Vermont Legislature SmartTranscripts:

[Alice M. Emmons (Chair)]: Let's go live.

[Troy Headrick (Ranking Member)]: We're live.

[Alice M. Emmons (Chair)]: Welcome, folks. This is House Corrections and Institutions Committee. It is Thursday, March 12, and we are back on H550. We have with us Doctor. From Department of Corrections, who's also with WellPath, who we contract with for providing medical services to our folks who are incarcerated. We are working on draft 1.3 because there is section six that deals with the medical care of inmates. And we just want to know just kind of what current practices and also this language in terms of administrative health care services to all inmates in correctional facilities, including transgender, gender diverse and intersex. So that's new language that would be added. And we just want to know how the world would play out So Doctor. Youich, you're welcome. And if you could identify yourself for the record.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Sure, I'm Doctor. Jim Mulliger. I'm the statewide medical director for WellPath in the Vermont DOC.

[Alice M. Emmons (Chair)]: Great. So if you could just kind of give us a broad overview of it. It might be helpful to look at the process in terms of when someone is going through a book and they identify as trans or gender diverse or intersex, what is then the role of WellPath? How does that get referred to you? Is WellPath actually there in booking when something like, with something like this, or is the person actually brought to the infirmary? What is the process?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Sure, well, as far as I know, we do not have a standardized process, and that's in some ways good and bad. I mean, we see to the medical needs of the person in front of us no matter So much like every situation is different and it's, while this is a big issue, the number of folks we've dealt with is still rather finite. So I would say each one of their stories is their story. So whether this comes up during incarceration, whether it comes up at booking, whether it's somebody who's known to us at booking that each one of those situations is a little different. I can give a snapshot of kind of, I was thinking, and again, my apologies, I've had this for about eighteen hours, which is fine, but like kind of where we are, where I expect us to be and kind of where we could go, and then some like nice things and maybe some pitfalls in the language that I see, if that's okay with the committee. Where we are, So we expect everybody to take care of So I would ask, there's kind of two or three aspects of this, is how do we take care of the person, whatever their gender expression or gender identity, the medical care of their body parts. Whatever your identity, if you have a cervix, how do we take care of your cervix? That is a good example because our DOC health and wellness colleagues, I think about six months ago, made sure that they said, Do you have the ability to do a Pap smear at all of the facilities? And it was a good question. I said, That's a good question. Let's figure that out. And we went all around. We made sure we had both the equipment and the expertise to do it at all facilities, and we do. So that's a good example of the provision of medical care. Then there's the affirming piece, right? And so we do expect people to use the Their medical providers should be, and this gets to the cultural competence piece, should know how to use proper pronouns, they should know how to, you know, we all make mistakes, how to apologize. Many of the things that, the testimony, from a month or so ago that individual was identifying. Now, are we executing on that perfectly? No. We did just have a gender affirming care training that was delivered about two weeks ago that was required for all medical staff.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So that aspect. The third aspect is the, gender affirming care piece. And in terms of, hormones and surgery. So currently

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: to qualify, and this is relative to some of the language in the bill, the first step is getting a diagnosis of gender dysphoria. And I know that's a sensitive thing because is this a pathological thing or is it just who you are? I get it. For medical decision making reasons, particularly if there's an irreversible surgical procedure, the first step is to meet with mental health to have that diagnosis of gender dysphoria. I see that the bill refers to, and I'm looking at page 12 under three C, and

[Troy Headrick (Ranking Member)]: it

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: says affirming medical care, including mental health care related to gender dysphoria or gender affirmation. So the way I perceive that's a little bit of a broadening, like suppose we've determined, you that we don't have a firm diagnosis yet of gender dysphoria, but we still, you know, want to affirm people's pronouns or whatever. Do I have that right?

[Troy Headrick (Ranking Member)]: Yeah.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah. And there's a little bit of and that particular goal seems to make sense to me. I think one of the things that I see both our clinicians doing on a kind of one to one scale, but also us as a group of clinicians trying to do is to make sure we're affirming gender while avoiding some of the concerning things that could happen. Some of these are theoretical, some of them are not. They're very specific things that have come up. For example, a pretty fundamental one that our PREA director, I forget her name, brought up at the last time is like, okay, I am a trans female. I want access to menstrual supplies. She made it pretty clear, Look, you're not menstruating, so we don't give those supplies to cis women who are menstruating, right? So that seems like a pretty straightforward. There's been a case, not a case, but a situation there were under the previous contract, there were some people getting facial electrolysis for hair removal, for permanent hair removal. We've been advised that we can't continue that. One, practically we can't continue because we can't find somebody to do it interestingly, despite a lot of work. But that situation aside, because our contract asks us to follow Medicaid guidelines and Medicaid does not provide facial electrolysis for gender affirming care, the DOC's legal counsel has interpreted that as we cannot offer that. So, one of the things I would like to avoid and maybe, and I'm not, this is, I'm going to step out of my, I'm going to stay in my clinical role, but talk about things that aren't entirely clinical. If the intention is to push the language of our contract so we could be proactive and offer that, fair enough. But the thing I would try to avoid as medical director over the clinicians I supervise is to not have them stuck between a rock and a hard place where we have language that would require them potentially, depending on the interpretation, to provide a referral to facial electrolysis versus a legal opinion based on our contract that says we can't. And most of the time I see people like, look, I'm happy. I want take care of the person in front of me. Just tell me what I'm allowed to do. And that's one of the challenges. So in that language of, okay, we want to be gender affirming, what are the boundaries around that? And I think the so we talked about like menstrual products, facial electrolysis, and then I'll give a third example, which is more so suppose somebody has been it's regarding more permanent surgical treatment. I'll try and be as vague as I can while being specific. We've had issues where people who have some clear paraphilia, which is why they're incarcerated because of some actions they took related to that, are looking for what they might consider affirmation that is concerning based on the nature of the affirmation they're asking for and the nature of their victims. I'm not saying what's right or wrong there or whatever, but I'm trying and we've actually had an expert from It's very difficult to find folks who are expert in paraphilias and gender affirming care in the carceral setting. That's a very niche thing. It costs a fair bit of money then and well spent honestly to get an opinion from a national expert in the opinion on a specific case. I want to make sure we have some boundaries that we can provide all the support for the person who's the individual who testified February. That person should really have her care really taken care of. And I want to make sure we have the protections for our clinicians that they're not stuck in this place where they feel like they either, A, have to do something that's not very good for the person or the community potentially, or that they're stuck with like two directives saying that they have

[Alice M. Emmons (Chair)]: And to go this

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: so that's where I'm kind of landing. I'm happy for questions or disagreement or I'm not pretending like I have all the answers. That's just kind of the world we're living in.

[Alice M. Emmons (Chair)]: Well, this is very helpful. Thank you. We do have a question here, Troy.

[Troy Headrick (Ranking Member)]: Yeah, incredibly helpful. Thank you, doctor. One of the things I want to make sure we do right is to include the discretion that we've included with housing placement, with searches that give the department or now in this case, WellPath, the ability to say based objective evidence, we're going to hold off on fulfilling that request. And I think that's paramount when you bring paraphilia into the conversation. And even the journey of gender dysphoria, even once diagnosed, is a longer journey than I think most people realize before we start talking about surgery. All of that, so I agree with you, and it is absolutely my intent to have those safeguards in place so that this truly remains a medical decision on an individualized basis. So, yes. That being said, do you have a good sense off the top of your head about what Medicaid would cover in and around gender affirming care? And let's even go as far as even once somebody's been adequately diagnosed as needing some of the more significant care.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah, I don't have a thorough understanding of the Medicaid guidelines though. And Doctor. Rapaport is the CMO at Medicaid who I've been communicating with about the issues, and that's who would have that understanding. The reason I know about the electrolysis is I communicated with him directly about that and he was very unambiguous. My understanding is that, it does cover hormones, and gender affirming surgery that there's some boundaries around that. I can't speak with any authority about what those are.

[Troy Headrick (Ranking Member)]: But it does cover hormones?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: As far as I know, yes.

[Alice M. Emmons (Chair)]: With Medicaid, it appears as if Medicaid is really the driver here in some ways in terms of what medical care is allowed or or not. Does the eleven fifteen waiver play into this at all? And if we. Is there any way of jeopardizing that waiver by offering care to folks who I'm just going to use the broad term, so I don't screw up. We're trans in one way or another. There any potential that we could jeopardize that waiver?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah. So I'm gonna, that's a great question and a big one and I'll give again my understanding of the eleven fifteen language is that we need to offer, and I read this very carefully mostly again, I'm a board certified addiction specialist, I read it in the language of addiction. Sort of language that I'm paraphrasing liberally, it says that we have to offer everything that our state Medicaid would offer, but it's in class or in kind or something like that. I was looking like, okay, so I want to offer long acting injectable buprenorphine. And it looks like potentially could we use this? Yes. But did we have to as a requirement to start the program? And my recollection when I looked at that was no, because we offer that class or kind of therapy. So I understand it. I'm not aware of anything that will allow us to be more generous than what our Medicaid, I don't know that that would jeopardize the eleven fifteen waiver if we have benefits that Medicaid does not include. I think that's, have, this is not theoretical, it's uncommon, but I have had people say, oh, I've been locked up so I could get insurance or I could get this benefit. I'm using the language the person used. I think we should be thoughtful about offering benefits that are richer than the community benefit, but I'm not saying it's incorrect. In speaking with our DOC colleagues in health and wellness, we talked about this specifically that would this be nice if we could, offer electrolysis? We kind of both thought like, well, yeah, so it might be nice. I just don't want people wedged in, but I don't think there's a danger of a richer benefit negating the eleven fifteen waiver.

[Alice M. Emmons (Chair)]: So doctor, I'm looking at just kind of what we talked about yesterday. And one of the questions I have in terms of the language we currently have in the bill is that the Department of DOC would ensure that department staff contractors receive gender response training. WellPath is one of the contractors. So, currently, is that occurring, that the department's ensuring that your folks are receiving gender responsive training?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yes. Yes.

[Alice M. Emmons (Chair)]: And how are they doing that and how often does that occur?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So, well, there's like anything, there's a formal and an informal curriculum. So WellPath does now have a formal curriculum. We rolled it out in our contract and it took a lot longer. We've been trying to do it since September. We just had everybody do it in the last two weeks. What we'd like to do, and I'm not sure where it stands, is put it Like everything in healthcare, there's a set of annual trainings you have to do where the fire extinguisher is, annual CPU things. This would just go right there. We would just treat that like everything else. There are some logistical barriers to putting that in there today, but I know that that's the goal. This is kind of nice. My understanding is that would be nationwide, so Vermont would be helping drive our care and other contracts, which a lovely thing. And then there's the informal curriculum, right? Like how do we, for example, in our provider meetings, really try and have a safe space like, hey, these are Some people get the whole gender affirming care process. Some people, they're still trying to get their heads around it right. So I try and offer a safe space where we can have those conversations and people can ask questions. So, there's an informal, informal curriculum. And it's required.

[Alice M. Emmons (Chair)]: It's required. Yes. So, the next question I have is when a person comes through, it's both the intake process as well as maybe they've been in the facility for a while, like maybe a year or two, they could be a detainee, they could be sentenced, and they're really finding that their gender, they're identifying differently. And DOC has to look at the classification housing placement for that individual. And the language that we have, and we had testimony yesterday from DOC, that there is a review panel that DOC has. And in the language in the bill, it's called multidisciplinary review panel. In the bill, it would be composed of medical personnel, mental health personnel with experience in gender dysphoria. I can't pronounce that word and gender affirming care and personnel who have received training aligned with nationally recognized standards for gender affirming care. Is that currently happening? Do you know that DOC, the department is reaching out to a panel such as this currently to help make decisions on the classification and the housing placement?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: We do not have a somatic provider, meaning non mental health provider, that's consulted as far as I know. I'm going to ask, if I may, ask one of my colleagues who is a really fast response on Teams if we have that weighed in on from a mental health standpoint. I would

[Alice M. Emmons (Chair)]: Yeah, because, so do you have a panel right now that you're part of, that WellPath is part of, I don't want to get into the specifics of what the language says right now. Is there a panel right now or an ad hoc group or something right now that the department, like at booking or if a person's been there for a while? Classify, place person in the housing unit.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So, unless it's our mental health group, which is not under me, we are not a direct part of that group. And I have some mixed feelings about that, not because it wouldn't be great to have somebody's expertise there, it's because how much we weigh into security matters could create a conflict of interest. And I'm just, so forgive me, I'm thinking out loud here. It could be totally appropriate to have somebody on that committee. I'd have to chew on that for a minute. No, as far as I know, we don't have anybody on the medical non behavioral health side that's part of the housing decision that we are consulted. And I'm asking Doctor. Richards who's our psychiatrist right now.

[Alice M. Emmons (Chair)]: Yeah, so we have language in the bill that would have a multidisciplinary review panel that would include, but shall be composed of individuals, including medical personnel, mental health personnels with experience and personnel who have received training aligned with nationally recognized standards of gender affirming care.

[Troy Headrick (Ranking Member)]: Psychiatrist would be considered medical personnel though, right?

[Alice M. Emmons (Chair)]: Scope of practice? Is it scope of practice though?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah. Well, there's the rich question that's been a problem in America for years. Oh, Alison says yes. Doctor. Richards says yes.

[Alice M. Emmons (Chair)]: Yes to what?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yes, here we go. Is mental health part of the housing panel for folks, for gender diverse folks in choosing, okay, Colleen is on it, but Colleen is there a WellPath clinician. So what I'm learning is that Colleen's are director of mental health on the DOC side, not part of the WellPath contract. And she would fit all of those things. She's just not a WellPath. And that's how we could avoid the potential conflict of interest because Colleen does not provide direct care. Doctor. Richards is saying there's not a WellPath clinician on that committee, but it's Colleen.

[Alice M. Emmons (Chair)]: But there is a DOC person that has medical.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Is a DOC person who's, and forgive me, I don't know what Colleen's exact credential is, but she's a therapist of some level of training. Colleen, if you're hearing this, forgive me, I should know what your credentials are.

[Troy Headrick (Ranking Member)]: Can you say a little bit more about what that conflict of interest, how that would present?

[Alice M. Emmons (Chair)]: We're gonna do some work.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Well, okay. Suppose, and I'm gonna, this could play out in positive and negative scenarios. So let me, I'm just gonna make one that's purposely negative. Suppose I was your doctor and I got to be a part of a group that decided whether you're going go to the place you want to deliver or not. That group decided no. And then you had to come see me and we talked about your whatever, The pimple on your knee or whatever. That's kind of a rough relationship to have. I'm not saying it's incorrect. I'm just, again, it's new information.

[Kevin Winter (Member)]: Well, no, the one thing I wanted to

[Alice M. Emmons (Chair)]: ask then

[Unidentified Member (likely Gina Galfetti or Mary A. Morrissey)]: is just for maybe for all of us. Does that mean is that so when they're talking about the most multidisciplinary

[Kevin Winter (Member)]: view panel

[Unidentified Member (likely Gina Galfetti or Mary A. Morrissey)]: here, does are they referring to WellPath? And are they also referring to that woman that he was just talking about? Is that who that group is? And is

[Troy Headrick (Ranking Member)]: that

[Unidentified Member (likely Gina Galfetti or Mary A. Morrissey)]: okay? That's my question, I guess.

[Alice M. Emmons (Chair)]: I mean, the current structure that's happening now.

[Unidentified Member (likely Gina Galfetti or Mary A. Morrissey)]: Yeah, is that like do you understand that Troy? And is that all good?

[Troy Headrick (Ranking Member)]: Yeah, but I have an understanding that Doctor. Richards has been part of these conversations.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: She has been, she's not on the committee that makes the decision.

[Troy Headrick (Ranking Member)]: So she's consulted.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: That's correct. So here's what she replied. I think it would not be appropriate for us to be involved in that level, but she put a question mark. She's thinking about it just like I am, right? And

[Troy Headrick (Ranking Member)]: she said, you're

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: not involved in their pre investigations or disciplinary actions, which is part of housing. And I don't, I'm just, you know, this is as rich as text can be. I know this isn't really a disciplinary thing, but we are talking about safety. Are people safe?

[Troy Headrick (Ranking Member)]: Is this perfectly safe for people safe?

[Alice M. Emmons (Chair)]: The language doesn't indicate where the medical personnel or health personnel is coming from.

[Kevin Winter (Member)]: Right. And

[Alice M. Emmons (Chair)]: I don't know where it is in the draft that you've got, because we had to put some draft and our reading off of.

[Troy Headrick (Ranking Member)]: 1.3 is on

[Kevin Winter (Member)]: page nine.

[Troy Headrick (Ranking Member)]: Can we But if that language just said in consultation with medical personnel that the multidisciplinary review panel is in regular consultation with medical personnel, that would not trigger that conflict, right?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Absolutely. I think that makes so much sense because what I would imagine, and I could be educated on this clearly, but what would I offer to that committee? I could offer what the person's anatomy is. I like it. We're not supposed to do kind of forensic general examinations. That makes total sense, right? Here's what their anatomy is. Here's what their sexual function could be in terms of safety. Here's what their process in where we are in terms of their transition. That all could be helpful that the person doesn't have to have a vote though.

[Troy Headrick (Ranking Member)]: Right, right.

[Alice M. Emmons (Chair)]: We might wanna think about that with Hillary with our next draft.

[Troy Headrick (Ranking Member)]: Yeah, I don't think this is insurmountable. Right.

[Alice M. Emmons (Chair)]: That's why this medical care, when we looked at this section, it just said to me, we're gonna have to do a lot more work on this. So what we may end up doing, Doctor. Is just put in some languages placeholder, because we're under a deadline to get the bill out tomorrow. And then once our schedule opens up a little bit here in the committee after that, once the bill is in the Senate, this committee can do more work on the medical care piece and then offer that as the bill progresses through the process. So another question that I have is dealing, if you go back, it's dealing with the searches, which would take a section four. And it says the department's currently what the bill is saying, the department would not search physically exam any individual for the sole purpose of determining the individual's genital status. If the individual's genital status is unknown, it may be determined during conversations with the individual by reviewing medical records, or if necessary, by learning the information as part of a broader medical examination conducted in private by a health care practitioner. So is that current practice that's happening, or is this going to be new practice and is it possible I'm well passed in?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah, I can speak to the medical part. I can't speak to what security does.

[Alice M. Emmons (Chair)]: Right.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: But it is not current practice to do, we only do any sensitive exam if we really have to for a variety of reasons and the trauma people have been through and whatnot. The challenge here would be this, it makes it sound almost incidental that would be like, oh, we did an exam and yes, we noticed X, Y, and Z. The problem is we don't do that incidental exam on most people, only everyone, but most people we don't for specific reasons. So I do think if that were a question and records can be incomplete, so records, it's totally appropriate to have, examination records, etcetera. Like, if we have a surgical record that says the uterus was removed, then the uterus was removed, right? We're not going to do some. The other concern reading this would be there are people who are dangerous that we wouldn't want to do a sensitive exam without some sort of security present. In those circumstances, we do everything we can to make it as private as possible. But that's

[Alice M. Emmons (Chair)]: I wonder if it's private could be interpreted that there is a private space away from living units, away from where other inmates are, that it's private as much as it can be within the infirmary or the health care arena.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah. And that's so and you know our infrastructure, this whole committee does. It's privacy is a giant issue. Maybe if I could suggest something that is done with a privacy commensurate with a sensitive medical exam or something. Like this is how we do sensitive medical exams.

[Alice M. Emmons (Chair)]: The way I interpret private setting is it's in a private room. It's a room that is separate from the flow of the facility. It's not talking about one person being there with the inmate. It's the setting is private from the rest of the building. That's how I'm interpreting.

[Troy Headrick (Ranking Member)]: And that makes sense. In some places we don't have that room.

[Alice M. Emmons (Chair)]: The infirmary or in the building itself?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: In the building itself. And infirmary if you mean in like the medical suite.

[Alice M. Emmons (Chair)]: Right.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: We don't always have a place to do that. A place with a door. We have a curtain.

[Alice M. Emmons (Chair)]: Okay. That's our door.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: We might have to have a security person. In most cases, we don't. But in certain cases we have to have a security person in the room with us while we're doing that exam. In reading this a little bit, it would give me some like, okay, is that security person allowed to be here or not? We do everything we can not to have that person there by the way.

[Alice M. Emmons (Chair)]: So if there's to be a search done of a person

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: We don't do forensic searches, just to be clear.

[Alice M. Emmons (Chair)]: It's just the DOC staff that would do it. And they wouldn't consult with the medical at all or vice versa.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: We won't this came up with drug stuffing and packing. Oh, okay. We will not look for things in people for forensic reason.

[Alice M. Emmons (Chair)]: Okay, sure.

[Troy Headrick (Ranking Member)]: So specific to this section, so page six, line 16 is where the section begins. I'm at the end of the section, so lines twenty and twenty one. The purpose of this section is just to say that the department shall not search or physically examine for the sole purposes of determining an individual's general status. And it talks about if that information is gleaned from other processes that have already

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: occurred- Like

[Alice M. Emmons (Chair)]: medical practices.

[Troy Headrick (Ranking Member)]: So you can just take in private out there, right? Part of a broader medical examination conducted by a health care practitioner, regardless of whether or they conducted that in private or not, doesn't matter.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: This

[Troy Headrick (Ranking Member)]: is where the information comes from that could provide information that has not been gathered through what we're calling an inappropriate search, which is to determine genital status.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Sure.

[Troy Headrick (Ranking Member)]: We can in private there and be done with this part of it. Okay. And it's the in private the way

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I read that, and maybe I was reading it incorrectly, Examination conducted in private, means secure to me, that means security is not allowed to be there.

[Troy Headrick (Ranking Member)]: Yeah, we can take that. We can just say conducted by a healthcare practitioner. Correct. So then we're referring to something that has already happened.

[Alice M. Emmons (Chair)]: Right. And the way we interpret private is a private room or setting, but that could be interpreted differently.

[Troy Headrick (Ranking Member)]: It could be. To

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: provide the committee reassurance, if somebody was called to booking in a public area and asked to examine a disrobed patient, I would fully expect that provider to be like, I'm absolutely not doing that. So that's, know, just to be clear, that shouldn't be a thing.

[Alice M. Emmons (Chair)]: So, Doctor, when you're looking at medical records, and I know we've in this committee have looked a lot over the years in terms of what comes with an inmate in terms of their medical records and their prescriptions that they have, and who their medical provider is or not, who their pharmacy is or not. For folks who identify gender identify differently. Is there a tendency for them to have more of their medical records with them or available from their that they have a primary care provider? Because many folks who are coming into the incarcerated setting do not have a primary care provider. They'll tell you they do. And once DOCs and WellPath Medical starts looking into this to get some of the records, They don't. And the same with prescription. They'll say they have prescriptions for certain medication. And yeah, they may have a year ago, but they never picked it up. Are you running into something different with folks who are, who identify differently with their gender?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Not that I'm aware of, and I'm not sure our sample size is large enough to determine, you know, a correlation there. But no, not that I'm aware of that we would have some different.

[Alice M. Emmons (Chair)]: But are you having access to their medical records out in the community?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: It's really variable. And I'm pleased to the degree to which we can get access. And it's more of an issue with people who come from out of state, or who are in state who've had out of state care. Vital has been fantastic. So if you're doing transitional care with a primary care provider in the state and your records are on vital, like there we are, you know, that's not a problem.

[Troy Headrick (Ranking Member)]: Kevin?

[Kevin Winter (Member)]: Can I ask what, with your experience with Vermont DOC, what is your sample size? Roughly how many individuals have you dealt with with this challenge?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I can speak to the active cases, which I think are single digits, but let me ask Doctor. Richards. Care spreadsheet.

[Kevin Winter (Member)]: And I would assume of this very small number, these individuals would come to you or would be involved with you because they're looking for assistance. They're not trying to hide their status. So, although security is always critical, I wouldn't think that there should be resistance to examination to understand from a medical perspective what the reality is.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah, I think that's gonna be very patient specific. So think of trauma people have been through. There's also some trauma even about what you call, I've run into this when I was first trying to understand folks who are experiencing this whole situation. What was hard to me is somebody said, well, you can't call them testicles. And I'm like, I know, but I'm trying to, you have a lump, I'm trying to make sure you don't have testicular cancer. I'm trying to be sensitive to the person, but I'm trying to call it what it is. This a while ago when I was on my journey, getting my head around all this. The reason I'm sharing that is that the way it is with one person is the way it is with one person. Does that make sense? I do think we would do everything in our power if we're like, look, we're trying to get you housed at wherever Chittenden say, we need some clarification on what's there. Can we collaborate on this? That's the way we would do it. I would hate for it to become a, you know, gosh, something that was traumatic or difficult for either patient or provider for that matter.

[Kevin Winter (Member)]: Right. I guess that's what I'm trying to say. I don't see this as needing to be an adversarial situation because if they're choosing to identify differently than the norm, I guess it's the only way I can say it. They should be willing to share whatever they know to get the assistance they want.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Possibly, I guess here's a situation and this is again, this is a little, I'll speak to my medical piece and just put the, so what if somebody says, you know, I want to be at Chittenden and it's not clear what their genital status is and they refuse to submit to an exam. So does this law weigh into that or not? Because they have the right to refuse medical care, right? That's it.

[Alice M. Emmons (Chair)]: The cyber has the right to

[Troy Headrick (Ranking Member)]: refuse. What this section is saying in those instances, we're not going to do a search for the sole purpose of determining the individual's gender of the sad. And I think that's an important protection. Because if everybody's identity journey is different, including for those who identify as gender diverse, transgender, and we're not even talking about intersex folks here. And that's part of this too. So again, if I am identifying as a trans woman, and we're having that conversation with DOC, this policy, this bill currently has outs, I'll call them, for the department to hit the pause button and to say, let's have a more detailed conversation here. That more detailed conversation is not going to include a search so that we can talk about your genitals as part of that conversation. I think that is an incredibly important protection here. Now, this section of the bill does allot the Department of Corrections to access medical records that may already exist.

[Alice M. Emmons (Chair)]: But WellPath does not do a search.

[Troy Headrick (Ranking Member)]: They may have in the past. They haven't done a search, but they've done And an that might be in their medical records, right?

[Alice M. Emmons (Chair)]: It'd be a physical. Right. But it won't be

[Troy Headrick (Ranking Member)]: a search. All this section is doing is saying, We're not going to search you as we determine whether or not you really are trans enough. That's what this section is doing. DOC. Right.

[Alice M. Emmons (Chair)]: The department. Yeah.

[Troy Headrick (Ranking Member)]: Well, this this section of the bill doesn't bring WellPath into it. Right. Aside from the fact that WellPath might have some records existing. Right.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So the clarity I would ask for would be that if DOC comes to us and says, we're trying to make a, and I think I know the answer based on what you're saying, we're trying to make a safe determination about this person's housing. Can you please do an exam to confirm X, Y, or Z? It sounds like we're supposed to say no.

[Troy Headrick (Ranking Member)]: I

[Kevin Winter (Member)]: I know the answer, but there are occasions where a physical search is required. Yes?

[Alice M. Emmons (Chair)]: Yes. But Wellpap does not Understand that.

[Troy Headrick (Ranking Member)]: And not for determining identity.

[Unidentified Member (likely Gina Galfetti or Mary A. Morrissey)]: And not for determining I understand.

[Kevin Winter (Member)]: But if there are those situations, you can't help but have an examination.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So we don't do forensic examinations.

[Kevin Winter (Member)]: Right, right. I understand that.

[Troy Headrick (Ranking Member)]: So you would say no in those instances.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So we would have to say no. Yeah. And I just want I the thing I would ask for is clarity. Just real clarity on that.

[Kevin Winter (Member)]: Say that again. You'd ask for what clarity?

[Troy Headrick (Ranking Member)]: Clarity in the bill. Yeah. And I I think I I now that I

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: think through it, maybe the bill I I see what you're saying. Yeah. The bill does that, but I it didn't come out at me. I would I would ask for it to be very clear

[Troy Headrick (Ranking Member)]: about that. Okay.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Not that we couldn't do an exam for a medical indication and we're used to this, like what what are we really doing here? Is this are we trying to help you with your medical problem? Are we determining some piece of evidence?

[Kevin Winter (Member)]: Right, exactly.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: And we, if the bill could be even a little clearer about that, I think that would be really helpful.

[Alice M. Emmons (Chair)]: And so that would be in what section of the bill, Troy? Would that be in the general identification and discrimination?

[Troy Headrick (Ranking Member)]: What do you have to do? The clarity that he's Or asking

[Alice M. Emmons (Chair)]: would that be in the searches?

[Troy Headrick (Ranking Member)]: I think it can belong

[Alice M. Emmons (Chair)]: All of it?

[Troy Headrick (Ranking Member)]: I think

[Alice M. Emmons (Chair)]: The classification I heard.

[Troy Headrick (Ranking Member)]: I was talking about Hillary's thoughts on this. But I think it's certainly I think we can clarify Section four. To bring some of this in that shall department shall not ask medical contractor to do any sort of forensic searching outside of normal medical.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Including, including.

[Kevin Winter (Member)]: Yeah.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So I would say, including.

[Troy Headrick (Ranking Member)]: Right.

[Kevin Winter (Member)]: So when a physical search is necessary, we prefer having a non doctor.

[Troy Headrick (Ranking Member)]: That's not what we're saying, that's

[Kevin Winter (Member)]: what I'm asking. What are we saying? Who's gonna do it if it's not gonna be a medical person?

[Troy Headrick (Ranking Member)]: We're saying nobody's gonna do a search to determine a genital status as we're talking about gender identity.

[Kevin Winter (Member)]: So we literally wanna be blind to physical data. That's not

[Troy Headrick (Ranking Member)]: what we're saying. I don't think that's true. Because we are allowing here, and maybe I'm missing the boat too, so tell me, but you are allowed to learn that information as part of a larger medical exam. And so I would think that DOC,

[Unidentified Member (House Corrections & Institutions Committee)]: if you're in one of these fringe cases,

[Troy Headrick (Ranking Member)]: is gonna say, we need to pause and perhaps have this be a part of that process. Would that be acceptable?

[Unidentified Member (House Corrections & Institutions Committee)]: It's not to determine genital status.

[Troy Headrick (Ranking Member)]: We have to know about this just broadly.

[Unidentified Member (House Corrections & Institutions Committee)]: Yeah. Sorry. Let's let's look

[Troy Headrick (Ranking Member)]: at what information we have. So in in a way, if we need to make it clear, let's make it clear. But I think the answer is contained within twenty and twenty one. I agree with that.

[Unidentified Member (House Corrections & Institutions Committee)]: And maybe we need to explicate. Right? But

[Alice M. Emmons (Chair)]: do you mean within twenty and twenty one?

[Troy Headrick (Ranking Member)]: I'm sorry, lines twenty and twenty one on page six, the very bottom of six that we were already talking.

[Alice M. Emmons (Chair)]: And you're on 2.1?

[Troy Headrick (Ranking Member)]: Yeah, I think so.

[Unidentified Member (House Corrections & Institutions Committee)]: Actually, no, I'm sorry.

[Troy Headrick (Ranking Member)]: I'm on 1.1. But yeah, a broader medical examination conducted in private by a health care practitioner.

[Alice M. Emmons (Chair)]: What page are you on on 1.3?

[Troy Headrick (Ranking Member)]: On 1.3, I'm at the bottom of page six, lines twenty and twenty one, which is part of 4B that we've been talking about.

[Alice M. Emmons (Chair)]: That's dealing with searches.

[Unidentified Member (House Corrections & Institutions Committee)]: Except this is not a search here. This is learning information as part of

[Troy Headrick (Ranking Member)]: a broader medical examination because we're not searching.

[Alice M. Emmons (Chair)]: But you're in the searches section.

[Troy Headrick (Ranking Member)]: Yes, we are.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: If it's okay with the committee, just need to step away for a moment. My apologies.

[Alice M. Emmons (Chair)]: Yep. Yeah.

[Troy Headrick (Ranking Member)]: We took the time anyway.

[Alice M. Emmons (Chair)]: The language here in B from what I had from yesterday's or one testimony I had from Hillary, this language was taken from the federal PREA language in b. Yeah. And what we're what I've heard what we're proposing right now is to take out on lines 21 conducted in private.

[Troy Headrick (Ranking Member)]: Saying it doesn't matter. I don't think that matters.

[Alice M. Emmons (Chair)]: You're saying it doesn't matter now?

[Troy Headrick (Ranking Member)]: I don't know if it helps anybody else. For me, it's useful to reground occasionally that we're not gonna be idiots and go blind and and, you know, just,

[Unidentified Member (House Corrections & Institutions Committee)]: you know, trust. Okay. But at the basis of this legislation or proposed legislation is respect. So how do we do both? Right.

[Troy Headrick (Ranking Member)]: Yeah, I don't want to let one trump the other. I don't want be a moron about it. And I think Doctor. Is acting for clarity in this section beyond striking in private that they're not going to be asked to do the search that Priya is saying is not awful. I think DOC has indicated before that if there

[Unidentified Member (House Corrections & Institutions Committee)]: is a question, they're gonna pause.

[Troy Headrick (Ranking Member)]: They're gonna tread water until they can sort it out. It's not let's blindly go ahead without having figured out what's going on.

[Alice M. Emmons (Chair)]: You would also have access to reviewing medical records. So if the person had had a physical at this point, that's part of their medical record. Yes.

[Troy Headrick (Ranking Member)]: Well, maybe that point is about to happen. Maybe they're about to have a physical exam broadly for their health in which this could be determined not as a search.

[Unidentified Member (House Corrections & Institutions Committee)]: I don't want to split hairs. I'm not trying to get cute.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: We're not in people's genitals very often.

[Alice M. Emmons (Chair)]: We're not what?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: We're not examining people's genitals I'll very give you an example, the eleven fifteen waiver, there's a requirement that we have to do a disrobed exam for youth 21 and foster graduates 26, and I fought tooth and nail to get language in there that was like if clinically appropriate or something, because most of the time there isn't a good reason to do one and the risk of sexual trauma in those individuals is so high that unless we have a reason to, we just don't.

[Kevin Winter (Member)]: What's the second category? So

[Unidentified Member (House Corrections & Institutions Committee)]: I guess for clarification then within the context of this bill and within the context of DOC, what is a broader or broad

[Troy Headrick (Ranking Member)]: technical exam?

[Unidentified Member (House Corrections & Institutions Committee)]: Does that mean anything to you?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: A broader, well, so if we had to do an exam for an indication, somebody says, hey, I have a discharge. Why don't we do an exam?

[Unidentified Member (House Corrections & Institutions Committee)]: So it's just a different reason.

[Troy Headrick (Ranking Member)]: It's not a descriptor of the kinds of things that might go into it?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yes. And I'm just trying I guess what I'm trying to say is I don't want the committee to have the impression that we do an unclothed exam on everybody. It's actually a minority of folks. I do think if it helps at all, I think if this question, if there was a reason we needed to know the genital status of somebody, we could have some sort of medical way of obtaining that information the way the bill is written. I think that we could, you know, they had some surgical treatment, we could get the surgical records. So I don't think that's.

[Alice M. Emmons (Chair)]: And that goes back to my question about having access to their medical records out in the community. That was my question because folks are coming in And if they are quite a ways along in their transition and they did have surgery, that will be part of a medical record in the community that you would have access to if they allowed it. Again, Yes. It's

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I mean, this is not a medical thing, but if that's what you're asking for, then gosh, you have to, you know, that seems like a reasonable ask, but that's outside of medical. It would be unlikely that somebody had that level of a surgery that we, there's only so many centers in the country that are doing that.

[Alice M. Emmons (Chair)]: Right.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So we should be able, it would be difficult to imagine, maybe if it was done out of the country, that would be one. If it was done somewhere else, that could be a situation where it'd be challenging.

[Alice M. Emmons (Chair)]: But you would have access, DOC, WellPath would have access to those medical records out in the community in terms of what the person has availed themselves of medically in their transition.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yes.

[Alice M. Emmons (Chair)]: And that would then be incorporated in the WellPath medical records for that individual.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yes. And there are barriers to getting records like that, but yes, barriers notwithstanding. Right.

[Alice M. Emmons (Chair)]: So we need to work with Hillary on more clarity in this section is what I'm picking up.

[Troy Headrick (Ranking Member)]: Don't think it's gonna take much. The language is important. But is there any

[Unidentified Member (House Corrections & Institutions Committee)]: part of this that we're still unclear about that requires and I'm asking DOC, Priya, Josh,

[Troy Headrick (Ranking Member)]: and Jen as opposed to Doctor. Youlig or Welpoth? What if DOC hits a snag?

[Alice M. Emmons (Chair)]: Well, that's why we got more work on the bill.

[Unidentified Member (House Corrections & Institutions Committee)]: I don't think there's anything further on this part of this that I can learn from Doctor.

[Alice M. Emmons (Chair)]: Deuliger. And DOC is going to be in the room this afternoon, we hope.

[Troy Headrick (Ranking Member)]: I'm legitimately asking if we need anything beyond the first sentence of section B.

[Alice M. Emmons (Chair)]: You mean, of section B?

[Unidentified Member (House Corrections & Institutions Committee)]: Yeah.

[Alice M. Emmons (Chair)]: Department would not, shall not search or physically exam any individual for the sole purposes of determining the individual's genitalia status. Period. Period.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: So I'll leave oh, for the, for the whole section b, that that's all you would put in there.

[Troy Headrick (Ranking Member)]: Yeah.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: It's very clear that we don't collect evidence. We do any sort of exam. It didn't hit me until the rich discussion that this is evidence. Took me a minute to get my head around. I guess I would leave you with that and let you guys decide how much, what you need or not. But it took me a minute to

[Unidentified Member (House Corrections & Institutions Committee)]: Well, so I mean, it sounds like that's like a guiding star, if not the guiding star. But suppose we were to cut down this section to just that first sentence, does that put you, the medical provider, well pad in an awkward position? There a case in which DOC is like, hey, we need to know this? Does that set up contradiction or conflict between you and them?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: To me, it sets up a bit of a mistake. It sets up like the department is selling shirts, but medical care. Like, okay, we'll do that for you. And then afterwards being like, wait a minute, we can't do that.

[Troy Headrick (Ranking Member)]: So I shall not ask a medical contractor to do a forensic.

[Unidentified Member (House Corrections & Institutions Committee)]: Yeah.

[Troy Headrick (Ranking Member)]: Yeah. Well, and

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: that's well known, I guess that this is a forensic thing. Maybe that's just me. Maybe if this is enough, I'll leave that to the attorneys and whatnot, and we'll just educate our providers. That's what we need to do. We'll just educate. That could be part of education instead of the bill, if that's fine.

[Kevin Winter (Member)]: Wouldn't we want to know if an individual presents with a cancerous growth rather than a unique genitalia? And why wouldn't, I mean, in those very, very rare situations, why wouldn't we want a medical doctor being one who's determining the physical status of an individual?

[Alice M. Emmons (Chair)]: I

[Kevin Winter (Member)]: think

[Alice M. Emmons (Chair)]: we have to be really clear when we're talking about searches. I

[Kevin Winter (Member)]: know, I'm being very specific, and that's where I thought on page six, line five, we were gonna add the words, The department shall not overrule solely on an individual's search. Because they may have a unique situation, but they truly That's not enough to say that they're a harm to themselves or to others. And so, we don't want to solely determine on that, but we don't want to go in blindly because

[Alice M. Emmons (Chair)]: But the search, this language under DOC, we're talking about a forensic search. We're not talking about medical searches. We're talking about a search to see if they're bringing in contraband, that type. If during that forensic search, Doctor. Eulager, there is an indication there could be a growth on their body somewhere that could be like, this could be malignant, this could be cancer or something, Would DOC staff, if they saw something like this in their regular search for safety of the facility and security of the facility, if they found something like this on a person's body that triggered, that they thought this really needs medical to look at, would they make a referral to the infirmary? They

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: typically do. Yeah.

[Alice M. Emmons (Chair)]: Okay. Okay. So that would answer your question, Kevin.

[Unidentified Member (House Corrections & Institutions Committee)]: I just want to make sure I understood the question. So are you asking for an addition to or a change to the language in five and six? You said solely, but what's the

[Kevin Winter (Member)]: My notes indicated that we were going to add the words solely on an individual search classification.

[Alice M. Emmons (Chair)]: That was nondiscrimination.

[Kevin Winter (Member)]: Well, that's maybe

[Alice M. Emmons (Chair)]: That was the non That didn't deal with the search. That was the non discrimination.

[Kevin Winter (Member)]: Yes. Department's decision We'll make a decision solely on the anatomy. Right. And what I'm saying is, the anatomy isn't understood from a medical standpoint, trying to make a decision in the absence of our data.

[Unidentified Member (House Corrections & Institutions Committee)]: But I think this is almost the exact opposite of that. It's saying an individual expresses a preference preference for a search, and you know their genital status. And you can overrule their choice about how to

[Troy Headrick (Ranking Member)]: be searched based on what you know. And you already know

[Unidentified Member (House Corrections & Institutions Committee)]: it in this case. That's not to be determined.

[Kevin Winter (Member)]: I understand what we're trying to do in the language here. We don't want that the genital to be the single reason we choose not to house an individual where they want to be housed for the treatment.

[Unidentified Member (House Corrections & Institutions Committee)]: Yeah, yeah, totally agree. I'm just

[Troy Headrick (Ranking Member)]: trying to understand the objection. But here, I don't think this solely would change that. Here, we're already saying, you already know what's going on with this particular individual in our hypothetical case. You know what's downstairs, but you can't make a decision based solely on that if they have expressed a different preference.

[Kevin Winter (Member)]: But if a physical surgery is necessary, I'd rather have a medical person doing it than a non medical person because they know what they're looking at.

[Troy Headrick (Ranking Member)]: But irrelevant here because you already know. Okay, fine.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I would just want our providers only to be, if they're doing a sensitive exam or any exam for that matter, it's to diagnose, treat or prevent a disease.

[Unidentified Member (House Corrections & Institutions Committee)]: And that was, yeah, I guess

[Troy Headrick (Ranking Member)]: that was the other thing. I'm gonna rely on DOC people to tell me about safety and risk and threat and all that stuff. And that's not to say this isn't relevant.

[Kevin Winter (Member)]: But in doctor's experience, he examined and had to convince the patient that what he was seeing is different than what they thought they were seeing, is what I was hearing.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: It was just being

[Alice M. Emmons (Chair)]: sensitive He around the has

[Kevin Winter (Member)]: to convince the DOC isn't gonna be in a position convince the person that there needs to be further. I'll stop. Thank you.

[Unidentified Member (House Corrections & Institutions Committee)]: No, was just trying to be crystal.

[Alice M. Emmons (Chair)]: So we're gonna have conversations with Hillary on this, and I might recommend that Hillary take a look at this YouTube just to understand the scope of the conversation that we had. This pertains to searches. And then there's also a section what Kevin brought up was the non discrimination that put DOC could not overrule a person's search classification housing or program placement request based on their anatomy, solely on their anatomy.

[Troy Headrick (Ranking Member)]: That was in yesterday's draft.

[Alice M. Emmons (Chair)]: That's in yesterday's draft. I'm looking to see, then there needs to be some clarity on the classification housing and program placement section. And in terms of those multidisciplinary review panels that they would in consultation. Just wondering where else in the current language that we're looking at that would tie in dwell bath, when we have dwell bath in the room.

[Troy Headrick (Ranking Member)]: Well, I think you could go through all of Section seven, which is all well thought. Or Section six, I'm sorry.

[Alice M. Emmons (Chair)]: Which one are you on? Draft one

[Troy Headrick (Ranking Member)]: point One one point three. Page 11. Section six, not section seven.

[Alice M. Emmons (Chair)]: For the proposed language there, on the top of page 12, on draft 1.3, Again, to the extent feasible means as best you can, that's flexible language and legalese. DOC and WellPath shall ensure the use of licensed health care providers with cultural competency to administer services to all inmates. How do you define cultural competency?

[Troy Headrick (Ranking Member)]: Is

[Alice M. Emmons (Chair)]: that part of your world at this point in terms of your licensed health care providers?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Was that question for me?

[Alice M. Emmons (Chair)]: Yes. Fix that.

[Kevin Winter (Member)]: Fix that. Right.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah. So, I think, as I mentioned last time, cultural competency is specific to the culture. So you could be culturally competent in one culture, but not another.

[Alice M. Emmons (Chair)]: But I

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: think that's also maybe a little bit academic. When I read this, and especially with the softening of to the extent possible, I get what the intent is here. We could wordsmith this till the

[Alice M. Emmons (Chair)]: Cows come out,

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I get it.

[Troy Headrick (Ranking Member)]: We have it defined in statute.

[Unidentified Member (House Corrections & Institutions Committee)]: We have it defined.

[Alice M. Emmons (Chair)]: Is that in our definition?

[Troy Headrick (Ranking Member)]: Yeah. Is it? And it's related to It's

[Alice M. Emmons (Chair)]: in current statute.

[Troy Headrick (Ranking Member)]: Related to 18 BSA two fifty one. I've already sent it to Tate in case we want to print it out.

[Alice M. Emmons (Chair)]: Okay. I

[Troy Headrick (Ranking Member)]: anticipated it's getting here.

[Alice M. Emmons (Chair)]: So then this section goes on, Doctor, to say the contractor would ensure the inmate's access to all necessary and appropriate medical and mental health care, routine and preventive medical care to an inmate's sex characteristics and affirming medical care, including mental health care as related to gender dysphoria or gender affirmation. So that's current language. At this point, I know we're not going to stay with this, but when we revisit this later on in a few weeks, this will be our starting point. So you may not be able to weigh in on it as much today, but in a couple of weeks, we'll have you back to really weigh in on this. Does that make sense?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I'm comfortable with that, yeah.

[Alice M. Emmons (Chair)]: Then we come into screening and assessments that when a person is coming into a facility and within fourteen days, And I'm assuming this would be I'm not sure if this includes ten days or not, the new language on B and C. The physical assessment would identify any medical needs, Health needs related related to gender affirming care. Are you able to do that now? Do you do that now?

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Can you tell me which page in line you're on?

[Alice M. Emmons (Chair)]: I'm sorry. Page 12, line sixteen and seventeen. That's under screening and assessments.

[Troy Headrick (Ranking Member)]: Is he looking at one point three? One point three, yeah.

[Alice M. Emmons (Chair)]: Screening and assessment, that would be, I'm assuming that would be when folks are coming into the facility, though it's not really clear if it's within that fourteenth day. Yeah,

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: the way I read that is that would, gosh, this is a person in our men's facility with a uterus and we're going to have to make sure that we have on our mind screening for, cervical cancer. That's how I got that. If it means, well, this person is on zero point four milligrams of estrogen and they want to be on zero point six and we have to make sure we do that today or else we're violating that. And I don't think it's the latter. And it could be, not that we wouldn't do that, but I'm just saying, you kind of have to triage what you're dealing with there. And so I review that as you should know who you're taking care of and what they need. The only other thing I would add to that, and I don't see this as, it doesn't concern me, I don't write bills for a living. People reveal what they're revealed to when they're ready. I don't want our clinicians to feel like they have to hammer all of the details out of everybody because that's what they're required to do. There's a time and a place when somebody's ready to reveal things to you.

[Alice M. Emmons (Chair)]: It may not be when they first enter Absolutely not. Facility and their booking.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Right. Right. And so I think I I don't have a big problem with this, you know, might be say, you know, within a therapeutic way or something, I don't know. But I I don't see this as an issue personally.

[Troy Headrick (Ranking Member)]: Ask a question. At the risk of opening this up again.

[Alice M. Emmons (Chair)]: It's right there again.

[Troy Headrick (Ranking Member)]: We are So section 1A that begins on 13 clearly identifies that this is the point in admission to correctional facility where we're gonna initiate a physical assessment. Do we need C here? Because this reverts back, it's the same language, it's identical, to departmental search, not a physical assessment.

[Alice M. Emmons (Chair)]: But Troy, the wink is distracted. I'm wondering, is it a screening and assess It's talking about medical care of inmates. And A is provision of medical care. And B is B, 1A pertains to that fourteen day minimum.

[Troy Headrick (Ranking Member)]: Yeah.

[Alice M. Emmons (Chair)]: 1B deals with screening and assessments. I'm not sure if it's within that fourteen or if the person's been there for a couple of years.

[Troy Headrick (Ranking Member)]: Right, that's fine too.

[Alice M. Emmons (Chair)]: The way it's laid out is confusing.

[Unidentified Member (House Corrections & Institutions Committee)]: We can fix that,

[Troy Headrick (Ranking Member)]: but my question remains, do we need C here? Because all of a sudden we're talking about departmental searches again.

[Alice M. Emmons (Chair)]: Again, and if the inmate's genital status is unknown, it may be determined during conversations with the inmate, well, who has those conversations? Is the DOC staff or the contractor?

[Troy Headrick (Ranking Member)]: I just don't know that we should be talking about departmental searches again within the context of medical assessments.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I would agree from my own standpoint that to me, I feel like here I could be interpreted as an agent for the department. Unless that's fine somewhere else.

[Troy Headrick (Ranking Member)]: Don't think we need to see here. Right. Repeated here. Problems with CSI, I don't think, even once we get them fixed, it should be here. Do you agree with that?

[Alice M. Emmons (Chair)]: That will be it for the medical care. Eulinger, it's been very helpful today because we know with this medical care section, I think where we're headed because, as I said, some folks are missing a little bit earlier this morning. Hillary, our legal counsel, approached me yesterday after we finished work. She had had some conversations with her colleagues in led to counsel the two legislative staff folks who work directly with medical and Medicaid with Committee on Human Services and Committee on Healthcare. They had some concerns about this section of the bill, really wanted to work more in-depth with it, because they're just in such a crunch with Crosshilder that what I think we may be doing as committee, people are amenable to this, is just put in some placeholder language so that it allows us time to keep the bill moving. And while the bill is over in the Senate, we can come back to this issue when people have more time really focused.

[Troy Headrick (Ranking Member)]: So by that, do you mean that we'll oppose language and work with them to put it in or that we'll amend it when it gets back?

[Alice M. Emmons (Chair)]: We'll have to work with whatever committee this goes to in the Senate, which we're trying to figure that out. But we're gonna have more time after we get out the capital bill to really get our head around this and bring in folks to testify, and they're not so busy and work up language. And then from there, we don't know what the process will be.

[Unidentified Member (House Corrections & Institutions Committee)]: And are you saying that sort of generally about the language or do you

[Troy Headrick (Ranking Member)]: mean like like this part or a couple

[Alice M. Emmons (Chair)]: of part only for the medic, medic, the medical part. So we could put in language such as. In terms of how we proceed with medical care for inmates who are in transition, the Joint Justice Oversight Committee needs to look at current practice and come back with recommended language. Just do something like that. So at least there's a section there that deals with medical care. But it doesn't lock in any language. So it's a placeholder. That's called placeholder language.

[Kevin Winter (Member)]: I don't like to use the term again, but I'm still interested in the magnitude, the sample size that you've experienced.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Yeah, it's about I asked and I put in the chat, it's about we're currently we're following about 11 or 12 folks in our system out of somewhere between fourteen and sixteen hundred.

[Kevin Winter (Member)]: Thank you very much.

[Alice M. Emmons (Chair)]: Again, they're under state custody. We're not this language to talk it more with folks who are incarcerated, but we're also looking at the safety within the facility and the culture within the facility. And as was testified yesterday from DOC, there are staff members who are transitioning as well. So it's more than just folks who are incarcerated under state custody. It's folks who are our employees, our state employees as well. For that, one thing that we are looking at. Doctor, is. We're looking at right now, and a version is to codify, put in statute, the PREA standards, Prison Rate Elimination Act. Do you have any thoughts or weigh in at all about PREA in terms of what your world or not? I know that's a little different than what we gave you a heads up on.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: I know I don't. I don't. But I, no. Not off the top of my head.

[Alice M. Emmons (Chair)]: Anything else, Doctor, before we take a break here? I want to thank you, Doctor. Ulicer, for really accommodating your time. Yes. For us, this is very helpful. What it really did is help us clarify some language in the draft that we've been working on that's not in the medical care sections specifically, but in other sections that does pull out the medical provider being involved. And you really helped clarify that for us.

[Dr. Jim Mulliger (Statewide Medical Director, WellPath for Vermont DOC)]: Well, I just, I thank the committee for their patience. And, you know, ten years ago, this was something we were hardly talking about and we're trying to all, so thank you for the times where I'm still trying to get my head around it, and I really appreciate

[Troy Headrick (Ranking Member)]: it.

[Alice M. Emmons (Chair)]: We all Join

[Troy Headrick (Ranking Member)]: the crew.

[Alice M. Emmons (Chair)]: We all are, but at least the key is we're we're working in a respectful manner. And we want to ensure that WellPath and your employees as well as DOC and their employees are respectful, as well as inmates are respectful.

[Kevin Winter (Member)]: That's the goal.

[Troy Headrick (Ranking Member)]: Good one.

[Alice M. Emmons (Chair)]: Thank you.

[Kevin Winter (Member)]: Thank you. Thanks, Doctor. Thank you.

[Alice M. Emmons (Chair)]: So, folks, let's take a break.

[Troy Headrick (Ranking Member)]: We'll be

[Alice M. Emmons (Chair)]: back here at 10:00. John just

[Troy Headrick (Ranking Member)]: John. John's John. I was jumping ahead.

[Alice M. Emmons (Chair)]: A good draft of the telecommunications bill, and maybe we can have a possible vote.

[Troy Headrick (Ranking Member)]: When we have time, want to them no one.

[Alice M. Emmons (Chair)]: Oh yeah. Yeah, you signed off, right?

[Troy Headrick (Ranking Member)]: Yeah, it

[Unidentified Member (House Corrections & Institutions Committee)]: was a two second thing.

[Alice M. Emmons (Chair)]: Yeah, signed off.

[Troy Headrick (Ranking Member)]: The quick version, our big massive committee conference,

[Unidentified Member (House Corrections & Institutions Committee)]: the

[Troy Headrick (Ranking Member)]: only thing that happened, they agreed with all of our stuff. They only wanted where we had taken out our state buildings. For inventory. The inventory.

[Alice M. Emmons (Chair)]: Want They didn't name a building after Alice. No. That's weird. Correction.

[Troy Headrick (Ranking Member)]: So I'm just trying to get through so people can have a break. But anyways, they wanted that in, and the reason why they wanted it in is because they wanted to have a list so that they could compare if we're leasing property and then we're at the same time trying to say, well, have empty space that we own. Should those people in a leased property be in the places we owned? Like, so that was their rationale. We're like, we're not fighting over this. So that was the only change we made. So So

[Unidentified Member (House Corrections & Institutions Committee)]: for the same reason, I'm not coming.

[Alice M. Emmons (Chair)]: Same reason why.

[Troy Headrick (Ranking Member)]: It was

[Alice M. Emmons (Chair)]: So right now, they already do that because they figure out they're looking all the time how much they're paying for leases in a community. And when that hits a certain level where it would be cheaper to have some in a facility, they're gonna move them to a state owned facility or build one.

[Troy Headrick (Ranking Member)]: So we didn't have a problem with that.

[Kevin Winter (Member)]: Sorry for

[Alice M. Emmons (Chair)]: that. But that's all. Okay. Let's take a break and show you come back here in a timely manner so we

[Kevin Winter (Member)]: don't

[Alice M. Emmons (Chair)]: keep John