I have been honored to serve as Senate Chair of the Joint Committee on Public Health during the 2019-2020 session. Since being appointed to this post by Senate President Karen Spilka back in February of 2019, I have had the opportunity to work, alongside my House and Senate colleagues on the Public Health Committee, on legislation and issues ranging from PFAS, to women’s health, to vaping, to local public health infrastructure, and quite literally hundreds of public health issues in-between.
Most recently, COVID-19 has dominated the state government’s attention and has placed additional demands on the committee’s members, as well as forced the Committee to shift to remote communication and to hold a remote hearing on late-filed legislation. But the gears of the legislature continue to grind, and over the past months the Public Health Committee has continued its work, culminating last week when the Committee approved our final nine bills.
Among the bills approved were two which were the subject of significant discussion and debate: the End of Life Options Act filed by Senator Will Brownsberger and Representative Louis Kafka, and the Community Immunity Act filed by Senator Becca Rausch and Representative Paul Donato.
Below I’ve provided a summary of what the bills do and the changes that the Committee made to them. I’ve also summarized the Committee’s process. This included hearings and extensive public input, all of which were critical to strengthening these pieces of legislation as they moved through the committee process.
The public hearings this session were the highlight of my time serving as Senate Chair of the Public Health Committee. The public’s participation was robust. In the hearing rooms, packed with people who had taken time out of their week to travel to the State House and deliver testimony on issues about which they cared deeply, we saw democracy in action.
The Process
The Joint Committee on Public Health has received 433 pieces of legislation for review so far this session. Over the course of the 14 months, the Committee held public hearings where each of these 433 bills were considered. For each bill, we reviewed the testimony, analyzed its likely impact, consulted with experts inside and outside the government, and then the Committee voted. Every bill was acted on: either favorably, unfavorably, or recommending a study order. A study order means that the bill is not being moved forward this session by the Committee.
This week, the Committee acted on the final bills that still remained in the Committee.
The Committee received more input on the aid in dying and vaccine bills than on any other issues that came before the Committee this session. This input came in the form of calls, emails, meetings, testimony, social media messages, in-person visits and petition drop offs, books sent through the mail, and protests outside the State House steps.
Prior to the public hearings on these bills, I attended as many meetings, conversations, and learning opportunities as possible. I met with wide-ranging stakeholder groups of my constituents, concerned citizens from across the state, experts, parents, children, advocacy organizations, lobbyists, and others. At the end of many of these conversations, I would ask them if they could recommend anyone else for a conversation.
When the Committee held public hearings on these bills, the amount of public participation was awe-inspiring. Both hearings took place in the legislature’s largest hearing room, Gardner Auditorium and both times it was filled to its 600+ person capacity. Each hearing lasted a full day. The hearing on vaccinations began at 1 p.m. in the afternoon and concluded just after 1 a.m. in the morning. People travelled from all around the Commonwealth to deliver three minutes of spoken testimony and to submit their written comments to the Committee.
In addition to the spoken testimony provided at these hearings, the Committee received thousands of pieces of written testimony on each bill. Subsequent to the public hearings for these bills, the Committee’s focus shifted to reading all of the written testimony that had been submitted.
Finally, the Committee returned to the legislators who had filed these bills. Having gone through a thorough listening and input process, the Committee recommended changes to both pieces of legislation and began working with the lead sponsors to amend the bills. Having redrafted the language of the legislation to reflect the agreed-upon changes, the Committee finally polled amended versions of the End of Life Options Act and the Community Immunity Act for a vote by committee members late last week.
The bills now go to the Clerk of the branch in which they were filed to determine if they will go to the floor or further committee review by the Ways and Means or other committees.
Community Immunity Act
S.2359/H.4096 – The Community Immunity Act was introduced by Senator Becca Rausch (D-Needham) and Representative Paul Donato (D-Medford).
As we anxiously await the development of a vaccine to protect us against COVID-19, we are reminded that vaccines are a potential protection against many serious diseases. Vaccines also protect communities. When enough people are vaccinated against a certain disease, the disease can’t travel as easily from person to person, thus curtailing the spread of that disease. This is especially important because some people cannot get vaccinated for certain diseases, such as people with some serious allergies and those with weakened or failing immune systems (such as people who have cancer, HIV/AIDS, type 1 diabetes, or other health conditions).
The Commonwealth’s immunization system urgently needs reform. Massachusetts Department of Public Health (DPH) data show inconsistent vaccination rates around the state. Last year, nearly 15% of the kindergarten programs that voluntarily reported data showed measles vaccination rates below the level needed to protect the community. And more than 200 additional elementary school programs did not submit any vaccination information.
The bill improves the Commonwealth’s ability to protect our health by allowing DPH to oversee a uniform process for tracking immunizations and exemptions, relieving individual schools and programs from the burden of managing this process.
Bill Summary
The bill does not remove the ability of parents to turn down vaccines for their children for either medical or religious reasons. These exemptions remain in state law. Under the bill:
- The Department of Public Health (DPH) will establish an immunization schedule consistent with accepted medical practice.
- Children attending schools (including higher education), preschool programs and camps need to show they either are current in their vaccines or have an approved exemption. Exceptions are also available for families who have just moved to the Commonwealth or are in the process of obtaining a needed vaccine.
- Medical exemptions are available when a person’s medical provider believes the medical condition or circumstances preclude receiving a vaccine. DPH will prepare a standard medical exemption form to be signed by the provider. The form will list a number of common reasons for a medical exemption, and an “other” category to be filled in by the provider. DPH must approve all valid and accurately completed medical exemption forms.
- Religious exemptions are available if someone states they have a sincere religious belief conflicting with immunizations. The form may not ask about the person’s particular religion, but it will include a notification that refusing to immunize is against public health policy and may result in serious illness or death. DPH must approve all valid and accurately completed religious exemption forms.
- Exemptions are good for up to a year.
- A private school or camp may require stricter vaccine requirements, but they must honor medical exemptions.
- Schools and other programs must report annually on the number of students who were vaccinated and exempt, without exposing identifying information. DPH will compile the information and report summaries of the information by school, municipality or region.
- DPH will set a minimum standard for “herd immunity” which is understood as a sufficient percentage of people receiving vaccines to protect the population against the spread of an infectious disease. If the vaccine rate in a particular area falls below the threshold, DPH can notify the families and conduct educational programs.
- The bill also provides DPH with authority to collect data to determine if particular areas have low vaccine rates. In those cases, DPH will notify families and conduct education and outreach.
Committee Changes
The Public Health Committee received extensive comments on the bill, both favorable and opposed. The Committee made a number of changes to streamline the bill’s operation and clarify its intent. Among the changes from the original bill were provisions to:
- Clarify that the bill applied to all early education and child care programs;
- Allow people with religious beliefs that conflict with immunizations to receive a religious exemption from vaccines. The original bill required that to receive the exemption, one’s religious belief must prohibit immunizations;
- Remove a provision that required those claiming a religious exemption to acknowledge in writing that their refusal may result in serious illness or death. This statement is instead on the application form for an exemption;
- Clarify that the exemption form may not ask about the details of an applicant’s religion;
- Clarify that while private programs may have stricter vaccine criteria, they must accept valid medical exemptions;
- Remove a provision allowing a “mature minor” to agree to preventive care such as immunizations;
- Add an authorization for DPH to conduct outreach to disseminate medically accurate information about vaccines.
End of Life Options Act
S.1208/H.1926 – An Act Relative to End of Life Options was introduced by Senator Will Brownsberger (D-Belmont) and Representative Louis Kafka (D-Stoughton).
This bill would allow patients with terminal conditions to choose a peaceful death with dignity. At the same time, it establishes a rigorous process for patients and physicians to follow in order to protect potentially vulnerable people from coercion.
The Public Health Committee heard hours of testimony both in support of and in opposition to the bill. We heard harrowing stories from people whose relatives suffered during their last days. Supporters’ testimony emphasized the need to promote autonomy and provide an additional voluntary medical option for terminally-ill people to control the timing and manner of their death. Opponents worried about the possibility of coercion and the risk of discrimination. We also heard religious-based opposition to the bill.
The Committee adopted a number of amendments to strengthen safeguards against undue pressure and assure a voluntary choice. This is the first time in the bill’s history that it has made it out of committee with a favorable report.
Bill Summary
The bill prescribes a comprehensive process for patients to access aid in dying medication. All information concerning the process must be documented in the patient’s medical record to create a formal record ensuring that the process has been followed properly.
Capable adult residents of Massachusetts would be able to request aid in dying if they are terminally ill. The patient must make both an oral and written request, at least 15 days apart. The written request must be signed by at least two witnesses who certify that the patient is acting voluntarily and not being coerced. The bill contains safeguards to ensure that at least one witness is not a relative, hospital employee, or someone who would financially benefit from the patient’s death.
The request would be coordinated by an attending physician, who is expected to have a prior clinical relationship with the patient. The attending physician would determine whether the patient is terminally ill, defined as having a condition reasonably expected to cause death within 6 months. The attending physician also must discuss the patient’s diagnosis, prognosis, risks, as well as discuss with the patient options for alternative and additional treatment, like hospice or palliative care.
Next, the attending physician would refer the patient to a consulting physician. The consulting physician’s job would be to medically confirm the patient’s diagnosis and prognosis, and to ensure that the patient is capable and acting voluntarily.
The attending physician would also refer the patient to a mental health professional for counseling. The mental health professional must confirm that the patient does not have a psychiatric or psychological disorder depression causing impaired judgment, and that there is no reason to suspect coercion in the patient’s decision-making process.
After both referrals, the attending physician could prescribe aid in dying medication. The attending physician must again verify that the patient is making an informed decision, and instruct the patient on how to self-administer the medication or how to lawfully dispose of it, if the patient chooses.
At any point in the process, the patient can rescind the request for medication in any manner. A patient’s act of self-administering aid in dying medication would not affect any insurance coverage.
Health care providers could choose whether to participate in providing aid in dying. Their choice or refusal to participate in providing aid in dying would not subject them to criminal or civil liability or professional discipline. If a health care provider is unwilling to participate, they must disclose their policies upon request and transfer requesting patients to new providers. Additionally, physicians must track the requests they receive and grant and report information about patients to the Department of Public Health.
Committee Changes
The Public Health Committee made several changes to the bill in response to concerns from diverse stakeholder groups. These include:
- Add that at least one witness cannot be financially responsible for the medical care of the patient
- Add that the attending physician must ensure that the certification of terminal condition, referral to consulting physician, and mental health evaluation are followed in the proper order
- Add that the attending physician must have a prior clinical relationship with the patient
- Add that the attending physician must recommend that the patient complete a MOLST form
- Add that the attending physician must educate the patient on how to self-administer the aid in dying medication
- Add that the medical record must document that the patient was offered other care options, like hospice and palliative care
- Add that in addition to tracking numbers of requests and prescriptions granted, physicians prescribing aid in dying medication must record their patients’ general demographic and socioeconomic characteristics and any physical disability
- Add that the mental health professional must review the patient’s relevant medical history
- Add that the mental health professional must determine that there is no reason to suspect coercion in the patient’s decision-making process
- Add that an emergency medical provider who finds a patient who has self-administered aid in dying medication should follow standard resuscitation protocol unless they found a MOLST or other legally recognized Do Not Resuscitate order
