HB 211 - HEALTH CARE INSURANCE Number 0273 CHAIRMAN KOTT announced the next item of business would be a continuation of the hearing on HOUSE BILL NO. 211, "An Act relating to liability for providing managed care services, to regulation of managed care insurance plans, and to patient rights and prohibited practices under health insurance; and providing for an effective date." Chairman Kott noted that Bob Lohr of the Division of Insurance was online to answer questions. He then requested a subcommittee report on Version N [adopted as a work draft 3/31/00]. Number 0305 REPRESENTATIVE GREEN offered a subcommittee report. He informed the committee that legislative staff members Janet Seitz and Kevin Jardell had "allowed the legislators to go about their business" while they met with members of both the doctors' group and the insurance group. As a result, they had ironed out all differences with the exception of the medical necessity and liability provisions. There is now a revised draft, Version S [1-LS0472\S, Ford, 4/5/00], upon which changes from Version N have been highlighted for committee members. Representative Green offered to quickly review the changes, then concluded by saying he sees nothing that adversely affects the state. Number 0428 REPRESENTATIVE MURKOWSKI added that Version S has no reference to medical necessity or liability provisions. Those have not been incorporated anywhere in the draft, he concluded. Number 0450 CHAIRMAN KOTT summarized, saying all of the issues have been resolved with the exception of the two on which consensus could not be reached, and that the bill had been brought back before the committee to address those policy issues. REPRESENTATIVE GREEN explained that when the subcommittee had reconvened and gone through the other changes, there was further debate on those two unresolved issues. "We did not see any movement," he said. "They both have good reasons for why they feel the way they do." The subcommittee finally had decided to simply leave the two contentious issues out of the draft, he concluded. Number 0520 REPRESENTATIVE KERTTULA brought attention to a letter that the committee had received via fax from Mr. Burgan expressing concern about not having been heard. She wondered if the two contentious issues are mostly the ones about which Mr. Burgan is concerned. REPRESENTATIVE ROKEBERG noted that he was planning to bring that up after the committee had adopted the work draft. CHAIRMAN KOTT thanked the subcommittee for its work and suggested adopting the work draft generated by the subcommittee. Number 0574 REPRESENTATIVE GREEN made a motion to adopt Version S [1-LS0472\S, Ford, 4/5/00] as the working document before the committee. There being no objection, it was so ordered. Number 0620 REPRESENTATIVE ROKEBERG directed attention to page 5, lines 18-23, of Version S. He noted that there had been discussion in the subcommittee relating to whether the Director of Insurance has authority under AS 21.390.20(b)(2) relating to the "non- hospital/medical service corporations," which are required to file their rates with the commissioner. Other health insurance companies are not required to file, he noted. The statute he had cited allows the commissioner to "come in and review things as necessary." At the subcommittee's request, he indicated, the Office of the Attorney General had provided a letter dated April 6, 2000; it says that while there is possibly the ability, there is no express authority to routinely review those rates. In light of that, Representative Rokeberg suggested returning to the old language that said the Director of Insurance, at the director's request, could require the managed care entity to provide actuarial demonstration of the increased cost. Number 0753 REPRESENTATIVE ROKEBERG thanked subcommittee members for their "Herculean job." He expressed pleasure with the resulting product, whatever its limitations. He said it is a matter of reality and what can be achieved. He also thanked members of the insurance industry, the medical association and other groups including organized labor that had participated in or observed the process over the past two weeks. Representative Rokeberg again pointed out that the subcommittee had left open the two primary issues, regarding medical necessity and liability. He said he is open to whatever the committee wishes to do on these issues, but isn't too optimistic that they can come to grips with them in a manner that would satisfy everybody. Number 0847 REPRESENTATIVE ROKEBERG returned to the issue Representative Kerttula had raised, two letters from Brady & Company, dated April 3 and April 6, signed by Mr. Ed Burgan. Of the two, he believes the one dated April 3 is the more important; it indicates Mr. Burgan had been available to testify before the committee on Friday, March 31, but was not given a chance to testify. Representative Rokeberg said Mr. Burgan has been fighting this bill and has been unresponsive to requests for information from the outset. He himself takes exception to Mr. Burgan's statements and to language used in the subsequent letter regarding the committee. However, he believes that points in the April 3 letter are appropriate to bring to the committee's attention. CHAIRMAN KOTT announced a brief at-ease at 2:51 a.m. After copies of the letters were distributed, he called the meeting back to order at 2:57 p.m. Number 1010 REPRESENTATIVE ROKEBERG, at Chairman Kott's request, commented on Mr. Burgan's first letter. Apparently, the committee had closed testimony and sent the bill to a subcommittee without being aware that Mr. Burgan was available to testify. Representative Rokeberg then presented the salient points in Mr. Burgan's first letter. The first relates to mitigating conflicts with the Employee Retirement Income Security Act (ERISA), with the suggestion of incorporating language that this [HB 211] would not supersede provisions of ERISA. Representative Rokeberg commented that these people complaining about the bill are not covered by the bill because they "are ERISA," unless there is federal law or state case law that says that the qualitative elements of any health care legislation can be applied to them. They want to make sure that they are exempt by putting this in the bill, he concluded. He added that he finds that incredible, on its face. Number 1103 REPRESENTATIVE CROFT asked if it matters. REPRESENTATIVE ROKEBERG said it does. He thinks it is appropriate, on quality care issues, to hold everyone to the same standard. REPRESENTATIVE CROFT observed, "We can't supersede ERISA if we wanted to. And if we're ... in conflict with it, we'd be in conflict with it and superseded it. So, 'infringe upon' is the only one that works here?" REPRESENTATIVE ROKEBERG responded that there is case law saying that the states are able to "stick their nose under the tent" on qualitative issues, and there may be provisions in federal law that specifically would allow the state to do that. This is related to the primacy of the state in regulating and selling insurance, which is very important. He agreed it could be called "encroaching on ERISA," but said that is going to be a matter of case law, and nothing can be done legislatively to force that issue, to his belief. However, those people are seeking protection against that. Number 1187 REPRESENTATIVE ROKEBERG noted that Mr. Burgan's second point was objection to the "three levels of appeal" in the internal and external utilization review. He said he isn't sure that Mr. Burgan entirely understands that. As it is structured, there are two internal reviews and one external review. The first internal review is the first phone call; the second level is the actual "72- hour and/or ... 18-day appeal"; and the next one is external review. Perhaps there should be a "shorthand" method put in place there, Representative Rokeberg added, but he doesn't think so. REPRESENTATIVE ROKEBERG turned attention to Mr. Burgan's third point, which speaks to medical necessity. He told members he tends to agree with what Mr. Burgan has to say: there needs to be a definition of medical necessity, but not in statute. It needs to be in the plan, to guide the plan about what is included and what is excluded from the benefits in each particular plan, and each plan is going to vary. Representative Rokeberg noted that this is at odds with what the medical association says. However, there has been discussion in the subcommittee about allowing medical necessity but putting some kind of fence around it, to have a cost- containment measure in there. In his own opinion, the AMA [American Medical Association] definition is "any willing provider," which is totally unlimited; although language indicates cost alternatives or containment in scope, it isn't entirely required. REPRESENTATIVE ROKEBERG reported that Mr. Burgan's fourth point is disagreement with who is included in the definition of a managed care entity. Representative Rokeberg said that is a central definition in the bill; Mr. Burgan's objections relate to the definitions of what an employer and employee health care organization is. He surmised that Mr. Burgan does not want the definition to include the organizations he represents, and Representative Rokeberg suggested that, indeed, the definition does include them. "On the other hand, he does have the ERISA fence around [them]," Representative Rokeberg added. "But if there was a non-ERISA group, which is ...." He asked Gordon Evans the definition of an ERISA group. Number 1396 GORDON EVANS, Lobbyist for the Health Insurance Association of America, suggested it is simply a group that is self-insured. REPRESENTATIVE ROKEBERG noted that the fifth point in Mr. Burgan's letter questions Representative Rokeberg's reasons for taking up the bill. He pointed out that the two letters from Mr. Burgan maintain a negative position on the bill because the suggestions provided had been ignored. Representative Rokeberg suggested it is important that the committee consider those letters. Number 1458 CHAIRMAN KOTT asked if any of the issues raised in the two letters were addressed in Version K of the bill [which had passed out of the House Labor & Commerce Committee as CSHB 211(L&C)]. REPRESENTATIVE ROKEBERG answered that the external review had been an ongoing drafting project for more than a year, and the issue of medical necessity is "on everybody's radar scope." He said he thought he had explained the ERISA matter. Regarding the managed care entity, he assumes that they [Mr. Burgan and associates] would like to have the words "employer" and "employer health care organization" removed from the bill so it would not include them. Number 1515 REPRESENTATIVE ROKEBERG said he thinks the medical necessity argument has merit in terms of its substance. "It's how we get there that's the issue," he added. Number 1524 REPRESENTATIVE CROFT expressed a desire to discuss the substantive issues that remain: whether medical necessity and liability will be in the statute or out. The insurance plan determines what conditions are covered, he noted, but the question with which the committee has to struggle is whether the treatment for that covered condition can be determined by the insurance company or by the doctors. Number 1630 CHAIRMAN KOTT thanked Representative Croft and said that is exactly what he intends to do. However, because of concern about whether Mr. Burgan had had an opportunity to testify, he thought the committee had needed to hear the points Mr. Burgan had forwarded to the committee in his first letter. Chairman Kott agreed that the committee needs to determine what direction to take with two major issues. He asked whether it was the will of the committee to leave "medical necessity" undefined or to define it using the language provided in the AMA version, Version K [CSHB 211(L&C)]. He offered his opinion that the AMA definition is unconstrained, too broad. Two other definitions had been provided to the committee from other states, he noted. Number 1706 REPRESENTATIVE MURKOWSKI explained that the subcommittee had not focused much attention on the second issue, liability, because they had reached an impasse on medical necessity; rather than spend a lot of time reaching an impasse on liability also, they didn't hear much from either side on it. However, one point raised by the insurance companies was that a liability provision may come out of federal legislation in progress now; it might be prudent to hold off on adopting a liability provision now and revisit the issue next year, Representative Murkowski suggested. Number 1773 REPRESENTATIVE ROKEBERG noted that subcommittee discussion had included the observation that under common law, if a cause of action arises against a provider, a person is not restricted in filing a lawsuit. What the liability language in Version K does is create a new cause of action. He thinks it is easier to define the cause of action if there is a failure to provide, he said, the theory being that the plan itself should be held responsible if it [its administrators] make the medical decisions. If the patient were denied coverage and there were an issue about that, that would give rise to a cause of action. There may be some difficulty under tort law drafting that pleading without a statutory cause of action, Representative Rokeberg said, adding, "I don't think that any patient is necessarily going to be deprived of their right to sue by not having a liability section [in HB 211]." He suggested the liability section just makes it easier to sue. Number 1850 CHAIRMAN KOTT announced that because the committee had been discussing liability, they would proceed with that topic. He noted that the relevant language is contained in Section 2 of Version K. REPRESENTATIVE CROFT read in part from Section 2 of Version K, which stated: (b) A managed care entity is civilly liable for damages for harm to a covered person (1) proximately caused by its failure to exercise ordinary care; or a health treatment decision that constitutes a failure to exercise ordinary care .... REPRESENTATIVE CROFT said that is codifying the standard under which everyone operates in everything. One has to use reasonable care toward people to whom one owes a duty, and one clearly owes a duty to the people for whom one is caring under a managed care plan. Although Representative Rokeberg had said it does not change anything, Representative Croft said he thinks it clarifies that managed care providers have a duty to act with ordinary care toward these people. Number 1964 REPRESENTATIVE CROFT made a motion to adopt Amendment 1, to incorporate Section 2 from Version K into Version S wherever appropriate. Number 1974 REPRESENTATIVE ROKEBERG objected. He explained that he would prefer not to include the liability language because it is a "cost driver" and establishes a new cause of action. He stated: What we get down to eventually, what the judge would do, would get back to the same thing we are discussing here. The ordinary care standard would be placed beside medical necessity to determine whether ordinary care had been provided, and they're all wrapped together. A judge could not say that the provider was or was not providing the ordinary standard of care without being able to define what medical necessity was, because that would be the argument. Number 2060 REPRESENTATIVE KERTTULA asked if anyone could give her an example of how liability would be approached now. REPRESENTATIVE ROKEBERG answered that if somebody had suffered damages as a consequence of being denied something like an experimental drug, there could be a cause of action saying that someone should have done something or should not have. He added, "I think you can do that now and . . . there's no statutory medical necessity." REPRESENTATIVE KERTTULA asked if including liability language would be just a codification of what the law is now. Number 2098 REPRESENTATIVE MURKOWSKI responded that it has to result from the failure to provide care or treatment covered by the health care plan. "So if your experimental drug is not covered by the health care plan, you're not there," she concluded. REPRESENTATIVE ROKEBERG suggested that was a bad example. Number 2110 REPRESENTATIVE KERTTULA asked whether this is the standard now, as understood from common law and case law. REPRESENTATIVE ROKEBERG said that is the issue: Does one allow the plan the right to define "medical necessary" or to list exclusions in the plan? "This is the debate that's been going on for decades," he observed. Number 2132 REPRESENTATIVE KERTTULA asked: If the committee left out a definition of "medical necessity" and looked only at the duty to exercise ordinary care, "isn't that what we would have without codifying it?" REPRESENTATIVE ROKEBERG suggested that the two are so intertwined that they cannot be separated. Number 2148 REPRESENTATIVE CROFT observed that non-ERISA plans now are covered by the ordinary standard of care. The question is whether ERISA plans are or are not covered by that same standard. "Normally," he said, "we can't substantively touch ERISA plans, but by this provision, . . . we can sneak under. That's how it can be both a do-nothing - besides codify the general standard that everyone lives under - and a cost driver." It is not clear now whether ERISA plans are covered, he indicated. This would be saying that even ERISA plans must meet the same standard. He said the question becomes whether this is the appropriate standard. It ties it back to a covered care or treatment, and it establishes for ERISA the same liability that applies to everybody in the non-ERISA world. Number 2241 REPRESENTATIVE ROKEBERG said he thought that made sense. He wasn't certain, but he thought Representative Croft was correct about the distinction between the ERISA and non-ERISA. Number 2256 REPRESENTATIVE ROKEBERG cautioned that including a reference to liability would definitely upset the "Brady Company crew" as well as the insurers. REPRESENTATIVE CROFT protested that line of thinking. Number 2277 CHAIRMAN KOTT invited further discussion of Amendment 1. REPRESENTATIVE ROKEBERG maintained his objection. He added that his vote on this matter would have nothing to do with the merits of the measure, but that he wanted to see a bill he was sponsoring pass this session. Upon a roll call vote, Representatives Croft and Kerttula voted in favor of Amendment 1. Representatives Rokeberg, Kott and Murkowski voted against it. [Representative Green was temporarily absent.] Therefore, Amendment 1 failed by a vote of 3-2. Number 2354 CHAIRMAN KOTT turned attention to medical necessity, the second major topic. Number 2366 REPRESENTATIVE ROKEBERG offered Amendment 2, which he said was the AMA language with the proviso that the plan can set out a different definition of "medical necessity." He explained that this amendment would require that a plan define in its contract exactly what it means by medical necessity or, by default, the AMA language would apply. Amendment 2 [originally an amendment to Version N, labeled 1-LS0472\N.2, Ford, 3/31/00] read: Page 3, following line 18: Insert a new paragraph to read: "(1) a provision that defines "medical necessity"; unless the plan sets out a different definition, "medical necessity" shall be defined as meaning those health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (A) consistent with generally accepted standards of medical practice; (B) clinically appropriate in terms of type, frequency, extent, site, and duration; and (C) not primarily for the convenience of the patient, physician, or other health care provider;" Renumber the following paragraphs accordingly. Page 4, line 10: Delete "(6)" Insert "(7)" Number 2432 REPRESENTATIVE CROFT responded: To say it means this unless you mean something different avoids the central question that we have been trying to get to a vote, which is if a plan covers a condition, but they are trying to give you a treatment that your doctor or you think is insufficient for that covered condition, can you go beyond the scope of the contract to say, "This is medically necessary"? "You want to treat me with drugs. I say surgery is what I need. You're telling me no, and I think for this covered condition . . . it is medically necessary get this form of treatment." He said the subcommittee had worked hard to get agreement on the technical issues, and people deserve some kind of clear decision in this area. However, [Amendment 2] is not a decision. It is still trying to "word smith it." REPRESENTATIVE CROFT made a motion to amend Amendment 2 by deleting the phrase "unless the plan sets out a different definition." CHAIRMAN KOTT announced a brief at-ease at 3:31 p.m. TAPE 00-50, SIDE B Number 0001 CHAIRMAN KOTT called the meeting back to order at 3:33 p.m. REPRESENTATIVE ROKEBERG noted that there had been testimony in the subcommittee that concerned the external review process, which has both mandatory and discretionary conditions. He called attention to page 9, line 2 [of Version S] as an example, and read, "The external appeal agency shall include among the evidence to be taken into consideration ...." He noted that it goes on to list subparagraphs (A) through (D). Then on line 12, it says "the external appeal agency may also take into consideration the following evidence", followed by (A) through (I). REPRESENTATIVE ROKEBERG said these are basically what defines medical necessity. However, there is a distinction made between the mandated "shall" and the discretionary "may," depending on the circumstances. One problem in trying to come up with a statutory definition of medical necessity is that each contract will be somewhat different because the pricing and underwriting will be different. One would have to underwrite to the "plain vanilla" definition every time one made up a health care plan. One couldn't have a menu of services in the plan unless one redefined medical necessity at every step. That is what patient choice is all about. That is also how to contain costs. That is why this is an argument between the insurance companies and doctors. The patients are caught in the middle. It is the legislature's responsibility to protect the patients, but there is a dual goal of affordability and quality care. Number 0122 REPRESENTATIVE CROFT referred to page 8 [beginning on line 19 of Version S], which read in part: (d) An external appeal process must include at least the following: (1) a fair, de novo determination based on coverage provided by the plan and by applying terms as defined in the plan; however, nothing in this paragraph may be construed as providing coverage of items and services for which benefits are excluded under the plan or coverage; REPRESENTATIVE CROFT said that is clearly limited to the plan. The next section says, "An external appeal agency shall determine," based on the medical needs. That looks good, he said, but it says, "and in accordance with the scope of the covered benefits in the plan." Medical necessity beyond the scope of the contract is "out," and he does not think that provision (H), which he paraphrased as "may take into consideration evidence of the community standard," provides authority to go beyond the scope of the plan. He thinks it can be a rational public policy choice for Representative Rokeberg to make, to stay within the plan, but it is important to be clear about the choice being made. REPRESENTATIVE CROFT noted that Version S says, "Only those covered by the plan and only those treatments covered by the plan." Even if there is a good argument that treatment which has been denied was medically necessary for one's covered condition, someone would not get it because it would say somewhere in there, "We don't do tonsillectomies." Representative Croft said he is not criticizing Representative Rokeberg's policy decision, but he cautioned not to mischaracterize what Version S does, which is to "limit to the plan." [Amendment 2] is a decision about whether to provide for medical necessity beyond the scope of the plan. Number 0216 REPRESENTATIVE ROKEBERG responded that Representative Croft was making a good distinction about whether it is inside or outside of the plan, and that is really the crux of the matter. Setting the scope of the plan sets the underwriting criteria for the plan. He said it only makes sense that one would be able "to have an underwriting fence around it in order to have an actuarially sound basis for rating it." If the external appeal agency could decide to step outside the scope of the plan, there would have to have a basis for it, in statute. The discretionary items in the bill allow some "wiggle room," but he agrees that this bill says one must stay within the plan. He characterized the AMA definition of medical necessity as "we believe this is necessary and we don't care what it costs." Representative Rokeberg said he thinks that is the right attitude for a doctor to have in terms of what the best care for the patient is. But, on the other hand, he thinks one ought to take those costs into consideration, depending on what type of malady it is. Number 0299 REPRESENTATIVE KERTTULA summarized: "The bottom line is that whatever we say is medical necessity is going to be the base line. If we adopt that definition, that's the bottom. Plans can add or detract, whatever they want to do, but if we [define] medical necessity, that, at least, is going to be required." REPRESENTATIVE ROKEBERG interjected that it depends on the definition of medical necessity. Under the AMA definition, anything goes. There is no limit on what could be charged. REPRESENTATIVE KERTTULA continued, "But if we define it, that's going to be the standard that is going to be used across the board for everybody if we go outside the plan." Number 0334 REPRESENTATIVE ROKEBERG concurred. He added that some language in the AMA definition speaks to certain levels but does not mandate; it is almost entirely discretionary. He said he could understand that because doctors think of themselves as both scientists and artists. "It's the art of the possible," he added. "This is why this thing hasn't been satisfactorily resolved in any jurisdiction in this country." He said he doesn't know if it is resolvable. Number 0405 REPRESENTATIVE CROFT specified that his amendment to Amendment 2 is on lines 3 and 4, to delete: "a provision that defines 'medical necessity'; unless the plan sets out a different definition." What would be left would be a paragraph beginning, "'Medical necessity' shall be defines as ...." Number 0425 CHAIRMAN KOTT noted that it deletes language up to the word "definition" on line 4. REPRESENTATIVE ROKEBERG announced that he had to leave for a House Finance Committee meeting. He commented, "If you add anything to it, the bill's dead, so I might as well go out and try to salvage another one." In reply to Chairman Kott's question as to whether he objects to the amendment to Amendment 2, Representative Rokeberg affirmed that. Upon a roll call vote, Representatives Murkowski, Croft, Kerttula, Green and Kott voted in favor of the amendment to Amendment 2. Representative Rokeberg voted against it. Therefore, the amendment to Amendment 2 was adopted by a vote of 5-1. CHAIRMAN KOTT brought attention back to Amendment 2, as amended. Number 0504 REPRESENTATIVE CROFT said Amendment 2 is essentially the AMA definition. It still seems to him that the Washington language discussed in subcommittee "has more sideboards" and would be less objectionable, and less likely to kill the bill, because it is something that Washington insurers are somewhat grudgingly living under, and a lot of companies operate in both Washington and Alaska. Although it is somewhat weaker, he would prefer the Washington language. REPRESENTATIVE CROFT explained that he'd had to amend Representative Rokeberg's amendment because he did not want it standing. He suggested that the committee table Amendment 2 and move the Washington language. He emphasized that he thinks there has to be some definition of "medical necessity" outside of the contract to make sure that medically necessary care is provided. He restated his preference for the Washington language. In response to Representative Green's question about how much of the Washington language he wanted, he said he wanted the whole thing. "If you delete that last sentence, I think you just took out the heart of the matter again," he added. Number 0552 REPRESENTATIVE CROFT made a motion to table Amendment 2. There being no objection, it was so ordered. Number 0568 REPRESENTATIVE CROFT made a motion to adopt Amendment 3, the so- called Washington language, as follows: The medical reviewers from a certified independent review organization will make determinations regarding the medical necessity or appropriateness of, and the application of health plan coverage provisions to, health care services for an enrollee. The medical reviewers' determinations must be based upon their expert medical judgment, after consideration of relevant medical, scientific, and cost-effectiveness evidence, and medical standards of practice in the state of Alaska. Except as provided in this subsection, the certified independent review organization must ensure that determinations are consistent with the scope of covered benefits as outlined in the medical coverage agreement. Medical reviewers may override the health plan's medical necessity or appropriateness standards if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice. REPRESENTATIVE CROFT pointed out that amendments may be needed to make the language conform to HB 211. He said what he likes about the Washington language over the AMA language is the last sentence of the former. He added, "You almost start with the provision language and then give the ability to break outside of it, but the burden of proof is on you that it is unreasonable and you need to step out." Number 0611 REPRESENTATIVE GREEN wondered whether that might help soothe the "opening wound" with Representative Rokeberg. He commented, "Part of the objection he made, that last sentence kind of helps it back in." REPRESENTATIVE CROFT agreed. "It is language that is an at least another jurisdiction," he observed, "and it is language that does seem to have you say you start with the plan, and you have the burden of proving why you need to go outside of it, rather than you start with the plan plus a statutorily defined medical necessity." Number 0657 CHAIRMAN KOTT restated Amendment 3. REPRESENTATIVE MURKOWSKI objected for purposes of discussion. She said she felt she had to take up Representative Rokeberg's banner [in his absence], albeit reluctantly. Her concern focused on the last sentence and the ability to override. She thinks that just puts one back in that position without the cap or the sideboards, "because you have a review process that's out there, and looking at the standards on an unreasonable or inconsistent with sound evidence-based medical practice, you could probably argue those terms all day." Representative Murkowski said she likes this language better than the AMA definition, and one reason is that it talks about the cost effectiveness evidence. "It's better, but it still does not give me the degree of comfort that I would like," she concluded. "I just haven't seen anything that is better than this." Number 0755 CHAIRMAN KOTT declared a brief at-ease, beginning at 3:50 p.m. The meeting was called back to order at 4:08 p.m. REPRESENTATIVE MURKOWSKI clarified that she had not withdrawn her objection to Amendment 3. Number 0791 REPRESENTATIVE KERTTULA stated that this is an incredibly difficult issue, and "it is hard to figure out how to drive any kind of path here." Upon a roll call vote, Representatives Croft, Green, Kott and Kerttula voted in favor of Amendment 3. Representative Murkowski voted against it. Therefore, Amendment 3 was adopted by a vote of 4-1. Number 0862 REPRESENTATIVE CROFT made a motion to move CSHB 211 [Version S], as amended, from committee with individual recommendations and attached zero fiscal note. There being no objection, CSHB 211(JUD) was moved from the House Judiciary Standing Committee.