year-round legislature – so this avenue often makes sense.

A second bill addressed several mental health hospitalization topics. There is a lot of focus and oversight regarding people who are held involuntarily as a “danger to self or others,” and that’s appropriate because there are serious civil liberties at issue.

That obscures the fact that 90% of people admitted for psychiatric care are there voluntarily, just like the person who has sought admission because of a heart attack or to have a baby. Vermont’s small scale, however, means that our inpatient psychiatric units are not segregated to have locked units only for involuntary patients. This bill requires informed consent, so that someone seeking admission knows in advance that they will be in a locked unit, and may be stopped from leaving if they ask for discharge and are found to be at risk to self or others – and thus subject to the involuntary hospitalization law.

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Two With Money

 Our other two other bills will go to Appropriations first.

Dr. Dynasaur is the umbrella name for our Medicaid programs that cover children and pregnant moms from low income families. As a partially federally funded program, Medicaid is very limited in the coverage that is permitted for undocumented immigrants.

Do we want to leave children without protection (born or unborn) based on an immigration status? Note that urgent care is always provided, but we pay for it in more roundabout ways. A Mom who had no prenatal care and gives premature birth, with high costs for the preemie, will get the care. The parents might get hounded for payment but it will be swallowed up into the hospital’s “bad debt” which is then cost-shifted to everyone’s insurance premiums.

Investing in preventative care through a state-funded program is not only the humane thing to do (or, in the words of a colleague, “the Christian thing to do”), but it also saves money. About half of these folks are here legally but their full status is still being processed; most of the others are our migrant farmworker families. The estimate is that this will involve about 22 pregnancies and 100 children. Our committee was unanimous on a bipartisan basis in voting for this bill.

The second bill represents the major work of the session for our committee. 

We have been conscious for many years about the facts that there are groups of people who, on average, have significantly worse health outcomes than everyone else. COVID brought it to the forefront. The primary groups are “BIPOC” (Black, indigenous and people of color); LGBTQ, and people with disabilities.

The reasons include a wide range of historic inequities or discrimination carried over to current hidden biases, many of them listed with source citations in the bill’s findings section.  Here are just a few of the examples:

Vermont was part of the eugenics movement of the 1930s, where people were sterilized without consent because we believed they were inferior and needed to be prevented from having children. It was used against immigrants of the time (mostly French-Canadian) and those in state institutions. It was seen as a money-saver when it came to the cost of caring for future generations of those deemed to be “insane” or “imbeciles.” No group was hit as hard, though, as the Abenaki people. That deep wound at the hands of our society led to an ongoing fear and suspicion of our medical professions, and thus, less use of appropriate medical care.

Blacks held back by generations of discrimination by law face greater challenges in basic steps forward such as homeownership, better neighborhoods, or educational opportunities. With higher rates of poverty, crowded housing, environmental toxin exposures, and lack of access to healthier foods, it should not be a surprise that there are higher rates of the kinds of overlying health conditions that make any other illness – like COVID -- more severe.

There are also unrecognized biases by health providers themselves. One example is called “diagnostic overshadowing.”  It means that if a person comes in for care with the label of “mentally ill,” a provider may allow that label to overshadow the recognition of an underlying condition.

Our bill would create a broad Commission to develop standards for data collection and to make recommendations about creation of an Office of Health Equity within our Department of Health. The original bill came to us proposing the immediate creation of such an office, and I wasn’t sure that was the right direction. 

Changing the bill to bring in the voices of all those groups most affected by health disparities first is the right way to identify the best path forward on how to address them. We have an expression in the disability community: “nothing about us, without us.” In other words, don’t help us by deciding us what is best for us. Listen to us to learn what is needed.

The one committee member who voted against the bill was not opposed to its goals, but believed we should be working through existing state agencies, rather than setting up a Commission to develop a separate, new office within the Department of Health.

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Next for Us

Our committee’s next task is not a bill; it is a recommendation we need to make to the committee that handles the budget for new construction. The Department of Mental Health wants to move ahead with a new facility that will add nine beds as it replaces an existing, 7-bed locked step-down program for current patients in our highest security level of involuntary inpatient care. It believes this is the best way to address the ongoing problem of long delays in emergency rooms for patient in a mental health crisis, because if more current patients have a place to “step down,” inpatient beds will open up.

The Department’s own reports, however, show that we also have people who stay in the hospital longer than needed because of the lack of supported community housing, nursing home beds, or group homes. The Department also reports that community crisis teams are so short-staffed that they only respond to screen emergency room patients. They have no time to fulfil their intended function, which is to respond to a person in crisis to help avoid the need to go to the hospital.

When there are limited resources at every turn, the question we need to weigh is which steps we should prioritize.

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  It is an honor to represent you. Please contact me (adonahue@leg.state.vt.us) or Ken (kgoslant@leg.state.vt.us) anytime to share your input, ask questions, or raise concerns. My full archive of legislative updates can be found at representativeannedonahue.blogspot.com. 


Saturday, February 13, 2021

February 13, 2021 Update

 

Legislative Update

February 13, 2021

Rep. Anne Donahue

 

There is often a disconnect between the bills that constituents lobby for, and the bills that actually come up for a vote. A current bill, H.81, is a good example.

For a couple of weeks, legislators have received emails from teachers about the importance of passing this bill. Many stressed this was not a bill that changed health policy, but was solely a “technical adjustment bill” to give lowest-paid school support staff a “fair shot” at negotiating health care coverage. I’m sure some of these constituents felt I gave pretty ambiguous replies: classic “politician responses” that ducked the question of whether I would support the bill. That would be a valid criticism. I said I would “keep an eye out for it and if it does move forward, I will keep your concerns in mind.” That ducked the question.

That’s because it is rare that a bill passes out of a committee in the same form that it started. If I said, “of course I’ll vote for it,” it would be disingenuous, and potentially a promise I could not keep. If a bill is not in my own committee, it isn’t possible to know the details of both sides of the issue. There is time to gain understanding of a bill before voting on the House floor, but there are hundreds of bills and those that are taken up receive hours of testimony before a committee decides on an action.

In addition, bills evolve significantly. H. 81 came out of committee with several sections that were added from a wholly different bill – one that was not at all about “technical adjustments.” The amendments change the structure of the benefits from how they were agreed upon just two years ago when statewide bargaining for teacher and support staff benefits was established. They remove the equity language that says that the percentage of premiums paid and amount of co-pays and deductibles “shall be the same for all participating employees.” In other words, different groups of school employees might now get different levels of benefits, which was exactly what the current law sought to avoid. I’d be hard-pressed to support that.

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Audio-only Telehealth

My committee has finished its work on the question of permanently extending access to the coverage that was created during the pandemic for audio-only phone coverage for health care. All the parties (providers, insurers and patient advocates) agreed that it has proven to be of great value for people without internet access. The only dispute was whether it should continue to be paid for by insurers and patients at the same cost as other telehealth or in-person care. Lowering reimbursement could mean providers couldn’t continue to offer the options, and the advantages to patients who have transportation obstacles or difficulty in getting time off of work would also disappear.

Our committee decided to maintain the same rate for a pilot period in order to gather and review a full year’s worth of data to assess how much it is used, whether it results in increased costs, and the impact on quality. The part most important to me was working on informed consent language. Patients must be told that they have a full choice to have an in-person appointment, and that the audio visit can be charged the same as for an inpatient visit. These phone visits can only occur if they are appropriate to the type of care needed. No offering to stich a cut over the phone!

The Senate gets its bite at the apple as well, so this outcome could change.

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Health Equity

My Health Care Committee has begun to take testimony on H. 210, which would establish an Office for Health Equity at the Department of Health to address health disparities caused by systemic biases against people based on race, ethnicity, disability or sexual orientation. There is considerable data about the impact of these disparities. I had a sister-in-law who had psychiatric disabilities and died of internal bleeding after her complaints were dismissed as being “all in her head” – after all, she was mentally ill and “we know how that is.”

COVID-19 had made the impact of disparities very public in terms of the rates among Black people, but this is also a deeply-rooted and longstanding problem. One of the most recent pre-COVID studies demonstrated an unusual twist to the impact of prejudices. Researchers were trying to figure out why whites were becoming addicted at such higher rates to opiods. What they found was that doctors were prescribing opiods less frequently to Black patients, because of broad perceptions either that Blacks had higher pain thresholds or they were more likely to abuse painkillers – neither of them accurate.

We had some tension in our committee on the first day after one member said he believed there was a problem with racism among individuals, but he did not think it was built into our systems. He asked for examples of what “systemic racism” means. The Director of the Office of Racial Equity was testifying, and she gave some illustrations, adding that “systems” were simply collections of individuals. Some other committee members chimed in. In a VT Digger article afterwards, Xusana Davis, the Director, said that while she disagreed with his comments, she appreciated that he was willing to engage in the conversation.

I believe she was underscoring where we need to go in learning from both our own experiences and that of others, and growing in understanding of exactly what it is that people mean by terms such as “systemic racism.” We may all end up being more on the same page if we allow for these conversations instead of moving into defense or attack mode. We’ve all got blind spots; we’ve all got learning curves. We need these dialogues, even if at times they get tense.

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Remote Voting: A Major Oops

The remote world of legislating is clumsy. It is not a good way to maintain a healthy process, but it’s what we need to do for now. However, we’ve just discovered a major glitch, and will need to make some mid-course corrections.

There are three ways that votes can be taken on the House floor. Most frequent is a simple voice vote: aye or nay. The body is making a decision as a whole, so individual voices are not counted. The written journal simply indicates that the matter passed. If anyone thinks the voice vote wasn’t clear they can request a “division.” This means the vote is taken by standing up to be counted as “aye” or “nay.” Finally, there is the roll call vote: each name is called, and each individual vote is recorded. Only with a roll call vote can legislators also give an explanation of their vote on the record. A roll call vote must be requested by at least five legislators. They tend to be fairly infrequent, and used for contentious bills.

In our remote world, roll calls remain pretty much the same. Each name is called out over Zoom. Voice votes were trickier to set up. To go off mute to say aye; re-mute, and then go off mute for the nays, with a cacophony of voices that would inevitably be more scattered, appeared likely to be unwieldy. Using those little blue hands we’ve become so familiar with causes its own problems. They are invisible to the public, yet visible as individual votes to other legislators, which does not align as a voice vote equivalent.

 Last year, we developed a tech alternative using an app that allowed a remote yes/no vote on an iPad which went directly to the House Clerk to record. If your screen froze, you could send your vote in by email, or use a phone “hotline” to the Clerk’s desk, or even just ask the Speaker out loud to call your name. The Clerk gathers these and announces the tally; the temporary remote record disappears; and the decision of the full body is recorded. There are potential inaccuracies, but no more so than when someone coughs in the middle of a “live” voice vote.

Even though the official vote was an aye or nay recorded for the whole body, the news media began reporting on the “unofficial” tally announced by the Clerk. Then they started asking for the records from the app. They wanted to see how individuals voted, even though it was officially only a voice vote of the full body. But they were told, sorry: the record disappears as soon as the vote is recorded. And that is what everyone understood when we agreed last year to this entire system to legislate remotely.

Except, that information was not accurate. As a member of the Rules Committee, I just received the update that came to the Speaker. The record for the App remains in cyberspace for 180 days before it self-deletes. Even though it may be inaccurate and was not intended to make a record of individual votes, that likely makes it a public record. The probable outcome is that we’re going to have to shift to the unwieldy, messy process of mute and un-mute for up to 150 people to speak at close to the same time to record verbal ayes or nays. Oh, what fun.

***

 It is an honor to represent you. Please contact me (adonahue@leg.state.vt.us) or Ken (kgoslant@leg.state.vt.us) anytime to share your input, ask questions, or raise concerns. My full archive of legislative updates can be found at representativeannedonahue.blogspot.com.

Saturday, January 30, 2021

January 29, 2021 Legislative Update

The “corona-coaster” with its steep ups and downs took on new meaning this past week in the state’s budget. Less than a year ago, we were all terrified about the financial impact of lost revenues. Six months ago, the projections were dire. Now, it seems that we’re rolling in money, thanks to our out-sized benefits from federal relief funds, which have proved to have real economic stimulus value. It doesn’t mean we are not still in deep economic crisis, with families under major stress and businesses hanging on by the skin of their teeth. It does mean we have some resources to shore up supports.

In the governor’s budget address, he stressed the need for the excess revenues – which will be very short-term – to be invested in one-time projects that put us in better shape for the future. It is wise advice, and it seems that the legislature is mostly on board (though not necessarily agreeing on which one-time projects those should be.)

If money is put into new initiatives in the base budget, when we are back on a normal economic course and the bonus money dries up, we will be facing the prospect of eliminating programs. No matter how new an initiative is, that never goes over well. Cutting back is politically challenging.

A one-time project doesn’t add to the base and can help reduce future costs. A good example is increasing investments in broadband, which is generally recognized as a key to long term economic growth and attracting new residents in younger demographics. That means the governor’s budget actually is level-funding many areas in state government while at the same time, making $210 million in one-time funding for economic recovery through investments in housing, infrastructure, broadband buildout, environmental stewardship, carbon reducing initiatives, and government modernization, among others.

There is too much to even describe in outline form in this update, but if you want a more detailed overview (with some helpful graphs included), you can see it by going to finance.vermont.gov/budget/budget-recommendations/operating-budget/fy2022 and choosing “Executive Budget Summary;” as a mere “summary” it is 41 pages long.

It is a definite concern in my Health Care Committee that nothing was referenced regarding health care funding or initiatives, not even in access to mental health supports, which we recognize will face new pressures as a result of the stress created by COVID-19. We will be reviewing our sections in detail for recommendations to the Appropriations Committee.

The biggest budget pressure point is the underfunding of our pension obligations. The state treasurer has made some suggested alterations that the legislature will have to assess. The pension funds are at a critical juncture. According to Treasurer Pearce, no action is not an option. As an example, the unfunded liability of the teachers’ retirement plan has increased from $711 million to $1.9 billion in the past 10 years. This is with the legislature devoting ever increasing general fund dollars out of the state budget to it each year, growing from $42 million in 2010 to $136 million in the current year. The state’s share is expected to go up by another $60 million to $196 million next year. These types of increases are not sustainable, with or without more tax increases. And failure to address it could jeopardize the solvency of the pension funds. That is not an option at all.

All of these decisions will play out on the House side in the next several weeks. The budget will then go to the Senate (they will, in our House opinion, gum all our work up!), then on to conference work to align the two, and to the governor. The good news is that the House Appropriations Committee is trying to expedite its review schedule, which would be in keeping with an aim to keep this session shorter than average and focused on the essentials. The session end is directly tied to completion of the budget.

This year, like last, there will be a separate bill that allocates the new round of federal relief funding. It is more targeted this time, so we will have fewer decisions to make – unless and until something happens down in Washington regarding further stimulus money.

About a decade ago, the legislature added language into statute regarding budget development and the purposes of the state budget. This is what it says:

“The State budget, consistent with Chapter I, Article 7 of Vermont's Constitution, should "be instituted for the common benefit, protection, and security of the people, nation, or community .. ." The State budget should be designed to address the needs of the people of Vermont in a way that advances human dignity and equity and in a manner that supports the population-level outcomes set forth in 3 V.S.A. § 2311.

“Spending and revenue policies will seek to promote economic well-being among the people of Vermont, and foster a vibrant economy. Integral to achieving the purpose of the State budget is continuous evaluation of the use of public funds by systems of outcome measurement based on indicators that measure success in accomplishing the purposes of the State budget.

“Spending and revenue policies will reflect the public policy goals established in State law and recognize every person's need for health, housing, dignified work, education, food, social security, and a healthy environment.

“As consistent with State law and in conjunction with the federal government, the budget will reflect support for economic development, public safety, transportation, and other infrastructure needs.

“Revenue measures shall also be based on the principles of sustainability and stability. The Administration shall develop budget and revenue proposals as part of a transparent and accountable process with direct and meaningful participation from Vermont residents.”

 Lofty goals, but worth putting in writing to try to keep at front and center of decision-making. How does accountability play out? While you can contact me or Rep. Goslant to share your opinion, you also do have a voice beyond our representational democracy. The opportunity to directly state your values and priorities is coming up next Monday in video-conference public hearings on the budget in front of the House and Senate Appropriations Committees jointly.

The two public hearings are on February 8, from 1 to 2:30 p.m. and from 6 to 7:30 p.m. via videoconference. You can sign up to testify using this online form: legislature.vermont.gov/links/public-hearing-fy22-budget, no later than this Friday, February 5. Instructions on how to access and participate in the hearing will be sent once you have signed up for the hearing. There will be time limit based on the volume of participants, likely in the range of 2–3 minutes. The public hearings will be available to watch live on YouTube at the following link: legislature.vermont.gov/committee/streaming/vermont-joint-fiscal, or on Onion River Community Access (ORCA) if you have access to it. For more information you can contact Theresa Utton-Jerman at tutton@leg.state.vt.us or Chrissy Gilhuly at cgilhuly@leg.state.vt.us or call 828-2295. Written testimony can be submitted electronically to Theresa or Chrissy through e-mail.

***

Other Notes

My Health Care Committee is currently taking up a somewhat discrete topic related to tele-health, on the specific subject of “audio-only telehealth” (translation: by phone.)

During the pandemic, insurers are paying for telehealth visits, including audio-only, as though they were in-person visits. This is under an emergency rule by state regulators for insurance plans regulated by the state, and voluntarily by other plans. (The majority of employment-based plans in Vermont are not permitted to be regulated by the state.) This has been a critical support during a time when it may not be a good idea to travel to the doctor’s office, recognizing that there are still many Vermonters who don’t have adequate internet for standard telehealth.

Insurers and providers agree that once the pandemic is over, audio-only visits will still have a place in the range of appropriate, quality health care options. Where they don’t agree is whether insurance should reimburse claims at the same rate.

Initially left out of this discussion were patients themselves, and I pushed to hear from that perspective as we finish testimony this week. The assumption has been that since this increases access (less time away from work, avoid travel obstacles, etc), health consumers will all support it.

But the question is one of cost. If you have a high co-pay, or a high deductible plan, “paying the same” isn’t a question of payment by your insurance. It’s out of your pocket. If you are choosing an audio visit, do you think there is equal value – or at least, equal trade-offs – such that it is reasonable that it cost the same as a doctor’s visit? Will you feel comfortable with insisting on an in-person visit if your provider is encouraging a phone visit?

I’d be interested in hearing your views.

***

  It is an honor to represent you. Please contact me (adonahue@leg.state.vt.us) or Ken (kgoslant@leg.state.vt.us) anytime to share your input, ask questions, or raise concerns.

Saturday, January 16, 2021

January 16 2021 Legislative Update

 Legislative Update

Rep. Anne Donahue

January 16, 2021


As we start a new session staying fully on remote platforms, the extent to which good legislative process is impaired becomes even clearer. 

Last year, the sudden shift to “Zoom” meetings came after a year-and-a-half of working together in committees and on the House floor. Now, we begin a new session with new legislators who have no opportunity to first build those working relationships. 

Vermont benefits from healthy turnover in our House of Representatives, with a blend of the new ideas and energy brought by newcomers together with some “institutional knowledge” from longer-term folks like myself who can help prevent wheels from being re-invented every two years.

The newbies, however, do have a learning curve. There is a need to understand the process itself, how committees function, how bills make their way through the system. Then there is grappling with the complexities of the subject matter itself addressed by each committee.

Just ask our district’s other rep, Ken Goslant, who is so pleased to have been reappointed to the Judiciary Committee. He will be able to really dig in this year, after having gotten that first session under the belt.

I have been re-appointed as Vice-Chair of the Health Care Committee, and we are fortunate to also have the same two other members on our committee leadership team. However, of the eight rank-and-file members, five are new to the committee and four of those are first-year legislators.

The orientation process to our tangled and multi-layered health care system has barely begun, and our plate is already full with issues that demand immediate attention: updating and revising the laws we passed in response to COVID-19 last year, and responding to the midyear budget adjustment proposals (with next year’s budget just around the corner.)

Under the Zoom constraints, we’re operating with roughly half of the time in committee we would formerly have had.

And we’re already half way through January! Yikes.

***

COVID Responses

Our committee met jointly with the Human Services and Senate Health and Welfare Committees to get updates on the state’s response to the pandemic, the vaccine rollout, and the expenditure of federal emergency funds; next week we’ll hear about the new federal legislation and what opportunities it will offer the state.

We had a presentation Friday to review the bills we passed last biennium, and it was a reminder of how many pieces need follow up. The crisis in our shrinking health care workforce is a huge one.

At the same time, both House and Senate acted quickly on one new response: a bill allowing towns some alternatives for this year’s town meetings in order to maintain safety.

Our local select boards will have the option of postponing town meeting for several months or moving all issues to an Australian ballot that is mailed to every voter (as was done for November’s general election.) Funding for the mail-in option will be provided through the federal relief funds.

***

Bill Explosion

The start of a session is when there are often news media sound bites about all sorts of new “legislative initiatives” that catch the eye. Be careful not to read too much into them – or you can ask Ken or me for specifics.

The reality is that hundreds of bills are introduced at the start of each session, reflecting the individual ideas of 150 House members and 30 Senators. The vast majority will not even be taken up by the committee they are sent to, let alone make their way through the long path to the governor’s desk.

Ten have been introduced in Health Care in the first week. Last year, the session’s total was 66. Of that, our committee passed 12, but only six of those came from individual legislators rather than through our internal committee work.

Although chairs hold the decision-making authority, most take input from the full committee about priorities, and that winnows out many of the proposals. But time often is just as much a limiting factor as lack of interest, along with the “must do” work outside of bills.

One thing is likely for any efforts by our committee in addressing large scale health care reform issues – access and affordability -- this year: there won’t be the ability to take any actions. Federal law (and to an even greater extent, federal money) heavily controls our options.

In the past four years, we had a dual focus. We were monitoring the “all payer” deal with the feds that allowed us to make payment system reforms that could be aligned between Medicare, Medicaid and private insurance; that 5-year deal was one of the few mechanisms available for reform under existing federal parameters.

We also spent a lot of effort protecting the stability of Vermont’s insurance market from changes being made at the federal level.

While it is highly likely that there will be major changes in federal law under a new administration, those will not be happening in the next three months’ time. We won’t have any ability to adapt or take advantage of changes, because we won’t know the new directions, yet.

One of the biggest variables is whether a federal law is written to control what happens, superseding state law, or creates options that allow states to establish their own initiatives. 

The classic example is “ERISA,” a longstanding federal law that bars states from regulating insurance that large companies create for their own employees. Whenever Vermont creates insurance coverage requirements, they actually only affect a limited number of insurance plans.

So, we will likely be on hold this year. There is no point in investing time and energy in restructuring health care if the work will be upended in six months.

***

My Bills

Notwithstanding the above comments, we legislators do keep introducing bills in the hopes that they will gain committee attention, if not this year, then the next. 

My list this year includes three bills that continue the efforts at parity and integration of mental health into health care, and one for creation of a working group for recommendation on much-needed reforms to our laws on addressing criminal justice system interrelationships with mental illness; 

Also, along with Rep. Goslant, a bill requested by the National Guard to match federal law in protecting employment rights, and the repeat bill on the effort to have military retirement pay exempted from income tax;

Whistleblower protection for law enforcement officers (to protect against retaliation when they do as we have directed them, and report wrongdoing by colleagues); removing the sales tax exemption from candy (I don’t believe in candy as being “food,” whereas food is an essential that should be exempt);

Can you believe that some car rental contracts in Vermont ban you from using them on dirt roads? It’s buried deep in the contract, and I think consumer deserve prominent notice!

I’m also the sponsor on a bill request from the American Kidney Association to extend medical leave and insurance to cover organ donors – an example of a bill that a committee wanted to support last year, but time was the barrier.

***

Access to Your Government

The upside to our Zoom world is your new level of access to seeing what we are doing. Every committee meeting is aired live on YouTube, but also archived. Just go to the legislative web site to look up bills, floor sessions, committee agendas, and committee meetings: legislature.vermont.gov, and feel free to ask Ken or me to guide you on finding what you are looking for.

There is also a wealth of information from presentations made to committees and developed by our staff, in particular both the overviews and “deep dives” by our legislative joint fiscal office (ljfo.vermont.gov), everything from revenue updates to how much a bill will cost the state.

Just meandering through that web site is an eye-popping number of “issue briefs” and topics that may rapidly suck you in... but in a more intelligent way that the way we sometimes get sucked into Facebook posts!

Some immediate examples of resources you might want to look at: the “health care 101” presentation that we are working through as our health care committee orientation (the second topic found under: ljfo.vermont.gov/subjects/healthcare/other-health-care-issues-and-information); the COVID-19 vaccine response plan presentation (legislature.vermont.gov/committee/document/2022/15/Date/1-13-2021#documents-section); and the 2021 presentation to us on “Principles of a High Quality Tax System” (found under the tab: ljfo.vermont.gov/subjects/revenue-and-tax/friday-tax-workshops-2019-session). 

***

And Then Other Stuff

As legislators, we also spend time outside the statehouse connecting with constituents and interest groups to help identify needs – such as touching base with the Northfield Select Board last week.

Ken and I also met last week to hear from the Northfield Savings Bank about some of the impacts of COVID. That presentation included an important information tidbit to pass along:

Were you expecting an automatic bank transfer of the $600/$1200 economic stimulus money but have not seen it posted to your account yet? There is an IRS glitch that occurred that relates to people who had accounts through their tax preparers which are now closed. 

If you might be in that category, you (or anyone) can check on the status of your payment directly through the IRS website.

***

It is an honor to represent you. Please contact me (adonahue@leg.state.vt.us) or Ken (kgoslant@leg.state.vt.us) anytime to share your input, ask questions, or raise concerns.


Sunday, September 6, 2020

September 6, 2020 Legislative Update

 The inner dynamics of a legislative body is fascinating, and I get a window into it by being a committee vice-chair and a member of the House Rules Committee. It’s a window into, but not membership, in the power-brokering that occurs with the Speaker and committee chairs. For this special session to finish the budget work and further allocate federal relief funds (work that was too risky to do in June when so much was unknown), those two items remain the priority. However, if there is time before the budget is passed, each chair has been told that he or she can prioritize one other bill in their committee to try to get across the finish line.

***

Health Care Priorities

My Health Care Committee chair and I have agreed that our priority is the passage of a health care workforce development bill that we had completed in February but that is being considered by the Senate. Assuming the Senate makes no changes to it so it doesn’t need to come back to us, the priority bill will become our hospital price transparency bill. The Senate is making changes to that one, so we will need to use our limited committee time to review that work and decide if we can agree in order to get it through.

Our health care work force was in crisis long before the pandemic, and we took testimony early in the session to dig deeper into it. We concluded that the most urgent gaps were in nursing at all levels and in primary care physicians, and that one opportunity would be through scholarship assistance for those two fields. We identified money towards these scholarships through accessing some that had been left partially unused from reserved funds from a court settlement.

Hospital price transparency is another really important issue. We got stakeholder consensus on a path forward to enable consumers to identify in advance what the actual costs to them would be for different procedures and among different hospitals. While many states have done similar things, the catch is that creating a user-friendly data base can be really expensive.

Our Senate counterparts like that bill, but want to add some new components – some things that are actually a new topic that would normally be a separate bill. So, if we want our bill to pass, we’ll need to take testimony from those affected in the small amount of remaining time. There are other bills we have received from the Senate, each of which would similarly require review time. The Senate says this new one is its priority, so it will be those others that are put off to be restarted next year.

***

Mental Health Crises

Speaking of needing “to take testimony from those affected,” which I think is a critical part of our job, our committee was asked by the Speaker to taken on the review of another topic that came a bit out of the blue. The governor’s budget arrived in the House three weeks ago with a proposal to add seven positions for mental health workers “embedded” in state police barracks. It was in the Department of Public Safety budget, so under the division of labor among committees, it didn’t come to our health care committee for review.

There is pretty widespread consensus that we’ve been asking police to be all things to all people, which had contributed to some of the current need for policing reforms. “Jack of all trades, master of none.” We can expect abilities to de-escalate and stabilize crisis situations, but we can’t expect every officer to be a mental health counsellor or expert on top of the myriad other responsibilities we place upon them. We are really pleased that the governor recognized this as a sufficient priority to find funds in a tight budget to expand mental health support. (On Friday, the governor also announced a number of other policing reform initiatives the administration is implementing in advance of any pending legislation.)

A few weeks ago, an increase in funding for mental health outreach was selected as the most important priority for policing reform in a survey completed by 1,446 people in Vermont. In all, 62 percent of those responding said it was “extremely important,” the highest ranking of any of 10 suggested reform initiatives. More than one item could be selected in the survey. The next highest rankings were for increased training in de-escalation skills (54%) and requiring the use of body cameras (53%).

So, this is a critical initiative, but it also needs to be done right. Neither the Department of Public Service, in drafting the proposal, nor the Senate members who were pushing for it, actually talked with those who would be affected: neither with the clinical community, nor those who are part of the community of people who have experienced mental illness, like myself. Many years ago, when I was still dealing with significant symptoms, I was involved in two different situations where police were part of intervention. One was superbly handled; the other was significantly mishandled. So, I know this topic up front and personal.

We need the mental health-law enforcement collaboration, but there are many different models for how to achieve it. A core question: should this be a mental health system program that responds to assist police, or should it be a police department program that incorporates mental health staff as an arm of its own organizational structure? When the expansion proposal was discovered buried in the Public Safety budget there was some immediate concern about the model and why others weren’t involved in the planning. So, the Speaker intervened to ask our committee to rapidly dive in to take broad-based testimony and make a recommendation to the Appropriations Committee by the end of this coming week. The House budget will be finished this Tuesday, so there was “placeholder” language included to reserve the funding while our committee does its review.

***

Health Disparities

The budget includes one specific proposal from our committee on further use of the remaining federal coronavirus relief funds. In the June allocations, we had asked for $1,000,000 to be put into special support for Vermonters who are members of “health disparity groups” who might need specific intervention – supports outside of what the general population needs. This included three groups where the particular concern was the higher risks from imposed social isolation: elders, people with disabilities, and LGBTQ youth. It also included groups with disproportionate rates of COVID-19 due to systemic health disparities: people of color and immigrant or migrant groups. The Health Department said they already had some emergency federal funds for that purpose, so our request was cut in half to $500,000.

Last week we heard what’s been done to date, and it was clear that although good work had happened, many of the groups we felt needed to be addressed had not received attention. We asked for an additional coronavirus relief fund appropriation of $1,000,000, including more explicit instructions about who to reach out to for identifying the specific needs, and the Appropriations Committee has added that to the budget.

***

The Environment

One bill that moved forward last week will allow Efficiency Vermont some flexibility in the use of the money raised through our electric bill surcharges. This highly successful program (it is a 4-to-1 return on investment) was created to focus on reducing electricity use. This bill will allow EV to strategically use $2 million of its $60 million budget to address efficiencies in heating and transportation. It does raise or spend any new money, but allows an added range of use. Coming up this week, it is expected that the Senate changes to the Climate Solutions Act will be coming to the House floor for final approval.

***

Cannabis

The marijuana tax-and-regulate bill was locked in a conference committee standoff between House and Senate, but each made major concessions last Friday afternoon. It appears that the final area of disagreement is solvable, so this bill is likely to move forward. The House has passed bills numerous times to make seat belt use a matter of “primary enforcement” (you can be pulled over for that alone; currently, there has to be another reason for the stop before you can get a seat belt ticket). Each time, the Senate has killed it. So, under the umbrella of the highway safety components of the marijuana bill, the House added seat belt enforcement. On Friday, the House agreed to drop that piece.

The saliva test in the House version (with the requirement of a warrant) has the purpose of screening drivers for drug use, similar to alcohol. The problem is that it isn’t remotely as accurate. It only detects presence of a substance, which could include marijuana legally used days ago. The Senate was adamantly opposed but has now agreed to it. The final big split was about whether towns have to hold a vote before a sales outlet can open in their community, or whether outlets are presumed to be permitted unless a town has a vote to prohibit. The Senate has now accepted the “opt-in” requirement.

That leaves only the disagreement over a tax structure component regarding how towns that permit sales outlets can share in financial benefits.

***

Please feel free to contact Rep. Ken Goslant (kgoslant@leg.state.vt.us) or me (adonahue@leg.state.vt.us) at any time with your inquiries or input. It is an honor to serve you. You can see all of my past updates at representativeannedonahue.blogspot.com