Legislature(1993 - 1994)
03/21/1994 03:00 PM House HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HB 414 - COMPREHENSIVE HEALTH CARE CSHB 414: "An Act creating the Alaska Health Commission; relating to the delivery, quality, access, and financing of health care; relating to health insurers, health maintenance to certain civil actions against health care providers and health insurers; amending Alaska Rules of Civil Procedure 26 and 27 and Alaska Rules of Evidence 802, 803, and 804; repealing Alaska Rule of Civil Procedure 82.1; and providing for an effective date." Number 019 DR. DON LEHMAN, President, Alaska State Medical Association, testified from Sitka and spoke in support of HB 414. He said the association recognizes the bill provides a framework for the study and development of significant reforms. He emphasized that Alaska is a diverse and unique state that warrants an Alaskan solution to its problems. Having said that, he addressed Amendment 16, relating to disability insurance claims processing. He explained that the current delay in the processing of insurance claims is a problem that is increasing for small and rural clinics. Dr. Lehman asserted that insurance companies do not make money by saying "yes," but by saying "no" and by saying nothing and doing nothing. He said there is no reason why patients' insurance claims should remain in the ditch for longer than 15 days and this amendment would improve health system efficiency which is a key to controlling health costs. DR. LEHMAN then addressed Amendment 17 and said the concept of a "market based single payer" system, developed by a doctor from Anchorage, is a uniquely Alaskan solution. He said this proposal combines the efficiency of a single payer with the economic reality of a market driven system. He stated it includes provider defined fees, patient copayments, sliding scale copayments, posted fees, comparison lists for consumers, voluntary expenditure targets, and provider peer reviews. Number 062 REP. G. DAVIS asked Dr. Lehman what he envisioned as the possible result of this proposed legislation as compared to the compromised bill. Number 065 DR. LEHMAN said the compromised bill was an all-encompassing proposal that investigated the problem and had a definite solution. He said he viewed the Governor's proposal as an outline from which further study could be done. He said development of an outline for health care system reform is clearly an important step to take in order to safeguard Alaskans from what bureaucrats in Washington might devise as a solution. He said he feels like a managed care system would not work in Alaska where there is one large urban area and scattered populations throughout the rest of the state. He stated the problem with the compromised bill is that it is unrealistic during this session. (Chair Bunde indicated that Rep. Nicholia arrived at 3:12 p.m.) CHAIR BUNDE indicated that because Rep. Olberg was not yet at the meeting, Amendment 15 would be overlooked at this time. CHAIR BUNDE asked that Amendment 16 be moved. REP. B. DAVIS moved to adopt Amendment 16. Number 090 CHAIR BUNDE objected for discussion purposes. He asked Rep. Toohey if she cared to speak to the amendment. REP. TOOHEY said she would feel more comfortable if COMMISSIONER NANCY USERA addressed the amendment. Number 096 NANCY USERA, Commissioner, Department of Administration (DOA), said Amendment 16 deals specifically with insurance claims processing. She stated the department thinks it is conceptually a good idea to expedite matters, although she questioned if mandating these new requirements would be adding costs to the system. She pointed out that DOA's interest was in streamlining and while this amendment would be advantageous to consumers filing claims, she was uncertain as to the additional costs to insurers. She mentioned that the Division of Insurance and several Representatives were in the audience and could possibly address this issue. Number 110 CHAIR BUNDE acknowledged the presence of Commissioner Lowe. (Chair Bunde indicated that Rep. Olberg arrived at 3:16 p.m.) Number 115 DON KOCH, Marketing Surveillance, Division of Insurance, Department of Commerce and Economic Development, testified on HB 414. He expressed concern that cost was being added in the form of an interest payment. He further stated that he did not come prepared to adequately address these concerns. (the tape was somewhat indiscernible) Number 135 CHAIR BUNDE said he understood Mr. Koch's point that there was insufficient preparation time for a detailed analysis. He then asked Mr. Koch if he cared to comment on "enforcement" when an insurer does not pay and the insurance is due. Number 137 MR. KOCH responded that conjecturing was difficult because there was no track record in dealing with this sort of provision. He said he would refer to consumer complaints to see if there were any statistics on late payments, but he suspected that a lot of this information does not get reported. He said there are specific time frames that inform insurers how quickly they have to pay. Number 148 CHAIR BUNDE wondered if he was correct in assuming that enforcement would follow if a complaint was filed with the division. Number 150 REP. TOOHEY asked if 15 days seemed reasonable. She commented that it seemed to be unreasonably short especially if planes were not flying in or out of Juneau for several days, thereby leaving only about a week to process a claim. Number 153 MR. KOCH said there may be some requirements (indiscernible) and he apologized for not knowing more about these regulations. Number 174 REP. VEZEY asked why Alaska Statute 45.45.010 was adopted as the specified interest rate. He added that he thought this was an inappropriate rate. Number 181 DR. LEHMAN said he could not speak to that issue and was uncertain where the rate originated. Number 186 REP. VEZEY commented that 45.45.010 specifies a 10.5 percent fixed interest rate not compounded, and given today's market conditions, this is an inappropriate rate if equitable treatment is the objective. He said he thought the rate was more appropriate as a penalty measure. Number 190 DR. LEHMAN said he thought this rate was set as a penalty measure as there currently is no penalty for delayed claims. In reference to Rep. Toohey's earlier question, he clarified that "15 days" refers to paying a claim 15 days after a claim is received, not after services are provided. Number 205 REED STOOPS, Lobbyist, Aetna Insurance Company, testified in opposition to Amendment 16. He said in spite of the requirement for completion of the claim, this does not guarantee that all necessary information has been submitted to the insurer. He offered this as a possible explanation as to why it might take longer than 15 days to process a claim. He said according to his clients, more than 80 percent are paid within 15 days, but those that are delayed often lack the necessary information from the provider to justify the claim. He said the second problem with this amendment is that on the request of the client, Aetna makes payments by batches to large providers. He explained that the 15 day payment schedule might not mesh with a monthly batch payment schedule. The third problem he mentioned was that interest beginning on the 15th day at the rate cited by Rep. Vezey seemed unreasonable. He said he knew of no other state with a similar provision and added that this interest would be triggered even if the information necessary to make a judgement was not provided. DR. LEHMAN responded by pointing out that "the claim form must be fully completed." Number 240 GORDAN EVANS, Lobbyist, Health Insurance Association of America (HIAA), stated he associated with the comments made by Mr. Stoops, and thereby testified in opposition to Amendment 16. Number 249 REP. B. Davis asked that Mr. Stoops repeat the reasons for opposition to Amendment 16. She asked if he maintained opposition to the amendment given that it specifies that the claim form must be completed. Number 253 MR. STOOPS said he did not believe his statement was inaccurate and said, "In spite of the fact that the bill says that a claim form is fully completed doesn't necessarily mean that the information necessary to justify a particular claim is present. Line 16 on the claim form might be filled out, but it might not be filled out with enough information to justify a particular procedure which has been accomplished, and if the insurer then comes back and says `we don't think you have given us the information that is required under our contract' there could be a dispute about whether the claim form has been completed." MR. STOOPS said this discussion was about terminology, but it would be better if the amendment was clarified to indicate that the information necessary to make the decision was available. Number 265 REP. B DAVIS agreed that perhaps modifications should be made to include the language Mr. Stoops used. She said she understood that just because pages on a form were completed, this does not guarantee that the necessary information has been included. She asked if this would be acceptable to Mr. Stoops. Number 270 MR. STOOPS said this would address the problem relating to subsection (b), but the other two concerns would remain. He restated those other concerns as: 1) an inconsistency between monthly batch payments and the 15 day billing period and 2) interest accruing on the 15th day as being an unreasonable provision. Number 282 CHAIR BUNDE said he would like to give the Division of Insurance more time to respond to this amendment, so with the concurrence of Rep. B. Davis, he would table this amendment until the next hearing of HB 414. Chair Bunde indicated that with the presence of Rep. Olberg the committee could now address Amendment 15. Number 290 REP. OLBERG moved Amendment 15. He mentioned there might be cross-reference problems because the amendment relates to the 3/11/94 version of the work draft rather than the 3/14/94 draft. CHAIR BUNDE objected for discussion purposes. REP. OLBERG said the amendment takes the health commission out of the rate approval business and out of the rate review business as well. Number 304 COMMISSIONER USERA said this amendment does two things: 1) it removes any review or relationship to insurance rates from the commission and places it with the Division of Insurance and 2) it dilutes the rate approval authority because the only requirement is that rates be filed with the division. She said the implications of this would be a reduction of the fiscal note associated with the rate review process and would probably, depending on regulatory requirements, effectively allow for the collection of additional data that is presently unavailable to the state. Number 326 REP. G. DAVIS mentioned this would not preclude the authority from establishing a subcommittee to review rates or anything else related to insurance. Number 334 COMMISSIONER USERA said she saw no provision requiring the Division of Insurance to provide any of this information to the commission, and further stated she did not know what confidentiality constraints were being placed on this information. She said as a practical matter her preference would be that the division put together aggregate information and report that to the commission. Number 354 REP. OLBERG said if rates were going to be regulated, then either everybody's rates or nobody's rates should be addressed, and this indicates that nobody's rates are going to be regulated. Number 357 REP. TOOHEY said basically this leaves it as status quo in that there is no regulation now. Number 362 CHAIR BUNDE asked to hear from the Division of Insurance on Amendment 15 and on the fact of current regulation. Number 364 BARBARA THURSTON, Actuary, Division of Insurance, Department of Commerce and Economic Development, testified on HB 414. She stated that currently the division does not regulate rates for most medical or disability insurance. She said that the only disability company they receive rate filings from is Blue Cross. She pointed out that this amendment would strengthen that situation and they would receive rate filings from other companies as well. She said this amendment would give the division more authority, but her concern was that it does not have any teeth in that if someone files an inappropriate rate, there is not much recourse from the division other than providing consumer information. Ms. Thurston wanted to clarify something from the previous week's testimony and she explained that companies do not file specific rates for each person because rates are set according to a formula. Number 390 CHAIR BUNDE asked if all kinds of insurance was handled in the same way. Number 395 MS. THURSTON said the division both reviews and approves for most of the property casualty. REP. TOOHEY asked how many carriers were used for auto insurance. Number 401 MS. THURSTON said a dozen do the vast bulk of the market. She said a lot of companies file but may not write. She added that they want to be able to write in all 50 states. REP. TOOHEY asked if that information was brought to the awareness of the public. She asked how to go about choosing the best auto insurance. Number 405 MS. THURSTON said there are two ways: 1) one could dig through the files which contain public information on rate filings, or 2) the division publishes auto and homeowners' rate comparisons twice a year and distributes the publication to various consumers throughout the state. CHAIR BUNDE commented that an informed consumer would shop around and call several agents. Number 415 REP. TOOHEY asked if this same sort of thing would be done with health insurance. Number 417 MS. THURSTON said this certainly could be done with health insurance and it seemed like a reasonable thing to do. She said if the division received rates on disability there would be a good chance of doing it. Number 420 REP. TOOHEY asked if consumers would be able to understand the ratings information. Number 422 MS. THURSTON explained that with the auto publication, which is analogous, the rates are based on fictitious scenarios. She explained that this gives a person an idea of which companies would have the best rates for a situation which approximates one's own specific situation. She added that a consumer could then call the agents of those companies. Number 434 CHAIR BUNDE asked about distribution of the auto insurance publication. Number 436 MS. THURSTON said a booklet called "Rating Examples" is published and mailed to anyone interested who is on the mailing list. (Chair Bunde indicated that Rep. Brice arrived at 3:40 p.m.) CHAIR BUNDE asked for further public testimony on Amendment 15. Number 455 MR. STOOPS referred to a chart, previously provided, which illustrated how other states regulate health insurance. He summarized and said eight states do not regulate at all, six states have a prior approval system requiring the division's approval before implementation, and the remaining states have a file and use system similar to the one proposed under this amendment. He pointed out that Alaska would move from having no regulation to having more mainstream regulation. He also stated that 90 plus percent of the claim dollars pay for medical fees and therefore regulating health insurance rates really addresses a small percentage of the problem and certainly does not address the lion's share of the cost. He mentioned an equity issue of regulating both insurance rates and provider rates if the object is to reduce costs. Mr. Stoops endorsed approval of Amendment 15. Number 479 MR. EVANS associated with the comments made by Mr. Stoops. He said this particular amendment approximated procedures used by Idaho, Montana, and several other western states. Number 487 JERRY REINWAND, Lobbyist, Blue Cross of Washington and Alaska, said he agreed, thereby testifying in support of Amendment 15. Number 493 CHAIR BUNDE said one concern previously expressed was the passing on of this information. He asked Rep. Olberg if there was an interest in having some indication in Amendment 15 that the division, when finished with its work, would pass information on to the health commission. Number 499 (Chair Bunde indicated that Rep. Kott arrived at 3:45 p.m.) TAPE 94-57, SIDE B Number 068 COMMISSIONER USERA referred to Sec. 44.19.626 page 15, line 19, and said the commission may obtain information from a wide variety of people who must provide it, and obviously the Division of Insurance would be one of those entities. She said the commission would require through some regulatory process that the division provide the information in an appropriate form. Number 082 REP. G. DAVIS added that page 13, line 4, reads that the purpose of the commission is to improve health care in this state by "establishing and implementing a system for collecting and analyzing information and data relating to the individual and public health care needs of and services provided to residents of the state." Number 085 REP. TOOHEY stated her support of Amendment 15 and said, "The thicker this gets the less chance it has of going anywhere... and I kind of like this sort of a step backward." Number 094 CHAIR BUNDE thanked Rep. Toohey for her support. Chair Bunde asked for further public testimony on Amendment 15. Hearing none, Chair Bunde closed public testimony on Amendment 15. (Chair Bunde took a brief at-ease from 3:48 to 3:50 p.m.) CHAIR BUNDE noted that Amendment 15 was before the committee, withdrew his previous objection and asked for the pleasure of the committee. Number 112 REP. B DAVIS moved Amendment 15. Number 113 CHAIR BUNDE indicated that Amendment 15 had been previously moved by Rep. Olberg. He asked if there were any objections. Hearing none, declared that Amendment 15 was so adopted. CHAIR BUNDE directed the committee's attention to Amendment 17 and asked Rep. Toohey to move the amendment. REP. TOOHEY moved to adopt Amendment 17. REP. BRICE objected to the amendment. REP. TOOHEY asked that DR. LEHMAN and COMMISSIONER USERA speak to this amendment. Number 127 CHAIR BUNDE said he realized DR. LEHMAN had previously spoken to this issue and asked if he would give a summation. DR. LEHMAN said the proposal combines the efficiency of a single payer system with the economic reality of a market driven system. (the tape was indiscernible at this point) CHAIR BUNDE, in response to Dr. Lehman's comment, noted for the record that not one bureaucrat smiled at the mention of the phrase "single payer" and suggested that perhaps they were restraining their glee. He asked Commissioner Usera if she cared to comment on Amendment 17. Number 144 COMMISSIONER USERA stated her appreciation of Dr. Lehman's comments and said her concern with this amendment was that it was very specific and that if any of the provisions were to drop out it would significantly change the definition. She suggested, on line 3, the deletion of "including provider defined fees" and the insertion of "and may include." Number 163 DR. LEHMAN said he had no objection to Commissioner Usera's suggestion. Number 166 CHAIR BUNDE, in response to Commissioner Usera, acknowledged that in previous discussions there was no hidden agenda with the inclusion of "single payer." Number 171 REP. BRICE asked for clarity on this issue, and after some discussion commented that the terminology of "market based single payer" was as confusing as saying "competitive monopoly." Number 189 REP. TOOHEY said possibly Dr. Lehman could address the issue of using the phrase "market based single payer." Number 196 DR. LEHMAN said his basic understanding of positioning the phrase "market based" with the phrase "single payer" was that there would still be one payer involved, although market forces would come into play as providers would be required to quote their fees. Patients would still elect to choose any provider that they wanted, recognizing that certain providers might be charging different fees for those same services. Number 218 COMMISSIONER USERA responded to Rep. Brice by asserting that "market based single payer" is a coined phrase. She said it is the moniker that has been placed on the primary comprehensive reform bill that has been introduced, and is meaningful within the current context only. Number 240 CHAIR BUNDE asked if there was any further discussion on Amendment 17. Seeing none, he closed public testimony and brought the amendment to the attention of the committee. Number 244 REP. B. DAVIS asked if including a definition section on "market based single payer" would be an improvement. After some discussion, she was informed that a definition was included in the amendment. Number 261 REP. OLBERG brought up the spelling of "payor" and "payer," noting that "payor" was not located in the dictionary. Number 273 CHAIR BUNDE commented that the question before the committee involved addressing whether or not "single payer" was as bad as some people thought "single payer" might be. Number 280 REP. TOOHEY stated her support of the amendment and of striking the phrase "single payer" and using the phrase "market based." Number 285 CHAIR BUNDE asked for the pleasure of the committee. He confirmed that Rep. Brice maintained his objection. Chair Bunde stated that there had been an amendment to the amendment so that line 3 of the second section of the amendment would read, "is based on market forces and may include" as opposed to "including." Number 296 REP. TOOHEY moved to move the amendment to the amendment. CHAIR BUNDE acknowledged that the amendment to the amendment had been moved and asked for further discussion. Number 298 REP. BRICE said his major concern was that the language had been watered down with "mays" instead of requirements. He stated this was the reason for his objection to the amendment to the amendment. Number 304 CHAIR BUNDE called for the vote on the amendment to the amendment that refers to the use of the term "may." Reps. Toohey, Bunde, Vezey, Kott, and Olberg voted "Yea" and Reps. G. Davis, B. Davis, Nicholia and Brice voted "Nay." CHAIR BUNDE declared that Amendment 17 in its amended form was now before the committee. He confirmed that Rep. Brice wished to maintain his objection and called for the vote. Reps. Bunde, G. Davis, Vezey, Kott, Olberg and Toohey voted "Yea" and Reps. B. Davis, Nicholia, and Brice voted "Nay." Chair Bunde stated that Amendment 17 as amended was so moved. CHAIR BUNDE directed the committee's attention to Amendment 18 and asked Rep. B. Davis to move the amendment. Number 326 REP. B DAVIS moved to adopt Amendment 18. CHAIR BUNDE objected for discussion purposes and asked Commissioner Usera for comment. Number 335 COMMISSIONER USERA spoke in support of this amendment, saying it was good consumerism in that it requires disclosure and is designed to be very specific so consumers would consequently have a clearer idea of what would and would not be included in their insurance policy. Number 344 CHAIR BUNDE said he would like to hear from the Division of Insurance. Number 345 MS. THURSTON said the division supports this and theoretically this is already being done in policy form, but not every consumer reads the policy. Number 356 REP. G. DAVIS said he has seen this in policies, but it is in legalese and very small print. Number 360 REP. TOOHEY agreed with Rep. Davis that this would promote consumer confidence but then asked what the cost would be. Number 365 MS. THURSTON responded that if this refers to a separate disclosure form provided by the insurance company, there would be an additional cost to the insurance company. She said she did not know what the cost would be. Number 371 CHAIR BUNDE observed that clarification was needed as to whether this was going to be provided by the state or by the insurance company. Number 376 MS. THURSTON said the division would probably need more specific authority in the statute if it was going to prescribe the format of this disclosure statement. She said the way it is written each insurance company designs its own statement. Number 384 REP. G. DAVIS commented if this was going to be left to the commission's discretion, then the amendment should be left as is. Number 393 CHAIR BUNDE closed public discussion on Amendment 18 and asked if there was further debate in the committee. REP. TOOHEY moved Amendment 18. CHAIR BUNDE observed that the motion had been made and he removed his objection. He asked if there were any objections. Hearing none, Chair Bunde stated that Amendment 18 was so adopted. CHAIR BUNDE brought Amendment 19 to the committee's attention. REP. B. DAVIS moved Amendment 19. CHAIR BUNDE objected for discussion purposes and asked for Rep. B. Davis's presentation of the amendment. Number 448 REP. B. DAVIS referred to page 16, line 10, and after considerable discussion about the exact location, Rep. B. Davis said she wanted to insert the language listed. Number 450 CHAIR BUNDE asked Commissioner Usera for further comment on the amendment. Number 454 COMMISSIONER USERA said this was part of subsection (b) where it says "the commission shall" and it adds two additional mandates, one is the incentive program bringing incentive providers to the state and the other is establishing advisory committees to make recommendations on cost containment. She referred to subsection (9) and said it was her understanding that cost containment had to be part of a comprehensive plan, but as this is premised the commission's analysis would be on packaged plans presented to the commission as opposed to the commission taking bits and pieces. She said she didn't necessarily object to establishing an advisory committee on cost containment, although she would prefer to have this under the "may" section because it is not necessarily a primary responsibility. She referred to (8) and said there had been a number of programs discussed in attempts to attract providers and they had all been costly. She said her understanding was that this refers to the design of an incentive program, not necessarily the implementation of that program. She stated again that her preference was to have this under the "may" section rather than the "shall" section because the resources were not available to the commission to do all of this and doing so would initially add significantly to the fiscal note. Number 486 REP. TOOHEY asked if "may" could be added in or after subsection (9). Number 489 COMMISSIONER USERA referred to page 15, subsection (a), where it reads, "the commission may" and clarified this would be subsection (4) and (5) of that provision as opposed to subsection (b) which reads, "the commission shall." Number 493 REP. G. DAVIS said paragraph (9) seemed to reemphasize what was inserted under the public health initiative and asked Rep. B. Davis for comment. Number 500 REP. B. DAVIS said everything under the public health section says "may" and this says "shall." Number 502 REP. G. DAVIS said these items seem to fit under the purview of the public health aspects and after considerable discussion he pointed out to Rep. B. Davis that subsection (9) seemed like a duplication. TAPE 94-58, SIDE A Number 020 REP. B. DAVIS said after more discussion that she would be willing to delete subsection (9). Number 023 CHAIR BUNDE said the committee could amend the amendment. REP. G. DAVIS moved to amend Amendment 19 by deleting paragraph (9). CHAIR BUNDE asked if there was any objection. REP. BRICE objected and asked for further clarification. CHAIR BUNDE asked Rep. G. Davis for comment. Number 033 REP. G. DAVIS said paragraph (9) appears to contain the cost of health care to include the public health initiatives. He added that he considers these to be general duties and inclusions of a public health policy. Number 038 CHAIR BUNDE then referred Rep. Brice to page 16. Number 040 REP. BRICE said he understood and withdrew his objection. Number 041 CHAIR BUNDE said the amendment as amended includes paragraph (8) only as (9) had been deleted. Chair Bunde mentioned that the student loan program was still operating at a deficit and could not afford a forgiveness program. He also pointed out that it would cost half a million dollars a year to establish a family residency program in Anchorage. He said the question is, "Do we want to encourage them to do something that is probably not likely to be funded?" Number 050 REP. G. DAVIS said he liked the amendment and thought that the inclusion of a student loan forgiveness program would shoot the amendment down. REP. B DAVIS acknowledged there were some problems with the health care program, but said she did not know why the comparison was being made between the two and asked for further clarification. Number 067 REP. TOOHEY said her understanding was that it had been suggested to delete "a student loan forgiveness program" because "that, in itself, was unacceptable." Number 072 REP. G. DAVIS responded to Rep. B. Davis and said he thought this was perceived as money outlay with no return and thought this would be detrimental to the amendment. Number 079 CHAIR BUNDE said his objection was not in reference to the notion of student loan forgiveness but that the student loan program currently operates at a deficit and any forgiveness program would increase that deficit. He restated that the proposed residency program would cost half a million dollars per year and he was not sure this was a justifiable expense. He asserted that this amendment was intended to design a program and does not fund or mandate a program. He said it could be assumed that the student loan forgiveness program relates to primary care providers even though it is not explicitly stated. Number 092 COMMISSIONER USERA asked if this was an assignment for the commission itself and not its public health committee. She noted that this really seemed like a public health matter of having adequate health providers in the state and she questioned if this would be better handled by the public health committee. Number 107 REP. B. DAVIS said she thought the role of the commission was to be responsible for overseeing all of this. She said this amendment was designed to work specifically with bringing in incentives that would allow other primary care providers to come to Alaska. Number 118 COMMISSIONER S. USERA said she was addressing where this would best fit in the bill. She referred to page 15 and read, "established a public health advisory committee," and on the bottom of page 16 she read, "includes (a) analysis, (b) assessment, (c) delineation, (d)documentation, (e)identification, and (f) recommendations..." She said the phrase, "a program to give incentives to primary care providers" might be inserted under (f) where it says "pertaining to the following." Number 137 REP. B. DAVIS agreed with Commissioner Usera that this probably could fit. CHAIR BUNDE asked Rep. B. Davis if she would consider ending the amendment after the phrase in section (8) that reads, "underserved areas of the state." Number 142 REP. B. DAVIS said this did not go as far as she would like, but "sometimes half a loaf is better than none" and said she would consider this. Number 148 CHAIR BUNDE said with the given modification he would consider supporting the amendment. Number 149 REP. VEZEY asked, "If we want to provide incentives, why don't we just pay them more money?" Number 151 CHAIR BUNDE replied by saying, "That's premiums on prices." He indicated that premiums on prices for health care providers translates into regulating rates. Number 155 REP. VEZEY said it seemed like the rates being offered would not attract providers, so other forms of compensation would have to be designed. Number 160 CHAIR BUNDE responded that the reason rural and underserved areas are underserved is not based entirely on price. He said it also has to do with where people choose to live. Number 165 REP. B. DAVIS said she wanted to amend the amendment according to Chair Bunde's and Commissioner Usera's suggestion. Number 169 COMMISSIONER USERA clarified this was on page 17, line 17, subsection (v), under the "may" section but is included in the task of the public health commission under the section (f) that reads, "recommendations, including recommendations for specific legislative action when necessary, pertaining to the following." Number 177 REP. TOOHEY asked if the phrase "student loan forgiveness program" was removed. Number 179 CHAIR BUNDE responded that everything after "underserved areas of the state" was being removed. CHAIR BUNDE stated that the amendment to the amendment deletes everything in section (8) beginning with the word "incentives." REP. B. DAVIS read, "...design a program to give incentives to primary care providers to practice in the state, especially in rural and underserved areas of the state." Number 188 CHAIR BUNDE asked if there were any objections. Hearing none, the amendment to the amendment passed. Chairman Bunde stated that Amendment 19 as amended was before the committee. He identified the location on page 17, line 17, section (v) and asked if there was any further objection. Hearing none, the amended Amendment 19 was so moved. CHAIR BUNDE brought the committee's attention to Amendment 20. REP. B. DAVIS moved to adopt Amendment 20. CHAIR BUNDE indicated that the amendment had been moved and objected to and asked Rep. B. Davis for comment. REP. B. DAVIS said "the amendment speaks for itself" and indicated that if there were any objections she had no compromise to make and so therefore stated that she would like for a vote to be taken on the amendment. Number 212 CHAIR BUNDE asked Commissioner Usera if this would impact the fiscal note. Number 213 COMMISSIONER USERA spoke in opposition to the amendment. Number 215 REP. B. DAVIS asked if the administration would accept "five" instead of "three." She said she did not think three people would be able to manage the workload and asked for a recommendation from the administration regarding this. Number 220 COMMISSIONER USERA said the administration's concept was that three people would direct the work of the commission and a support staff would be available to do much of the day-to-day analysis. Number 226 REP. B. DAVIS maintained that she wanted the amendment to be voted on and she encouraged committee members to do what they thought was best and to vote in favor of the amendment. Number 231 REP. BRICE moved that an amendment to the amendment be made by changing Step "C" to "A" and Range "26" to "10" on page 14, line 28. Number 256 REP. OLBERG said his fiscal note indicated nine employees and $150,000 worth of technical and legal assistance. CHAIR BUNDE said there was an amendment to the amendment. After hearing an objection from Rep. Toohey, Chair Bunde called for the vote. Reps. Kott and Brice voted "Yea" and Reps. G. Davis, Vezey, Olberg, B. Davis, Nicholia, Toohey, and Bunde voted "Nay." CHAIR BUNDE stated that Amendment 20, which would increase the members of the commission to five and further define the membership of the commission, was before the committee. There being no further discussion, Chair Bunde called for the vote. Reps. B. Davis, Nicholia, and Brice voted "Yea" and Reps. Vezey, Kott, Olberg, Toohey, Bunde, and G. Davis voted "Nay." Chair Bunde declared that Amendment 20 failed to be adopted. CHAIR BUNDE, indicated that Amendment 21 had been moved and asked Rep. B. Davis address the amendment. Number 286 REP. B. DAVIS referred to page 22, line 2, and said this would delete "(a)" and would also delete all material on lines 14-16 on page 22. Number 293 COMMISSIONER USERA said the administration received a letter of opinion from the Department of Law in response to Mr. Michael F. Ford's comments. Her recollection of his testimony was that there was a problem with the Governor getting involved with the legislators' purview. She stated that, in essence, the letter received says that because of the nature of the work of this commission, they do not know when a plan is going to be available for analysis and to have to go back to the legislature for a specific extension authority would not be very cost or time effective. Furthermore, one of the primary purposes of this commission is to provide management and implementation analysis for plans as they are presented and at this time it is not known, for example, when the primary federal plan is going to be firm enough to be workable. The idea here is that the Governor would have the authority to extend the deadline for making that report. She said the administration would certainly be amenable to making that more explicit but as a practical matter having to come back to the legislature just to say that the deadline has not been met does not seem to work very well. Commissioner Usera noted that the letter had been made available that day. Number 321 REP. B. DAVIS said even with the letter, the language needs to be more explicit. She further stated that she did not quite see the validity of taking authority away from the legislature and giving it to the Governor, based on the possibility that there might be some difficulty with meeting the deadline. She added that the window would be more than seven months and could possibly be one or two years. Number 328 COMMISSIONER USERA said they would be happy to talk about crafting something more narrow. She suggested that perhaps it was because she was sued so often for not meeting deadlines that she was particularly sensitive to providing some flexibility. She again suggested that the letter be taken into account and that crafting something more narrow be looked into. Number 336 REP. B. DAVIS withdrew her objection. Number 337 CHAIR BUNDE brought Amendment 22 to the attention of the committee and asked Rep. B. Davis to address the amendment. Number 340 REP. B. DAVIS moved the amendment and explained that the date for the forms to be completed was set at July 1, 1995. Number 348 CHAIR BUNDE asked Commissioner Usera for comment. Number 349 COMMISSIONER USERA deferred to the Division of Insurance. Number 352 MS. THURSTON said she was unsure of the time lines involved and that the division would probably receive relevant information from one of the national organizations working on uniform claim forms. She added that although she was unsure, she thought this timing sounded reasonable. Number 359 REP. TOOHEY said she had inquired at the Division of Insurance about this specific time line and the deputy commissioner said this time line was too close and that June 30, 1995, was the date suggested as being most comfortable. Number 363 MS. THURSTON said the deputy director arrived... (indiscernible). Number 371 REP. TOOHEY withdrew her objection after it was pointed out that the difference between June 30, 1995, and July 1, 1995, was only one day. Number 373 COMMISSIONER USERA said there was not a big objection to this time frame, it seemed reasonable, and the division had avoided a specific time frame because they were waiting to see the national standards. She said the division found this as an acceptable amendment. Number 382 CHAIR BUNDE asked if there were any objections to Amendment 22. Hearing none, Amendment 22 was so adopted. Number 384 CHAIR BUNDE indicated that Amendment 23 was before the committee. REP. B. DAVIS moved Amendment 23 and said she would like to delete "may" and insert "shall" on page 16, line 11. REP. TOOHEY objected. Number 398 COMMISSIONER USERA mentioned there had previously been extensive discussion on this and a compromise had been struck that the commission not be mandated but be allowed discretion. She said, therefore, the administration believes the wording is appropriate as it is. Number 405 CHAIR BUNDE asked for further discussion. Hearing none, Chair Bunde called for the vote. Reps. B. Davis, and Nicholia voted "Yea" and Reps. Kott, Olberg, Toohey, Bunde, G. Davis and Vezey voted "Nay." (Indiscernible regarding Rep. Brice - the voting record showed that he did not vote.) Chair Bunde stated that Amendment 23 failed to be adopted. CHAIR BUNDE noted that the next meeting on HB 414 was scheduled for Wednesday, March 23, and Rep. Brice would have an amendment at that time. Chair Bunde said he intended to move HB 414 from the HESS Committee at that time. Number 419 REP. B. DAVIS asked if another witness from insurance would address Amendment 16. Number 424 CHAIR BUNDE confirmed that Amendments 16 and 24 would be addressed. Number 426 REP. B. DAVIS requested that there be further clarification from the administration as to the exact workings of this bill. Number 431 CHAIR BUNDE said the current working draft committee substitute would be available to the committee members before the next meeting to allow for further study. Seeing no further business before the committee, CHAIR BUNDE adjourned the meeting at 4:55 p.m.
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