All right. Good morning, everyone. It is April 23rd, and this is your Senate Health and Welfare Committee. Today, we're going to be going through some bills and hopefully to get to closure and be able to vote on all of the bills that we have for us today. So, and before we do that, I thought it would be a good idea just to share with you that our committee has been chosen to begin using captioning for the audience. So, when we're speaking and we'll try to articulate as carefully as we can. The captions will be will scroll with the zoom with the YouTube with the zoom and with the YouTube so we'll be able to see what we're saying and folks out in the zoom world will also be able to see what we're saying. That that's just heads up and just remember I think for all of us that when captions are captured with an with what we're saying they are not always accurate, but we'll hopefully they will be. Thank you all for your understanding as we go forward. So this morning we have Jen Carby, Jen we're continuing work on some of the bills. We decided today to start out with H 104. So why don't we look at that together, and then we can decide how to proceed. Great. So did you want to look at the amendment or did you want to look at the, because it's not a straight just a little one line do you want to reminder of what the bill is and then we please. Yes, we just pull up the bill that came over to you. I think that will be helpful. You know and we also have the amendment on our iPad so we could pull the amendment up on our iPad while we're going through the bill. It's not a big. No, it's a very short. All right. So for the record Jennifer Carby legislative council. This is H 104 as it came over to you from the house this is the act relating to considerations in facilitating the interstate practice of healthcare professionals using telehealth, and it creates the working group that would look at different methods for facilitating the practice of healthcare professionals throughout the US using telehealth, the number of members and the amendment would add in as a new number five, the commissioner of mental health or designee. The working group is directed to compile and evaluate these methods, including so some of the options they'll be looking at would be creation of telehealth licenses waiver of licensure national licensure compacts and regional reciprocity agreements, and then directs them to consider certain issues when they're evaluating the potential options for use in Vermont. And OPR is leading and and assisting the working group the report is due by December 15. And that's about it. Okay, can we scroll back up to the working group please. Yes, the members. Yes, the members right just to go through and to take one last look at who's involved. Yes, we have the director of OPR representatives of the healthcare professions associated with OPR that would be selected by their respective licensing board or by the director, the executive director of the board of medical practice representatives of the healthcare professions licensed by the board of medical practice selected by the commissioner of health, then the amendment would add in here a new number five the commissioner of mental health or designee. Then representatives of healthcare professional organizations representatives of health insurers and other interested stakeholders. Okay, that that looks pretty comprehensive committee questions for Jen, I guess I guess you could take it down unless someone. Okay. Questions on the bill questions on the proposed amendment. I can just put that up if you want as well. I don't know committee do you want to look at it. Well, I would like you to have at least seen it. Okay, yeah, I'm looking at it on my iPad. Okay. Okay, that works. Committee questions, comments. Okay. Very good. Okay. So, I guess I would entertain a motion on h 104 as amended by draft 1.1. Right, I think you need to, to vote on the amendment and then the bill as amended. Okay. Okay, yeah, we've done it both ways but this. Okay, that's fine. Go ahead. Go ahead, Senator Hooker. I think we're going to have to accept the amendment as drafted in draft 1.1. Okay, there's a motion to accept the amendment. Any discussion. All right, Mr. Clerk. All right, thank you. I'll call the role at this time. I'll start with myself. I'm a yes. Senator Hooker. Yes. Yes. Senator Hardy. Yes. Senator Lyons. Yes. Okay, I have a vote of 500 to advance each 104. I'm watching the. Yeah, yeah, the captioning and Senator Lyons, you growl and have a main. And Senator is Senate is center. And I believe Senator Hooker was US Senator Booker for a minute there. And there was a vote of 500. Oh no. I don't see it. I just turned off, you know, there is a way to, to not see it because I don't see it. I just turned off. You've got a little, you have something on your, on your bar below that says live transcript. You can click it on. Okay. You don't have to see it because it's probably distracting. Yeah. Three days. Turn it off on my, on the TV. My husband is known for just pushing buttons. I don't see it. I don't see it. I don't see it. I don't see it. I don't see it. I don't see it. Subtitles. Awesome. Okay. So I'm looking for a reporter for H104. And who is up for this. I think it is probably either. Senator Tarenzini or set Senator Cummings. Is there a volunteer. Josh, this is an easy one. Okay. Sounds like my turn. I think, I think you'll do a terrific job. And, you know, I think this is really a huge step forward for us in terms of understanding telehealth. So. When, when in your expert opinion center lines, when would you think that this would be reported out? I think it would be reported out on Tuesday. And then you would report it on Wednesday. All things being equal. Okay. Does that work with your schedule? I believe it should. So. Okay. All right. Terrific. I think because you followed my direction and took the vote on the amendment, you still have to have now vote on the bill as a man. Oh, Senator. I mean, I think that's a good idea. I think that's a good idea. I think that's a good idea. I think that's a good idea. I think that's a good idea. I. I was on the bill. So Senator Tarenzini is reporting the amendment. Now let's see what we can do with the bill. Senator. I move that we pass H. 104. As amended. By the committee. Okay. Discussion. All right. Mr. Clerk. Senator clerk. Okay. Okay. Myself. Yes. Senator Hooker. Yes. Senator Cummings. Yes. Senator Hardy. Yes. Senator Alliance. Yes. The five zero zero. So Senator Tarenzini. You can take the. Send the amendment. Okay. Okay. And then that all goes up to the secretary's office by email. With the vote. And your name as reporter. Okay. Excellent. That was a hard one. Okay. Let's keep going. Jen. We have one 20. Okay. Yes. That's right. Why don't we. Look at that. All right. Pull that one up and I will. Put it up. So he was making a, I think a few changes as we were talking yesterday. And perhaps I will do the same thing. I think that's. Fairly productive. So you had changed the name to the commission on affordable accessible healthcare. So I had made that change. Committee, if you have, if you want to stop anywhere, please do that. We'll have a fuller discussion after we've been through the bill once, but just. If, if you think you see something that absolutely needs some change or you want to add. And then we'll go back to it afterwards. So Jen, I do have a question. Is there a difference between a committee and a commission like anywhere like. Statutorily or whatever. I don't think so. I mean, I, you know, a lot of it is just how we sort of choose to name them. I tend to think of a commission as being something. Sort of.  Call it a commission. Let's, let's, let's hold that one. I'm writing that one down. And we'll come back for that to that for discussion. I'm agnostic on it. I think it is a committee. It could be a working group. Commission just gives it a little more. I don't know. Appearance of standing, I guess. So do you want me to just. Flag for you right now that the things that are. Yeah. Different from what we went through at the last time. All right. So I think we had. Looked at this new finding and you'd asked for a small change to it. So it now it says the ever increasing cost of prescription drugs continues to significantly increase the cost of health insurance and limit individuals ability to access care. So that's the. Change here. Oh, wait, Jen. Sorry. Yes. Back on number two, which there aren't changes on at the moment, but we had gotten an email. I think you were on it about how this, these numbers have changed with the new subsidies. Now that there are the federal subsidies for sing. For individuals. And I. I don't know if we want to change those numbers based on. If they're updated numbers and we, they're, they're validated. I, I, I do know the person who sent them to us. So that might be something we could update. Yeah. And you may want to think about how you want to approach it. I'm not sure it makes your point as compellingly with the new numbers. And so maybe instead of saying currently, we could say prior to the. American rescue plan act or something like that. So that it's. In 2020. Right. Let's do that. Okay. Okay. Highlighting that. All right. Thank you, Senator Hardy for flagging that. All right. And then we have again, the. Name, which we'll revisit. Yes. Before we get off the findings. We had, can we connect this to current law to act 48? In any way, put a finding in there that just says, you know, we're hoping to. Make sure, be sure, ensure that the policies, the principles of act 48 are considered. When looking at. I guess if you're going to put act 48 in, then you'd have to put in all statutory, you know, statutory reform efforts that are, that are in place. So is that it's, that's different from act 48. We've taken steps. At 48. Oh, sorry to interrupt. Madam chair. I'm looking at Jen first. And then we'll. Right. I think there are, um, there are a number of principles for healthcare reform that were adopted in act 48 and codified as well. So they're actually in act 48 twice because they got it incorporated into the green mountain care board chapter as principles for healthcare reform. So I certainly think you could, you know, restate your commitment to the principles adopted in act 48 or, or incorporate them in, in some way, if you want, I think that that idea of adopting the principles has become kind of a touchstone for some people in the area of healthcare reform. So I, you know, it certainly still, um, Still, Val law still has a lot of, of words and phrases that we could pull from, um, to reiterate in here if that's something the committee wanted. Yeah, I was going to say, I don't know if it's in the findings or in the, there, um, the creation or duties or whatever, but some kind of cross references to exactly that, the principles of healthcare reform, which is I think 18 BSA 93 71, you probably have that's right. I was actually going to suggest that that might be the more appropriate place for it. So let's hold that thought and, um, we'll go from the findings and scroll and then scroll down to the, what the, right. So this is the, the powers and duties. Um, I'm, and I don't know if you'd put that in, in the lead in language or what they're considering or maybe something to keep that in, in, um, sort of the focus through which they are looking at these specifics. Yeah. So I'm looking at number five, which has been added. So when we get the green. Okay. Yep. The green. Yes. All right. You're going. I know, I know. Okay. I'm aware. All right. So, so go ahead, Jen. I was just trying to, to figure out if you're still, if you want to go through what's before that first going through before that, we'll get to that. Okay. This is, this will be a point of discussion when we, after we've gone through the bill. Thank you. Okay. Um, so we have the commission, it's memberships. It's powers and duties and what it considers. Um, there had been a change here from the chair, taking out the language about looking at the efficacy of the all pair model and instead looking at how alignment of Medicaid, Medicare, and private insurance, patient care, management rules, and guidelines affect access to an affordability of care, including access to referrals for extended care, counseling, We have a fuller discussion. If you would like to, that's what we'll do. Okay. And then we have the new number five that I added based on your discussion yesterday. So one of the things for the. Commission to look at would be the. Findings and recommendations. From previous studies and analyses relating to the affordability of healthcare coverage in Vermont. And madam chair, did you want to. We're good. We're flagging that one. I mean, this might be where this might be where the. Previous studies and principles of healthcare reform. As expressed in act 48. And I would say other statutes. So if we could put that in there. That sort of fills out. Some of the work. Yeah, I think we may want to think about what you're looking to get from each of those items. Because this one. I think pretty clearly directs people to particular. Documents that have already been created. Whereas the other may be kind of the lens through which they are looking at all of these. Okay. That's a good point. Yeah. I think we should put it under the creation. And I have some wording. If we want, once we get back to that. Oh, right up in the. Yeah. Okay. We can certainly look at that sort of does what you just said. It's the lens through which they look at everything. Well, so if we're going to do that, then I just want to encourage us to look at also some of the principles around what's going on in current healthcare reform. With our care management process and linking. Medical. Mental health care, mental health care, social services. So I think that's a good point. Okay. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I'm thinking. Medical. Mental health care, mental health care, social services. So the whole another. Layer. Okay. So keep going, Jen. Okay. So that is. Takes us. Oh, there is one other thing. It's not in yours. And I don't think it. Will affect much for you, but for as far as assistance. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that should actually be hired. My understanding from JFO is that this should be hired through the office of legislative operations. Not through the joint fiscal office. So I have that in sort of my. Working updates. And that's not up for discussion. All right. So then we have. The, some of the pieces from act one 30. That were added. So this is that section on. Requiring the ACOs to collect and analyze clinical data. In order to determine the quality of care provided, implement targeted quality improvement measures and ensure proper care coordination and delivery across the continuum of care. And provide the results of those analyses to the Green Mountain care board. And I see a hand from Senator Cummings. Senator. Have we. I'm just thinking that the concern about. The overhead cost at. The ACO. Do they have the staff and technical ability to analyze clinical data? Well, yes. They're going to hire an MD. I think they do have an MD. Who it works with them. And they are currently doing this. This kind of work, but it's nowhere in their charge, a charge to an ACO to do this. So any ACO would be responsible then for this. Clinical data analysis. I happen to know. When we heard from the FQHCs, when they were interested in forming an ACO, they also brought in their. Work that they're doing on adverse childhood experiences or on social determinants. So there's, there's a lot of clinical data analysis. This is also consistent with blueprint and so on. Then we have the section that comes from S. 132 section six. This gives the office of the auditor or the state auditor access to the records of an ACO. I want to, I, we need to have a discussion about this because as you read this, and it's something that. I am now very sensitive to, and that says any affiliated entity within it. That's one, but number two, but we'll have a discussion afterwards, but we should understand that there's currently a lawsuit going on between the auditor and the ACO. And our legislative. Rule I think has always been not to get in the middle of. The legal action. So I'm very concerned about keeping this. This in at this time. Among other things. So. Then we have a new section that I put in at the request of the chair based on some. Testimony that you heard the other day. Around pharmacy benefit managers and three 40 B entities. So this is an entirely new section. I would add to an existing statute. On pharmacy benefit managers and required practices with respect to pharmacies. But add on some specific three 40 B provisions in a new subsection D that says a pharmacy benefit manager shall not create any additional requirements or restrictions on a three 40 B entity on the basis of the entity's direct or indirect participation in the three 40 B drug discount program. And the three 40 B. And the three 40 B. And the three 40 B. Require a claim for a drug to include a modifier to include that the drug indicate that the drug is a three 40 B. Drug unless the claim. It should be is for payment directly or indirectly. Like that fix here. By Medicaid or restrict access to a pharmacy network or adjust reimbursement rates based on a pharmacy's participation in a three 40 B contract pharmacy arrangement. I know we got a little testimony on that, but do you have more information on the sort of. Context of this. By any chance. We can talk about that later. I do also have context. So Jen, go ahead. I mean, I understand that there have, there are. Certainly tensions between the work that the pharmacy benefit managers do and the, the incentives in the three 40 B. Drug discount program. So this, I believe, is to address concerns from the pharmacy side. About. Conditions that pharmacy benefit managers are imposing on them. That are. Specific to their participation in the three 40 B program. And I understand this language. This language is similar to some that was. Utah. Recently enacted in Utah. I did look at the Utah language, which is a little bit more extensive. Which doesn't mean you need to make yours more extensive, but. But some of that may provide some of a little bit of the context. Madam chair. I don't know if you have more background on that other than, I think that's just. Yeah, at a very high level, the three 40 B prescription drug program. Allows for reduced pricing for prescription drugs. And so patients get their prescription drugs. At a lower rate when it's in a three 40 B pharmacy. And FQHCs, of course, are part of this. And then there's some other others across the state. If a PBM, then. Charges. Take some of that money away from the three 40 B program. So the three 40 B program benefits the patient, but also the provider, the, the pharmacy that, that's providing the, the drug. In this case, it could be a FQHC. But if you take away. That incentive for the pharmacy, then. There, the, the, the pharmacy may not be able to pass savings on to the patient. So that's the. Right. So I'm, if I can clarify a little bit, the three 40 B drug discount program is really about how the, the covered entity, the participating entity. Acquire the cost at work. They acquire the medication and the idea behind the federal program was it's available three 40 B participation is available to hospitals and FQHCs and certain other. And facilities for their outpatient. Medication. So nothing that, that happens in patient. And the idea was to allow the, those providers to retain that difference between, what they acquire the medication for and what they get reimbursed by the insurer or their payer for as a way to, to help with their social missions and, you know, to their care of their patients. And so it doesn't necessarily always get passed on to the. Patient. But the savings is really supposed to accrue to the entity. And so it doesn't necessarily always get passed on to the. Patient. But the savings is really supposed to accrue to the entity itself. And so when, if the PBM is not reimbursing the pharmacy, the regular amount that they would be reimbursing the pharmacy, that kind of undermines that three 40 B incentive. Three 40 B program is itself is, is fairly controversial at this point. And there are, are proponents and opponents of continuing it in its current form, both I think in the state and at the federal level. Okay. I mean, I'm familiar with the three 40 B program. I. Right. Organization that used it. And that's fine, Jen. Your information is super helpful. I was just wondering what the problem is we're trying to fix. Like what is happening that this language came and we got a little information, but I'm sorry. At this point in the session, we're getting so much information that I can't remember exactly what they said is happening. I mean, it's, it's the pharmacy benefit managers are imposing more restrictions and requirements and, and basically trying to damp down participation in the program. And so this is to try to prevent that. Is that essentially what your understanding is, Jen? I don't, I, I don't know the specific problem. I have to say that that is looking to be solved. I think the language came. I got more, more language than background. Yeah. There's, I did send an article out that's on our webpage and that. I believe Jesse Barnard and others testified on it. The day before yesterday and then yesterday there was testimony from Blue Cross and Blue Shield. I guess it would be my hope that the. I think it would be my hope that folks who are interested in this, who are out in the zoom world could get together and come to some resolution of differences and help us understand how to. How to maintain the three 40 B program as it is now. Because I do think that there is a benefit. To patients. And so that's the, that's the concern that, that I would have, but just this is a request for folks who are in the zoom world to maybe connect with one another. We don't have a hallway for you to visit. Whether or not in our committee room. If we were, I might suggest the. That you get together and try to resolve. Some differences for us on this one. Okay. Section. Six is the stay health improvement plan. So this came out of S 132 as well. And this has the commissioner of health rather than the secretary of human services or designee being the one to adopt the state health improvement plan that sets, sets forth the health goals and values for the state. And in the current and existing language, the, it would be now commissioner, not secretary may amend the plan. As that individual deems necessary and appropriate.  So really sort of looking at the existing duties. Asking to see what there is now, but also what their plans are for the future. And madam chair, I know that this would be a good idea. I think that would be a good idea. I think that would be a good idea. I think that would be a good idea. I think that would be a good idea. And section seven here, which is a new section would require the commissioner of health to submit copies of the current state health improvement plan by January 15th. And madam chair, I know that this was your language. And I'm wondering. By changing it to the commissioner of health. And, you know, I understand that makes some sense, but the. Would that, there's no language to also include, for example. Diva or Dale or all the other. Other subsections of the agency of human services, which also are relevant to. A health plan. And I think that's why the secretary was charged with it before, because the secretary is overseas, all of those divisions within the agency of human services. Well, and the, but the, the plan goes outside of the agency. And it looks to all the data that exists. For people and organizations in the state. So then it would help inform where. The commissioner of health would have the knowledge and the, to go out and. Can certainly connect with anyone. Within the agency to do that. But. So. It does seem more appropriate to have the commissioner of health and charter. I think it's a practical matter that commit the department of health. Maybe I'm just looking at the plan itself, the, the current plan. And I think. It already comes from the, I think the. Designee here in practice has been the commissioner of health. Yep. So I'm not sure from a practical standpoint that this is. A change to the current practice. But it does make that it does put that change into the. It puts a responsibility in place that I think is important. And then we can, it will. It's been lagging. Let's put it that way. Was that a thought, Senator Hooker? I didn't want to move on. If you were going to say something. Okay. So we have additional reports. So this one in section eight is from S 132. And this is the one that would require the green mountain care board to report in January. Regarding the increases in health insurers, administrative expenses over the most recent five year period. And compared with the increases in the consumer price index. Section. And then we can see that. And then we can see that. And then we can see that. Section two would have the ACOs. Provide by January 15th at description of their initiatives to connect primary care practices with social service providers. Including the specific individuals or precision titles responsible for carrying out those care coordination efforts. Section 10. Was the primary care visits without cost sharing. Reports also from S 132. And then we can see that. And then we can see that. And then we can see that. And then we can see that. January 15th diva in consultation with others report on the analysis of the likely impacts on qualified health plans. So that's the individual and small group plans. Patients, providers, premiums and population health. Of requiring the plans to provide each insured with at least two primary care visits per year with no cost sharing requirements. So diva does the one for the individual and small group with the large group. Plans including the plans for. State employees and school employees of again, that same. Two primary care visits per year with no cost sharing. And as Devin Green previewed a little bit in her, her testimony. To the other day, one of the issues that always comes up in this area is the high deductible health plans and their eligibility for health savings account under federal law, which requires or only allows certain things to be covered without cost sharing. And so that, that is often the hurdle here, but we'll see what the result comes back from these analyses. And then we have the effective dates, had been taking effect on passage, but if you're doing that PBM language, it seemed to make sense to have that start on a date certain and apply to contracts entered into or renewed on or after that date between the PBM and the pharmacy. That's similar to the approach that Utah had taken in theirs. Okay. All right. So we have some area, we have some things to discuss. So let's take the bill down and then we have the bill on our, we have it on our webpage on our iPads. So Jen, I think you're keeping track. I'm keeping track. Everybody's keeping track. I'm keeping track of what they'd like to go through. So the first one. Is what findings or not? The first one is right. The first one is findings. And so far we have. Changed in finding number two. The timing of that. Financial. Estimate that that cost estimate for a family of four. From being currently to in 2020. Which thank you, Senator Hardy. That was an elegant solution. Good, good job. Okay. We're good with that one. What's that? Yes. And I may need to make a few conforming grammatical changes to put it in the past tense. Number three, the new number three is around the cost of prescription drugs. There's any additional thoughts on those on that. I mean, what you could say a lot on that one, but with this. That speaks for itself. And there definitely have been reports on that one. Yep. All right, that was it for the findings, unless there are additional findings that people want to. Consider or propose. Okay, we're good. Right. Okay. And then we get into this commission task force committee, whatever you want it to be. Let's, let's call it something now. We'll settle that one. I think committee work, work, work group. What. I think committee or work group because a commission. I agree with Jen sounds like it's much longer. And in this sort of blue ribbon commission kind of thing that goes over several years. This is around for six months, basically. Yeah. I mean, I don't think it's going to be a task force since it sort of has a mission or. Yeah, that's good. I like. It's good. Okay. I will change that throughout. Thank you. And then the sort of cross-reference to the principles of healthcare reform. You can find them, everybody. There's a list. Of, and they're really. They're more like principles. And I would suggest putting them under creation. Sort of something like, and Jen, you'll have a better elegant way of putting this, but something like in keeping with the principles of healthcare reform under 18 BSA 93 71. There is created the, the. A task force on sort of. Making it the umbrella under which everything else is looked at. So I'm not sure if I would make the task force itself. Sort of consistent with that. Cause I'm not sure that. That it's the creation. I think it's really, I mean, if I understand what you're looking for them to do, you're really looking for them to apply these principles in their. Decision making. Consideration. And. Right. So it doesn't seem like it. I mean, maybe it would be a duty, but it's sort of like overarching their, all their duties is. It's a lens basically. Right. So I'm almost thinking at the, in the. Powers and duties at the beginning of that. My other. Go ahead. Okay. Finish your sentence. No, I'm thinking out loud. So, so. I don't need to do that. So, uh, I'm also thinking that as we developed. Uh, the, the principles for the ACO. Uh, which comes after act 48. And I know in act 48, I was the one who suggested that healthcare is a public good. And we put it in. So it's there. Uh, but also the, um, Having some of the principles that are within the. Establishment of any ACO, I think is also important. So. No, I'm not. I like the broader, just sort of, um, general healthcare. Before you, before you, before you suggest they are not, I mean, I would suggest that we look at them. Uh, because they do call for. Uh, continuity and consistency for our healthcare. System. So to build a system that has continuity for patients who are moving from acute care to more chronic care and patients who are moving from a hospital setting, for example, to a substance use disorder counseling environment. So those kinds of things, the care management piece to me is important. So let's look. Can we Jen pull up. The principles, uh, that, um, Senator Hardy has identified and then maybe look at, um, the principles that have been written since that time. I don't want to lose sight that work has been done. After act 48. I was very much engaged in act 48 and I was also engaged in the others. And I know others here have been as well. But. He's up. Oh, shoot. So here is, these are the. Uh, What was enacted in act. Uh, 48, but has also been amended. Over time. Um, in the statute. These are the principles for healthcare reform. Senator Hardy. I think this is what you were referring to the 18 days, say 93 71. Yes. Um, and so it starts with that there. Uh, the general assembly adopts the following principles as a framework for reforming healthcare. And Vermont. And then it goes through. Senator Hardy said, I think 13. Yep. Don't know 14. 14. I don't know if you want me to walk through them or you just want them. Up. You're muted, Senator. Oh, I was going to say, if you scroll down through them slowly, we'll be. Okay. Okay. Okay. Sounds good. Okay. They look good. That seems to cover. Just use those. We don't need to go any further. I think. So I think we can. Put a reference. To those. Um, and I'm, I'm thinking of it in the. Powers and duties kind of lead in. Um, Under paragraphs. See. Yeah. Yeah. That makes sense. Okay. Um, so I'm just going to, for the moment, I'm going to make a note that. Just says add. Add. Yeah. We'll say act 48 principles. Reference, but we don't really have to. Call it. Act 48. Um, Right. So, all right. I will look at how to incorporate that in there. Good. Senator Hooker. This is what you were talking about earlier this morning. It is, it is. Um, and I. I would like to. Have a language in there regarding transparency and accountability. So that Vermonters understand the ACO. And it's a fact on them. I think this is broad enough that it will capture any, any. Entity within our healthcare system. Well, are you talking about the lead in center lines? Are you talking about the lead in center lines? Are you talking about the lead in language or the number two? I think Senator. I'm talking about the lead. Maybe onto C2. Is that where you are? Senator Hooker. I'm on. I'm on two. Okay. We're the. Yeah. We have crossed out. Um, the language regarding efficacy of the all payer. Uh, of the all payer. Conville care organization model. But, um, I would like to. See it replaced with some reference to. Helping Vermonters understand. What the ACO is and its effect on them. But if you think. If you think that. Oh, go ahead. Go ahead. No, I was going to say. With the reference to the principles. Of healthcare. Um, That might help cover some of this. Since, you know, it talks about having the committee look at transparency and accountability. So, um, but. If there's a way to incorporate that just so this committee. Can. Allow Vermonters to understand. The process and how it's affecting them, including how it affects them when they're being discharged from the hospital and that continuity of care. I'm not sure that Vermonters really understand what the ACO is, but. You know, So my guess, my question is this. The. Is this committee going to go out and present. Information to. People. And if this committee is going to do that, we should say something upfront about that as a charge. And then the committee itself should. Based on prior reports and reform efforts. Structure what the committee would like to present. So I don't think that having. The committee analyze the ACO is something that this committee can do. Nor the. It will take the consultant. All of his or her time or their time. So, and thinking about this. That's all I want to say at this point. Center Alliance. I agree. I don't think the committee has sufficient staff. I agree. I don't think the committee has sufficient staffing or time or expertise to evaluate the ACO. I completely agree with that. One of the things that we heard. Testimony on though was that. It's potentially a good opportunity to find out what Vermonters. Understand about our healthcare system broadly, including the ACO and how it impacts their health. And so I think that that might be a good charge given that this committee is supposed to be going out around the state. Or task force now. Now it's a task force. You know what you're saying is important. But I do think that. The. The work of the committee and the listening tour that's going to go on. We'll allow for people to make comments. You're, you're, you're right. They will, they already have. And there's a strong group. There's a, there's a large group of people who. Really disliked the ACO. And I don't know why. And there, there may be some. Some underlying reasons for that. But as some of it is related to understanding and some of it is related to understanding. What's happening. But you're going, we're going to hear that as people go around the state, that's going to be expressed. So the question is, is it the job of this committee to go out and explain everything up front. Before taking. Testimony. So that, that's a, that's a discussion probably. That the committee is going to go out and explain everything up front. That's, that's, that's a discussion probably. That the committee is going to have to have as it convenes itself. I don't see the. Language related to. The ACO statute because there could be any ACO it's not. You know, if you're. If you're concerned about one care, then people are going to tell you you're concerned about one care. You're concerned about one care. For me, this task force is looking at insurance costs. Out of pocket cost. Cost of care. Access of access to care on the ground boots on the ground for people. That's a very different. Look. Then what is going on and the review that the CMMI is making around that. That's a very different thing. I agree. I agree with your program. Right. I agree. Animals. I agree. I agree. Senator Lyons. And I said that. And so. What I'm suggesting is in the language that you suggested. The how alignment of Medicare. That we just include how Vermont's all payer. Accountable care organization model. And alignment of Medicare, Medicaid, and then the rest. So that it's just the, I, I, I will not, I, I won't entertain that. I just don't think it's something we will. You just don't want it mentioned at all. Nope. Why not. That's part of our health care. It's two different things. What you're looking at when you talk about alignment, private insurance, patient care management, rules and guidelines. We're talking about very specific things about cost and transparency. When you look at an ACO, you are looking where we're thinking about an organization that's building. Clinical data for clinical improvement. And for building. You know, I think as the committee forms itself and discusses this, it may well be that the committee wants to present information and ask questions about any type of organization that's out there, whether it's an FQHC, a hospital. A rural clinic, a free clinic. So all of those things are things that the, that the task force can look at and listen about. So why don't we list that then. That would be a long list. I mean, I just, I, you know, I think we're wanting to hear about that. What they're experiencing and their day-to-day care, the money that they're paying for their premiums, what it's costing them, how they can see improvement when they're discharged from a hospital, how they can see improvement when they, their limit on counseling services and, you know, all of those things are so key and important to people right now. That, that that's what I want to know. I want to know what, what are the glitches in the system that are keeping people from accessing care, whether it's cost. Or whether it's. Some clinic that's a hundred miles away and you have to get to three times. Well, I certainly don't want to keep people from expressing themselves and, and from learning from these listening sessions, what Vermonters are feeling. My concern was that, you know, we have the system in place. This is the one that we're using. And people don't know what it is. And it was, you know, a simple, simple, helping people to understand how the system is being run. But certainly I don't want it to keep. This bill from going forward. So, you know, we can move on. I mean, there is language that just a Barnard suggested for this. Also, you know, maybe you want to look at that. I think with the language that we're using, I mean, I looked at Jess's language and the language that's in there that you suggested is. The language isn't accessible to average Vermonters. And so that's why, you know, talking about like, how does the system impact their care? Which is what you just said. I mean, you know, maybe we just say that. How does the overall system, including blah, blah, blah, blah, impact the care of your care as Vermonters. Define blah, blah, blah. Well, I mean, hospitals, the accountable care organization, clinics, medical practices, and we add, you know, we list the things that are part of the system, insurance companies, all of those things. And, and, and see what people have to say. And why don't we do it this way? Why don't we say the accessibility of care through, through the system, through public and private insurance. And hospitals, clinics, and other care facilities, because there's a, that we could have a list a mile long and I'm not, and I do think there's a distinct difference between what you're talking about when you say ACO and what a clinic is. Very different. Well, so this is the charge of the committee. To consider the effects of this system, including a few that we can list on including it means that there are many others. So it's not just the ones that are listed. Okay. And the effect that they have on Vermont's on Vermonters and their healthcare. Yeah. I mean, it's the. Yeah. Okay. All right. So it's the public and private insurance. It's access to physicians and other providers. Access and care coordination. So there's a whole lot in there. Senator Cummings has a question. Yeah, Senator Cummings. I, I don't think we can tell Vermonters what they can talk about. Exactly. If we're going out there and they have concerns, they can talk about them. You can't. I mean, I've had the experience of telling the nuclear physicist that I'm sorry, you can't talk about safety and Vermont Yankee. I have to let them talk. I got in trouble for that, but they're members of the public and they have a right. To be heard. Why can't we just say how Vermont. How the Vermont healthcare system affects them is impacting their, their lives. I'm with you on that. That's what that, that is what I. Is part of the healthcare system. If they come out. I think you've got advocacy groups that. Love it or hate it. I don't know anybody loves it. I doubt that the average for monitor has any idea what it is, how it works. And they aren't focused on it. They're focused on how come. When I was going and paying $99 for the physical therapist. And suddenly it costs $300. I think you've got advocacy groups that. Love it or hate it. I don't know anybody loves it. Well, we figured out why. Those are the things that are impacting people. So, so Senator, if, if, if I'm hearing you right now, I completely agree we, we should. Vermont or should be coming in and saying exactly what's on their mind. About the healthcare system and how it affects them. Period. So maybe we just say that how the system, how the healthcare system is affecting them. Period. Or something similar, a number two. Your lives and their access to healthcare. Yeah. I like that. Okay. And the cost. Yeah. Access and cost. Access. Well, cost definitely affects access. Yeah. So the, the one here says. Access and affordability. Of care. And then what about the, what about the phrase at the end of that, including access to referrals for extended care, counseling and social services? Do you want to include that? Or just. Forget it. Well, I think that that, that speaks to your continuity of care.  Yeah. That was the point. So. Okay. All right. So, so I need a little guidance now on what you have decided.  And then you added and their access to healthcare. And then you added in costs.  So what, what do you want? How broad. Does it make sense to you? Senator Cummings. It's all. So do you want to. Try to clarify. You've had an idea. I think what we want to know is how the present Vermont's present healthcare system. Is impacting their lives. Is impacting their lives. That positively negatively, but how it's impacting their lives. And then I guess you get the, the subsets. Including. Accessibility or availability. Cost. Imposed limitations. What about the. Going there. Accessibility. Affordability, which is cost. And then. Do you, do you think we should add anything, the phrase that's already there that including access to referrals for extended care. Counseling and social services. Did that, you want that. That. That suggests continuity of care. Given some of my recent experiences. I am starting to question whether. Always doing the lower priced. Or cost option like physical therapy.  I've had. Several people I know had very bad experiences. With that. At what point do you go to the more expensive option? Well, we're going to hear that.  People are going to share. I guess the question is loud. Yeah. So what, what are you allowed to access? Go ahead. Senator Hardy. I, I like Ann's language. Let's just keep it simple and just say how the. You stated it and a center coming. Sorry. How the healthcare system is impacting the lives of her. Just. Period. And then if we start to list things, then we argue over the list. So let's just not list anything. Yeah, it is impacting their lives, their access to healthcare. Their lives and their, and yeah, and their access to healthcare. And could I just ask that we say all Vermonters and Vermont businesses? I think we referred to that. Yes. Yes. Good point. You may take some of the edge off if we get S 88 moving. What's S 88. Oh, that's the separate. Well, it's the insurance house keeping bill, but now it's got the healthcare market separation. I got to. We've got it. We. I'm sorry. I'm sorry. I'm sorry. I just asked that we say all Vermonters and Vermont businesses. I think we referred to that. Yes. Yes. Good point. You may take some of the edge off. If we get S 88 moving. I'm sorry. I'm planning to get it out today. Oh, really? So we should talk because. Okay. Another topic. Are we all set with this? So, so well, what you've landed on, I think is how Vermont's current healthcare system is impacting Vermonters and Vermont businesses and their access to healthcare. And I would say all Vermonters costs and access. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. We want access and affordability. Both. Or not. It's up to the committee. I'm sorry. I'm just so tired. Poor Jen. All right. Access. Not, not cost. Access and affordability. Yes. Yes. Okay. So you want to know how, how. How is the current healthcare system is impacting Vermonters. And Vermont businesses. How about access to quality healthcare? Cost effective. Well, acts cost is. Affordable. Access. If you can afford it, you can't access it. Okay. Okay. And their access to affordable healthcare. Yeah. Yeah. That's good. Okay. Senator Hooker, I heard you on the all, but I think it's, um, I don't know. So how Vermont's current healthcare system is impacting all Vermonters. Sounds like you need a. Macro and not, and you're not interested in. And individual. All right. We're going to listen to all. Everybody. We're going to listen to everybody. But if you don't. Okay. So all this necessary, that's fine. I think if you're, if the task force is supposed to consider how the system is impacting Vermonters and Vermont businesses. It includes it. It includes everybody. I mean, that's not, it's not, you're not identifying segments of the. State. Okay. Talk about, can we talk about individual. Vermonters. Yeah. And Vermont business. I'm not even sure about Vermont. If we say Vermonters, are we leaving out. We're not saying illegal immigrants. People aren't supposed to be. I mean, I think. Right. I think you're residents. Right. I mean, we could say Vermont res individual Vermont residents and Vermont businesses. Or impacting Vermont residents and Vermont twice.  Residents and businesses. Yeah. See, this is why we should have stopped with a short phrase that and suggested. Ever that easy. In this discussion. This is sausage making it. And it's finest. Yes, it's beautiful. I can only imagine what the live transcript sounds like. Josh. We will meet it at the next. I'm here. I'm here. I'm here. This will be the last time. This will be the last time that health and welfare is selected. To be the committee of. Experimentation with closed captions. So I do also want to know you do have Katie here. And I know she has a smaller window of availability. So maybe I will. Go off and look at what you've done so far for a few minutes. Okay. I just want to reiterate my concern about having that section in. On the audit piece. And because I do feel very strongly about not getting involved in the middle of a. Legal action. That's generally a good principle. Yep, I do. It's in court. With that. Right. We do. There's actually a statute about. Yeah, I understand. Yeah, just take it out. We also got a couple emails from folks about the three 40 B thing, which we can look at. If we want. Yeah, we'll pick that. Let's pick that one up later. But you're right. Let's pick that one up later. What we do need to look at it. Okay. Well, I will work on these. What you've done so far in this. I'll just be on. Okay. As Katie is here. There she is. Okay. Thank you. You've come, you've, you've come and saved us from ourselves. And just to let you know. That's what staff usually does. Katie, the. Today we are a part of the it's work to add closed captioning. To our committee. So our committee. Is anything that we say is put into closed caption on zoom and on YouTube. Doesn't guarantee that it's going to be a direct translation or. You know, so, but I just to let you know, that's happening. Okay. Great. Thank you. So go ahead. We are on the agenda with you. What do you want to take up first? Because I know you have something to stay on both of those bills. It's up to you. I have both pulled up ready to go. So. Okay. Let's, which, which would you think is less time consuming? 46. They're both pretty brief. Let's then let's go to 210. Okay. Disparities bill. See it only. It's only going to 10. So you've got a whole lot of people. Out there scrambling for 10. In the closed captioning. Oh, okay. Okay. So are you seeing draft 3.2 on your screens? Yes, we are. Thank you. Okay. So I kept the highlighted changes from yesterday, thinking that you might want to just take a look at those again. And I've also highlighted the changes you've made since yesterday. So I'll walk you through the, the first section is findings yesterday. There was a change added overnight. So I will scroll down to provide you that language. So there is a new subdivision 10. And then an amended subdivision. 11. Which previously was 10. So the new subdivision 10, the, the committee heard testimony. That there should be findings. About. Native American populations, particular, particularly individuals. Living in Vermont. So the first finding has to do with national data. And then the second one is more specific to Vermont. So in this subdivision 10, according to the Indian health service, the American Indian and Alaska native people have long experienced lower health status. When compared with other Americans, including a life expectancy among American Indian and Alaska native people. Born today that is 5.5 years less than the U.S. All races. So the first finding has to do with national data. And the second finding has to do with national data. So it's 5.5 years less than the U.S. All races population. And then. The second. Change. There's language. Borrowed. From the. The house resolution that passed on eugenics. And there's a direct quote there. And I will go through that with you. And I will go through that with you. And I will go through the bill that came over to you from the house. Of the state's 1931 sterilization law. So that reference has been retained. So this new language is out as outlined. And the house's resolution. Vermont state sanctioned eugenics policies. Targeted Vermonters of Native American. Indian heritage, including French Indian and. Canadian heritage as well as the poor and persons with disabilities. Among others. These policies, including the state's 1931 sterilization law. Are examples of past injustices and the healthcare system. They continue to impact members of these communities in the present day. That's terrific. Thank you. The closed caption said. Evan Nike as in sneakers. Oh my. Madam chair. Evan Nike's family is being. So Katie and I went back and forth last night. Till pretty late to get these two. And the one of the. The reasons why she has the national data. Is it's really hard to have to find specific health data. For Native. Americans in Vermont. And that's sort of part of the point of the bill. And with all the work on the data. And. In looking at the, the finding that we had in there before the previous number 10, it did make a reference to the eugenics. Movement and in looking at the house resolution, it seemed like their language, which has already passed the full house. I think. Unanimously. Or almost. Was really specific and based on a lot of research that they had done. So that's why we thought that sort of. Quoting it directly was really helpful. Yes, that's excellent. That's very good. And I'll say that. When I taught genetics culture and society, I went through and tried to find the same type of data. It's not, it's not easily found. There are some arch. There is some archival material, but that maybe our archivist could look fine for us someday. But this really, I think is excellent. It's good. Good job. Okay. Okay. So the next section was the legislative intent and purpose section. And we have lead in language to this and the general assembly believes that. And then there's language we looked at yesterday. So I. I'm trying to remember if there is a change since yesterday. But this is the language about, oh, there was a change. We added a cross reference. This is the language about. The challenge of coming up with a proper. Categories and definitions. And how this bill continues to. To kind of shine a light on that difficulty and also try to move. Towards. Working on this issue and the terms we use. In. 18 BSA chapter six, the new chapter that this bill creates. So the language reads that definitions of racial categories. And identities can be difficult to agree upon as they often create hierarchies and comparisons that center work. Prioritize one group. Or identity over another. And fail to recognize historical inequities and oppression. Definitions. Also shift over time. As broader cultural norms change. Well, potentially problematic in order to align with data collection standards and create consistency. This bill does. Does use the term non-white as defined. And so. And also seeks to create new definitions that better reflect racial and ethnic identities. And categories pursuant to section six of this act. And section six. Is the new language that was added. Or excuse me, this cross reference is the new language that was added. And that references the study that we looked at. Yesterday. And section six that has. This look at. Terms and categories as part of the first year report back for the advisory commission. So I will move past this. And then we get into the new chapter itself. Chapter six. We start off. With a definition. A previous version that you looked at. Had language. That cultural competency means. Acquiring cultural humility and a. Set of integrated attitudes. That incorporation here has been removed. And favor of adding in. Stand alone definition of cultural humility. Meaning the ability to maintain an interpersonal stance that is other oriented or open to the other. In relation to aspects of cultural identity. That are most important to the client or patient. And then the rest of this section has of course been renumbered to reflect the new definition. Katie. Just so that I know. That center alliance knows this, but that definition came from. Dr. Coleman at UVM health center. And based on her testimony. The chair had reached out to her about the language. And that's what she suggested. But thank you. I was going to say that. And you. I'm happy you said it. That's fine. Great. Now I think, you know, Dr. Coleman I think is going to be very important as we move forward in the area. Of health disparities. I think she'll be an excellent resource for us. In the future. Now and in the future. I was, I was almost tempted to suggest her on the working group, but I don't want to. On the advisory group, but I think it probably doesn't make sense at this point. Sorry, Katie, go ahead. Okay. I'll keep moving. The next section has to do with establishing the advisory commission and changes here include to the membership. So as we talked about yesterday, adding the chief prevention officer or designee. I think it probably doesn't make sense at this point. Sorry, Katie. Go ahead. Okay. So as we talked about yesterday, adding the chief prevention officer or designee. And then the committee also asked to incorporate a member. Appointed by the Vermont developmental disabilities council. So that person has been added. And then I noted as I went through the bill last night. That we have staggered terms for the. The start date, for example, some of the members. Some of the members have a two year term. And then others have a three year term. So because we have, at my count, 29 members. Not including the large members who have an automatic one year term. I had to update all my numbering. So now I have. 10 folks starting for one year term, 10 for a two year term and nine for a term of three years. So that's my way of doing it. So I'm going to go ahead and make a quick. Make a quick math to work out to make sure the, the staggered terms will work and catch. This is, this is really good. I mean, I think about the, the times being on a board and then trying to figure out membership and length of term. And who's turning over when and how. And thank you for doing that. And then powers and duties. Yesterday there was quite a bit of committee discussion as to whether to provide a date certain on when the office of the health equity would be up and running and what the correct date would be the committee landed on not later than January 1, 2023. So that's not a change from yesterday, but it's still reflected in the language. Again not a change from yesterday, but one of the tasks of the advisory commission is to advise the Department of Health on any funding decisions relating to eliminating health disparities and promoting health equity and language and the General Assembly has been added. So the advice goes not only to the Department of Health, but it also comes into the General Assembly. Then in section subsection subdivision seven, there's language about advising the General Assembly on efforts to improve cultural competency, cultural humility and anti-racism. The draft yesterday only referred to humility and because we updated the definition, I've reflected the change there to mirror the language and the definition. Okay, so I'm moving to the studies and at the end of report backs, I shouldn't call them studies, report backs at the end of the bill. So again we have kind of the same change that we just looked at instead of referring to cultural competency and humility, I'm using the full term cultural humility to reflect what is in the definition section of the bill. And then this section six has had some changes. So if you remember the bill that came over from the House had a report back that would be part of the advisory commission's first annual report and it specified specific items that were to be part of the first annual report. So the only item listed on the version that came from the House was budget recommendations for continuation of its work in fiscal year 2023 if the advisory commission deemed it was necessary and the committee yesterday chose to add and for the funding of the Office of the Health Equity itself and that is kind of a counterpart with the decision to provide a date certain by which the office is funded. So the committee discussed yesterday language about using the appropriate terminology and the appropriate categories when collecting data. So yesterday the committee only had this language in subdivision a although it wasn't labeled as subdivision a yesterday regarding appropriate and inclusive terms to replace non-white and yesterday you chose to add the language in B which has to do with data categories beyond white and non-white and the committee chose to add a cross reference to the language that is in the new chapter that talks about the advisory commission along with the executive director of racial equity to really focus on this work. So this isn't changing that requirement. This is just giving a date certain by which the general assembly hopes to have information from the advisory commission on that work. And then the this report would also include seeking recommendations from the advisory commission on for most effective use of funding that's received by the state through ARPA in a manner that promotes health and achieves health equity by eliminating avoidable and unjust disparities in health on the basis of race ethnicity disability or LGBTQ status. And that is it for changes. That's a lot of work in a short time and thank you for a very clear explanation Katie really terrific thank you very much. Just a question that I have for you we and Nolan is here and I'm wondering Nolan do we have a fiscal note on remind me on 210 there obviously there's a an advisory committee but I think most of those folks are already compensated through their work or yeah so for the record no online all the joint fiscal office there was a fiscal note for this has passed the house the house put the money for this in the budget it was 180,000 that 180,000 would be to cover per diems and whatever else was needed so assuming that it's still in the budget on the senate side the fiscal note will just say we'll not change much except for minor language changes. Okay that's good to know I think we did see that early on and then the the other question I have is from your experience Katie and Nolan will this then this will go will it go by rule 31 to approach other the free Katie on that one. I think that would be a question for the secretary bloomer I'm okay trying to think if the appropriations would have an interest in the language about recommendations but I would defer to the secretary bloomer. Okay well we'll see what happens with that that's actually an important question because at the very end where it talks about ARPA funds the appropriations committee has been is I think a little bit sensitive and probably justifiably so about any suggestions for use of ARPA funds although this is just guidelines and criteria. I would say a bare minimum you should let them know that the money on the house side for this was in the budgets that we we did that in our budget memo it's one of the member of the bills listed right in the beginning and this is right there with it. Yeah and I heard they love our budget memo. Yep it's thorough. The other thing I will just flag is the language around data responsiveness the money for that was actually an h315 act nine so that's already locked so the but that's actually that section's already been funded which section is that data? Oh at the end yeah yeah okay well thank you that's good all right okay uh committee discussion on the bill. Senator Taranzini. Yeah I'll set Senator Lyons let's uh let's go. Wow that's awesome I love it. Anybody else disagree with that? No I just want to thank Katie for all the work she's put in in the last couple days there's been a lot of back and forth and a lot to keep up with and Katie you've just done a fantastic job so thank you so much. Ditto okay all right so uh seeing no further discussion on the bill proposal before us I would entertain a motion from somebody on draft 3.2 as amended this is a strike all amendment is that right Katie? I move that the committee approve draft 3.2 of h210. Okay uh committee discussion all right Senator Taranzini please um take the vote please. All right thank you um myself Senator Taranzini yes Senator Hooker? Yes. Senator Cummings? Gotta get closer to your mic Ann. Oh yes Puerto Rich. Thank you Senator Hardy? Yes. Senator Lyons? Yes. I have five uh yeses zero zero zero excellent excellent reporter um so I I just have this inkling that Senator Hardy would like to report this and uh it is a critically important bill for the committee so Senator after you report it will be uh please um understand that I may stand up and say a few words so it isn't important. Of course yes I would love to report it thank you. Good all right good good you've done a lot of work on it. Katie will you send me the clean draft thank you. And yeah then if that gets up to the secretary's office today then it'll be on notice on Tuesday then we'll have two bills up on Wednesday we're gonna have unless it goes to a probe so I don't know what will happen there we'll have to find out. Okay let's move on to uh H46 Katie. Okay um I assume you're seeing draft 1.1 this is an amendment to H46 which is the bill on miscellaneous mental health provisions that we looked at yesterday and a suggestion was made to amend section one to get rid of the um phase here she and use more gender and neutral language so that was required in two different places and that change has been made by striking out all of section one um having a new section one here and the change is online 11 and 12 um before the person may be admitted as a voluntary patient the person shall give consent in writing on a form adopted by the department and then similarly in subdivision one online 14 striking his or her the person understands that treatment will involve in patient status and the other um corrections had already been in the bill so that is it for this amendment. Okay uh questions I think that cleans up the language nicely it's a good catch so committee questions discussion so section two remains the same I'm trying to remember how many sections are in the bill in total or well five sections with the effective date but four substantive sections and everything else would remain the same with this amendment okay all right discussion questions hearing none I would accept a motion someone so moved all right senator taranzini has moved draft 1.1 proposal of amendment for h 46 so that was a motion for the amendment was it not senator correct okay discussion all right please call the vote okay senator taranzini yes senator hooker yes senator comings senator you're muted sorry saying hi the grandkids when they came in yes good okay senator hurdy yes senator liens yes 500 on the amendment all right now a motion can be made on the bill as amended for each 46 and to send to the full senate so moved discussion hearing none uh senator taranzini please call the vote okay senator taranzini will be yes senator um hooker yes senator comings closer to the mic dan yes it's a quarter of an inch literally uh senator um hurdy yes senator liens yes 500 so uh 46 on mental health is there someone who would like to report this bill senator comings are you open to reporting a bill or are you overwhelmed with other bills i prefer not to i've got okay just a lot i'm balancing if no one else will do it i guess i'll do it and is there someone else senator hooker or i could do it if you'd like sure okay that'd be good all right thank you um katie what other bills do you have for us that's all i have this morning all right so this is great um thank you for all of your hard work these last few days and weeks um um thank you so um that and then so the clean copies of everything need to be gotten so 46 to senator hooker and 210 to senator hardy and then you oh and then the other thing i think while you're here i would ask for um section by section of h171 as amended and and while you're here also we might share uh with folks that uh h171 was in appropriations yesterday they took all of the money out they modified katie was it they modified the number of the sections that had uh money in it and i'm trying to remember i haven't looked at their amendment today but maybe you could help did they take section 10 and 11 out completely um so section 10 is still in but it is now just um a report back on how the money was spent instead of a working group with recommendations on how to spend the money and section 11 was taken out with the caveat that language would be added to the budget that would have um dcf come up with a plan for the expenditure of the child care stabilization funds um that plan would go to the chairs of the two subject matter committees and that the chairs upon their approval would refer the bill to joint fiscal committee for consideration or not the bill the the plan yeah the plan that's not too different from what we had but it's okay great can i ask section 10 was that the whole working group thing was just removed yeah so section 10 and 11 both had a working group and the working group concept has been removed from both although section seven not seven section 11 still directs dcf to consult with stakeholders and they in this j i'm sorry i'm the they would still it would still go through joint fiscal for section 11 yes section 11 not but not section 10 was the money that has to get out the door a little i think which one was quicker 10 or 11 but i was told originally from by dcf was that section 11 had to get out the door faster right which is why we did put in some we did put some guidelines in and criteria so it's a little bit of a concern but we'll see what happens with that then if i recall section 13 the education system analysis was also taken out of the bill i can't remember if that was put in the budget it says here in the amendments section 13 that's only subsection d that's the money oh yeah that's the money okay they actually actually it was there was i'm not unhappy with what uh how the bill has come out it's really mostly the money so we actually do have a bill left which is different from what has happened sometimes in the past so we do still have a bill to report remember the last time we did this i was a reporter of the bill and never had an opportunity to speak to it on the floor because it was right they put the whole all the language into the budget too right yeah right that you know i think when a committee does its work we ought to be able to express what some some of the policy okay so we're finished with that you know jenna's katey thank you nullin thank you i don't know how many times to say it um so jenna is going to be coming back with with uh 430 and 120 i think that we deserve just a couple minutes of break so jen with due respect let's come back in five minutes


from the broadcasting house here in Nairobi, Kenya. This is Power Talk, a show that comes to you so that you can be able to inspire you, motivate you and push you to become the better version of yourself. Right here we discuss issues that matter when it comes to relationships and life issues. Today we are broadcasting also on our website www.y254.co.ke. So make sure that you head over to our website if at all you want to watch us online. We are broadcasting also online on our website. Our handles are on and they are up and running. I shall mention them in a few. Now today our subject or of discussion is about love and trust in marriage. That's right, love and trust in marriage. This is a very fundamental issue when it comes to marriage, love and trust. These are the cornerstones of every marriage. Without trust, marriage is a break. Without love, marriage is a break. But now according to statistics in the recent past, the number of divorces have increased significantly over the past five years right here in Kenya. Now while at the end of 2020 that was last year and the beginning of this year 2021, the total number of registered divorces or those that are pending before court is predicted to be more than 2000. This is an alarming rate. Now the question is why? Why is it that we have a problem in the increased number of divorces in Kenya? What is the reason? What are the pillars that are broken? How can we build love and trust in marriage? And actually what are the ingredients of a healthy marriage? This morning these are the questions that we are trying to find out the answers to. I'm joined by Pastor Shadrach Manghera. He is a senior pastor at the Calvary Covenant Center in Kamulu. Thank you sir. We are also expecting the presence of Pastor Helen Jiru from World Harvest Ministries Church in Kawangwari. If she shall join us today, we shall also have her on set. But make sure that you can be part of this conversation. The hashtag is Power Talk Show on Twitter at Ram Aguko, at Y254 channel. Make sure that you head over to Facebook and tell us what you think. How can we build love and trust in marriage? Fundamental question. Remember the cornerstone of all marriages is love and trust and the question is what are the reasons for the increase in the number of in the cases of divorces in the country? How do we build love and trust in marriage? Pastor Shadrach. Yes sir. Tell me love and trust. Yes. How important are they in a marriage setting? Yes, just like you already mentioned there are quite very key pillars to any successful marriage and one that lacks either of the two or maybe more others that have not mentioned but measure the two. You'll find they really struggle quite a lot because from the very beginning you have to understand what is trust and what is love and then you have to know the source of trust and the source of love. Yeah because I believe many people when they get together maybe they go because they just looked at each other and loved each other but they really didn't do the needful for them to be able to build that trust and also to develop love. Both of them. You're saying it's possible for you to marry somebody in the assumption that yes we love each other but the trust is not the fundamental issue of trust? Very possible. Very possible because there are other issues that can be presenting themselves maybe you look at what they have or maybe what they own not necessarily trusting them but because of the material things that you see. We've had that discussion before on this show. The love for money. So can money build or break these two things love and trust? You know money is good. Money is good in fact in the good book Bible it talks about money being very good but the love of it it's always the root cause of all evil the love of it but money is good it's necessary therefore money can either break or even build a trust in any marriage. It can make a break. Yes. Let me find out the side of making it. Yes. Yes. Elaborate of that. How does it build? This is how it builds. For example if I'm courting somebody you know and I come as I am okay they find me with my 20 shillings and then from time to time I keep on building that money you know and they know also the source of the money where it has come from I build it up to a level that is to some point let me say some point you know this person will look at me and say okay I've seen this person grow from zero to something you know it is building a kind of trust in that sense. Okay. Yes. Okay. I don't know if if if the one can bring a little force. Professor. Yes. When someone is planning to get into the institution of marriage and you're saying love and trust has to be there. Yes. Is there any procedure that someone needs to follow when it comes to acquiring these two aspects these two virtues which one ought to come first is their love at first sight. Yeah that's a very good question love at first sight this one happens ordinarily to everybody you know you know in fact you look at someone then you love them from how they look like okay before you even begin to interrogate the deeper part of their lives and that's why now courtship comes in you know courtship now it's way by now we begin to learn one another you begin to know each other and then you may be you may make a conclusion whether what you saw is really what you expect you have now achieved at the end of the day. Yes. And okay let let me digress to yet another issue of trust. Yes. Yes. But from another perspective well love is I mean trust is often the first and the biggest casualty of infidelity. Yes. When you look at trust and okay if your partner cheats on you how can you move on from that and rebuild the trust because from that point trust was broken. Yes you know when somebody has cheated on you already the trust has been broken. Yes. And trust is one thing that it's too hard to build but it's too easy to break and when it's broken sometimes to rebuild it it becomes a big challenge therefore it is incumbent upon the two of you if you agree and say now this mistake has taken place but we need to move forward then you need to seek guidance help so that you know the reasons as to why it first happened that you cheated or somebody cheated on you what was the reason what were the underlying causes you know. Yes of course the work of the devil from beginning to end but then you have allowed yourself to be an instrument of the devil to make that up so it is important to go back to the root cause if you don't address the root cause and you just you got quoted say okay now let's forgive each other and let's move on and then things will just be better you know you will find yourself going back to the same same problem. Can trust be rebuilt again? Yes it can be rebuilt but it may take too much time or longer than you expected because there's always that fear what if what if they do it again what if they hurt me again and you know that is a problem how can you be able to be sure that they won't have you know another affair you know that is a question because now that is what can make someone to say you did this a few years back you know in the course of a woman a woman will say I remember back in the year 20s which and they give the date you did this you did that you did that over this long period of time there was a an issue of trust in this relationship so there is how can you get that assurance that we are safe. Yes and that's why it begins now from the two of you you know you have to really make it a point upon yourself to change and you know this change comes from within this change is not from outside like maybe the things I'll say or do but should begin from the innermost part of you so who should change the person who cheated or the the person who was cheated on I mean actually it's very important for both of you to have a change of attitude because if you were cheated on you say okay me have no problem it is not me who did it remember man is not an island you never know the things can go the other way around and you find yourself in the same sport so in the good scriptures it says that help someone was falling down to rise up again okay but you take care that you don't fall while helping them to do what to rise so both of you must be keen and be careful and say this thing has visited us our relationship let us guard it let us take care of each other let us hold each other accountable you know in this relationship for for couples that have been in marriage for not so long for a short period of time when they go through hurdles you know they normally say that the first few seasons so the first few weeks or months are normally good because now when when it comes to now the serious issues of marriage that's when things when things hit bedrock trust is broken love is broken is it possible for a young couple a very young couple to be able to rebuild whatever that they have done well in advanced and still get to the level that our old folks have have reached because right now divorce cases are a lot amongst the you know young couples as compared to Aluakitambu and you are not wise yeah yeah yeah and it's it's quite alarming that the the number of marriages that are breaking immediately after getting marriage or weddings but again as you've said the older folks head away they put themselves together but i believe we still have a chance even in this generation so for this generation they can still be whatever they have yes we still have a chance the most important thing i believe should be we need to understand each other's background you know when you when you get married to somebody you're marrying them from a maybe from a different background and this is what i say you must all bring your suitcases with you in the marriage and then you begin to unpack together maybe there were habits that you you used to have then you check on them and say no this one has put it aside there were good things that you used to to do say okay let's carry this one on in our marriage you know so when you understand the background from which you have come from and then you begin to build a relationship and new okay not not uh uh now saying now the way i used to live my life that's how you shall be you know as a man maybe you didn't care so much about eating at home you know now you're married now you're married you must get at home you must begin to adjust and change and this is a problem you know someone still bringing the bachelor life yes yes into marriage thus affecting the fundamental issues of of marriage how then can you say that it is possible if that is possible does it mean that someone is just not ready for marriage and that's why they are bringing their old life into this marriage and that's why we we we we tell people most of the time go for pre-marital counseling it is very crucial these sessions may look like a waste of time but the truth of the matter is they're quite helpful because like when you come for to me and i'm counseling you i'll ask you important questions i'll ask you what is the vision you have for your marriage you know you know people think that a vision is only for a company an organization or maybe for something like that you know i'll ask them what the vision do you have for your family you understand if they say oh we'll have just good time we'll have many children i tell them no please go back and first of all write your vision and then let's come and begin to talk because that's the foundation of your marriage yes every marriage should that also be done in the middle or in the course of a marriage again to re-evaluate your marriage and build up again very very very important because even when if you got married without having a vision it's not too late it's not too late to start it's not too late to say let me have a vision for my marriage i want to see myself in 20 years from now with this woman with this man how will my life be you know so for a couple that is having a problem right now that they are going through you know the the the the hills the mountains and the valleys yes um you you'd say that they need to sit together and have a discussion afresh to re-establish themselves the discussion should not be based on even or like even re-establishing but now moving forward because they're already in moving forward now victoriously okay and this now brings in the question of communication good communication you know and where there is communication things will work where there's no communication things will crumble communication is a problem communication has always been the key problem why many marriages end up in divorce lack of it so um looking at the aspects of infidelity yeah uh so can you say was teaching the course of could it be the course of a marriage a marriage problem a marital problem or could it be as a result of other underlying factors uh i think this one could best be answered by somebody who has been involved in this directly but uh now looking at it from other aspects yeah can you conclude that that for someone to cheat there was a problem initially that enabled them to have the ability to you know to cheat uh you know everything that happens everything that happens i will tell you ram it's a choice it's a choice that somebody makes you know even for you to go and cheat on your spouse it's a choice that you make and i always say that even not making a choice is still a choice you understand because god has given us the free will the free gift of making choices in life you know you can choose to love your wife to love your husband to be uh respectful to her to honor her and to honor your marriage bed you know you can make a decision and therefore i could not say that uh these people they cheated just because they or they found themselves in that particular scenario no it began somewhere in their mind they allowed a thought to be developed in their mind and that thought led them into making certain decisions that's why choice is all we have today we can choose to stay right to stay uh uh to maintain fidelity in our in our marriage you understand to be to be uh loving to our spouses and all that it's a choice we make today yes and these choices that we have made are you know have the ability to you know either spearhead take us forward or you know still push push us back yeah so it's about choice yeah choices they say they have consequences the results now um we're still on building building this aspect of marriage and trust one may feel as though you know family and friends could be you know also a source of uh comfort you know emotional you're going through emotional pain or you know you want to talk to people you love and trust so um is is this also a solution family and friends confiding in them when you have a problem of love and trust in your marriage i would love to really not concur with that because even the people that you may want to confide in they have their own issues and they have their own problems and sometimes those that you confide in instead of them giving you a good shoulder to lean on you know instead they'll make matters worse that's why i always think that when something has happened in a relationship the only people who can bring a solution into that relationship is the two of you see what's that the two of you the husband and the wife first help me understand yes i want to you're a senior person yes yes yes and i really want to get this straight yes when when couples are going through a marital problem who should they confide in themselves you see when you talk about confiding it means now you're putting everything that you have okay on the table if you don't have the ability to admit before your spouse that this what i've done this is what led me to do this this is why i i got this money from here you know if you and we don't have that ability to do it to your spouse then i doubt you'll be able to do it to someone else so the starting point you start from the two of you and then you seek cancel from now maybe a counselor a pastor your parents so at what point do you see cancel from other people immediately you have agreed because agreement starts from now let's be vulnerable let's now be open so it means seeking seeking a third parties intervention is being vulnerable to that third party first of all it's between yourselves and when you're you now give your issues to another person it means now you're completely bare before them so now you're trusting your life your issues with them believing they'll help you get a solution and but i'll tell you the solution comes from you as a person to make that decision a choice who should this third party be who should be an intermediator you know when couples are having a fight a counselor will be very good and also if you guys got into you have some what to call if you had a church wedding or maybe just a another wedding but you had some friends who stood with you at that particular time you could talk to them come on like the best man best man or the best couple you see you could talk to them right and and and also put your issues openly before them what i encourage people is don't talk to everybody don't talk to everybody maybe your aunt your uncle your everybody tell them all your issues that are happening marriage you know some of them may not help you some of them may even encourage you to to move out and to move and to go your own life yes in loss yes at what point should you involve your in loss now in your marriage in your marriage don't they have the ability to break the trust between the two of you now yeah you have said very well in loss you need to add another one there outlaws we have in laws and outlaws the outlaws now those are your friends your the friends that you you hang out with the people that the ladies that you meet in the salon the chama ladies you know the gentleman that you go and watch football together you know the people that you go together in in in safaris you know those are outlaws and then of the in-laws people are actually related based on your marriage so so someone like my best friend ought not to be involved in my marital issues i suggest i suggest it to be done very cautiously yeah very very cautiously yeah because if it's not done cautiously if not it's not if it's not done cautiously it is possible it is possible that they may not give the best advice that you really need so that's why i said marriage issues you know this marriage issue married was started by god it's a union started by god when god was bringing man together he was all alone so i think our best solution comes from god himself mother-in-law your mother all father-in-law coming into your marriage but uh you will respond to that after this break okay be part of the conversation um how can you build love and trust in your marriage the hashtag is power talk show on twitter at rama google at y254 channel this is power power talk remember we also asked our viewers to be able to send in their thoughts in regards to these all their opinions uh record yourself and send us a one minute clip and we shall play them right here on y254 we shall do that after this break