Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Welcome back after a very, very short little break of changing the guidance. We're continuing on budget adjustment and we have Vermont Department of Health in to go over budget. This is always really confusing, which is human services actually has jurisdiction over most of Department of Health, but there's so much of it that interlapse with healthcare. It is very hard to

[Brian Cina (Member)]: It's very to in technical

[Rick Hildebrandt (Vermont Department of Health)]: healthcare and human services. I completely agree. And in truth, really, what I was hoping to do is take this opportunity to introduce myself and tell you a little bit about me, what my experience has been so far, what some of my priorities are, you know, having stepped into this. And that'll that'll be much of what I talk about. So I think that's helpful regardless just to to do that with you guys. So anyway, nice to meet you all. My name is Rick Hildebrandt. As many of you know, I am a physician. I am still practicing. I work to see patients on the inpatient unit at Rutland, and I've done that for thirteen years. So inpatient medicine is my love. I've been in Vermont since finishing my residency in Dartmouth, again, thirteen years ago. And when I started practicing here, there was a couple of things that were immediately apparent to me. One was that there were decisions that were being made at the time that there was not a single clinician at the decision table, and they were making some decisions that were confusing to me because of that. And it wasn't because they weren't invited. It wasn't that people didn't want doctors or nurses there. It's just that people weren't really raising their hands to join the meetings. A lot of clinicians really just want to do clinical medicine. So I started inviting myself to a lot of meetings, and that found me on a leadership track at the hospital, which was not in my plan at all. I was planning to be a clinician my whole life. But I ended up in a series of promotions over the time I was there and into leadership and executive positions. The other thing that was immediately apparent to me was that I can't solve the problems of my patients in the four walls of the hospital. They're bigger than me. They're bigger than us in that building. So I started working with local community partners first on very tangible hospital kind of things like readmission rates and ED utilization, things that I knew a lot about. And care coordination with our primary care physicians, with our area VNAs, the skilled nursing facilities, to just improve the care of patients. And that was very successful. But as time went on, I still saw the same issue where people would come back time and time and time again with the same problems. And it really boiled down to the social drivers of health were causing a lot of folks to need health care. They didn't have access to, and you guys know this more than most do, they didn't have access to transportation or to money or to food or to all the things that are required to be healthy in life. And as a result, they end up getting chronic illnesses and getting hospitalized. So that led me to seek out different boards and commissions around the state. I joined the local designated agency's board. I joined the board of Vital. At that time, I was something called the CMIO, which is chief medical information officer. It's really interesting job, the interface between EMRs and doctors, which is a challenging space to say the least, but gives you a lot of insight. I have interest in technology and data. I joined the Board of Medical Practice, and I served as their chair for four years, which was great to get into that sort of regulatory space a little bit and understand a little bit about medical regulation. Anyway, I was also the COVID czar at our hospital and got involved in that a lot and enjoyed the I was the chair of the Confection Control Committee. And for a while, I had said to myself, hey, if and when Mark decides to retire, I'll consider throwing my hat in the ring. And when he did, a lot of people sort of encouraged me to seek out the position, and I did. And after six or eight months, I found myself here. It took quite a process to get through, but it's been a whirlwind. Since arriving at the health department, I've been really, really impressed with the caliber of the people that work there. I don't know what I was expecting exactly, but these are phenomenally intelligent, incredibly caring individuals who they're driven so much by the mission of the health department. And that was really striking to me. I'm learning a ton. I'm learning that I have a lot more to learn. And I'm learning from the colleagues that I have at the health department who are really knowledgeable. So here are the vision, the mission, the values of the health department, I just put that up there to share it with you and also say that part of the reason I also did seek out this position is right now is an interesting time in public health. There is an attack on science and on public health itself, and that felt like a calling to me, and this vision really did, and the mission really speak to me as well, and part of it is when I sought out this position.

[Alyssa Black (Chair)]: All

[Rick Hildebrandt (Vermont Department of Health)]: right, so public health is a hard thing to define. I've certainly found that to be true. And in the health department, we use this scheme to try and define it, detect, connect, prevent, respond. So as a tangible example, a number of months ago, we detected a number of cases of pertussis, which is whooping cough, in a school in Washington County. And we responded by providing the school community with the resources that they would need to help immunize or protect themselves with PPE. And we alerted the area health care providers to help them prevent the spread and share the knowledge. So detect, connect, prevent, respond is the approach we use. And we do this in, yes, infectious diseases, but there's so many other places that the health department touches that I didn't know about, whether it's environmental health, school nursing, chronic disease, building healthy behaviors. There's so many different places that the health department does connect that's not just the ones we hear about with Cyberonics. So I often refer to this organizational chart just to remind myself of all the different areas that we are involved with, and we call this the chicklet map. And

[Brian Cina (Member)]: all the pieces Because the little things like chicklets. Chicklets. Not even, like, chickens.

[Allen "Penny" Demar (Member)]: Was about to

[Alyssa Black (Chair)]: pick like, see,

[Megan Pope (Financial Director, Vermont Department of Health)]: it's that you should not But I have good day. That's to eat. Right?

[Rick Hildebrandt (Vermont Department of Health)]: Right. So the Chicks. Chickens.

[Alyssa Black (Chair)]: You know?

[Rick Hildebrandt (Vermont Department of Health)]: The health department has a wide range of activities, from very concrete clinical things like the Office of the Chief Medical Examiner, nursing home visiting, or the laboratory testing that we provide across the state. And then others that are much more community based, like chronic disease prevention, health promotion, environmental health, which looks at water, air quality, and food safety. And thankfully, we have experts in all of these fields, I am not an expert in all these fields, but we have incredibly intelligent, well educated individuals who know a lot of stuff about these things. So if there's ever an area where you are all interested, I can make sure to bring the right person that can answer your questions.

[Alyssa Black (Chair)]: Can I answer dumb questions?

[Rick Hildebrandt (Vermont Department of Health)]: No dumb questions.

[Alyssa Black (Chair)]: Yes, there are. But sometimes you can do dumb questions. What's the difference between the green chiplets and the blue chiplets?

[Rick Hildebrandt (Vermont Department of Health)]: So yes, there's a different one that separates them out. The green are in the commissioner's office.

[Alyssa Black (Chair)]: Okay.

[Rick Hildebrandt (Vermont Department of Health)]: So and the blue chocolates are within divisions. Okay. Thank you. That's what they

[Brian Cina (Member)]: I thought maybe it was, like, sugar and, like Oh,

[Alyssa Black (Chair)]: that's Yes.

[Rick Hildebrandt (Vermont Department of Health)]: That is.

[Brian Cina (Member)]: Like flow charts. Alright, so one

[Rick Hildebrandt (Vermont Department of Health)]: thing that I felt is very strongly as part of my job is to ensure that I preserve the trust in public health. Vermont came out of the pandemic with a high degree of respect of the health department. That is not true everywhere. There are some states in our nation where the health department had a really bad rap after the pandemic. That was not true here, and I credit the health department and Doctor. Levine for doing the work that they did to keep that. And I have to maintain that trust despite a near onslaught of attack against public health, which has been challenging at times. But we need to be the rock that people can rely on for trusted medical science and research information. That needs to always be the case. We always have to make sure we have accurate information that we're providing to the public. So that's something that I feel very strongly. The other piece, though, is trust is about relationships more so than authority. So having people in our local communities who know the individuals that work there, that know the staff persons, the school nurses or the clergy persons or the individuals in schools or in hospitals, in our local district offices and around the state, they can build those relationships and have that trust. And that is so valuable within the health department. Alright, so there are a few issues that I wanted to touch base on that have already come to surface and will certainly continue to come to surface over the course of the year. First among them is immunizations. So with immunizations, there have been a lot of false claims of falsehoods that have been fueled by these changes that have been happening at the CDC. Just this past week, we've heard some pretty loud announcements around changes to their recommended vaccine schedule. And we have, for a long time now, for several months, been working with a large group of stakeholders within state government to ensure that regardless of what happens on the federal landscape, Vermonters continue to have access to immunizations. That includes Caledonia, who's the Department of Vermont Health Access, OPR, Financial Regulation, and many, many more. And we've been working with you all and with other legislators to introduce some legislation to make sure that, again, Vermonters continue to have access to vaccines and that we publish the most up to date research on what is effective. We're going to do

[Alyssa Black (Chair)]: a flyover drive through of the bill that Human Services has in their committee. We're going to do that next week. Need to. Five four to come.

[Brian Cina (Member)]: Yes. Were the pertussis outbreaks related to a lack of immunization?

[Rick Hildebrandt (Vermont Department of Health)]: Every case of pertussis was either unvaccinated or under vaccinated. Thank you. Every case. I can tell you I had a whooping cough. So way back when, they didn't give boosters because we didn't know. So if you were old enough, they would wear off, and it was awful. I mean, was really terrible. Now it wasn't as kid as at that age. As an infant, it could

[Brian Cina (Member)]: be deadly, but You're supposed to get boosters for that?

[Rick Hildebrandt (Vermont Department of Health)]: Yeah. Yeah. Oh, I'm sorry.

[Brian Cina (Member)]: It's in the it's in

[Rick Hildebrandt (Vermont Department of Health)]: the tetanus shop.

[Allen "Penny" Demar (Member)]: It's in the

[Rick Hildebrandt (Vermont Department of Health)]: tetanus shop. But the TDAP has it in. But it's you know, because you cough until you vomit. Yeah.

[Brian Cina (Member)]: It's just I'm awful. I'm an anti vaxxer now. So

[Alyssa Black (Chair)]: Tell me your no.

[Brian Cina (Member)]: Thanks. Let's not get into it today because people

[Alyssa Black (Chair)]: I'm don't wanna happy

[Rick Hildebrandt (Vermont Department of Health)]: to talk

[Brian Cina (Member)]: about it later.

[Alyssa Black (Chair)]: All right.

[Brian Cina (Member)]: The doctor may convince me otherwise, though.

[Megan Pope (Financial Director, Vermont Department of Health)]: Take five minutes.

[Brian Cina (Member)]: Okay. Let's move on. The next one,

[Rick Hildebrandt (Vermont Department of Health)]: that has certainly come to light is around substance use disorder. This isn't a new problem we have in Vermont. And frankly, Vermont has done an excellent job at our response to substance use disorder. The hub and spoke model, I think, has been particularly effective. And I've seen that in my own practice, where ten years ago, when I was caring for folks in the hospital, they were actively using IV drugs and had endocarditis or infections of the heart valves routinely. And I'm seeing so much less active IV drug use and more people who are in recovery, maybe with relapse, and you still support the endocarditis, but it's dwarfed by the number of people who are in recovery or get in treatment and receiving Suboxone or methadone or some form of treatment, which is really, really encouraging. That being said, there's certainly gaps and challenges within our system. Recovery housing is gap that we have for sure right now. There's a spectrum of care that we need for folks who need covered services. They need hospitalization and acute services. They need residential treatment facilities. We recently worked with Valley Vista to open a lower intensity residential treatment facility, which is wonderful. And then recovery residences, which is that longer term measured oftentimes in years where people live and work with oftentimes peers who are in recovery themselves. The other piece about substance use disorder, though, is the landscape is changing. It's been heroin and opiates for many, many years in Vermont and around the country, and it's changing. We're seeing much more stimulant use disorder, cocaine. And unfortunately, we have seen some increases in methamphetamines, which is, in my assessment, the worst thing that humans have ever invented. It is just so hard to treat and so hard to help people who have meth use disorder. People can become very, very violent when they're using it because of the stimulant effects. And my colleagues around the country who care for folks with this regularly, it's really harrowing the stories that they can tell you. So it's not very high in Vermont with math, but it is unfortunately increasing, and stimulants around the country are increasing as well as in Vermont. Polysubstance use, though, is also a significant challenge. So it's something we're keeping a very close eye on. We're changing some of our reports to show not just opiates, but also other drugs of abuse because of that.

[Alyssa Black (Chair)]: Allen?

[Allen "Penny" Demar (Member)]: Here's a question. I think I just saw something, supposedly the news. Drug deaths have dropped, but the drug use mostly has increased twenty three percent to twenty five percent. So do we have medicine that counteracts that, or what's the reason for that? So I don't know that I

[Rick Hildebrandt (Vermont Department of Health)]: can speak to the exact reason for that. I can tell you there's no MOUD. There's no Suboxone or Methadone for stimulants, okay? So that's part of the challenge, that the treatment options are not the same. And an MOUD really has been a game changer in the opioid world. It has significantly helped. There has been a change, which is a good change, if you can see it that way, from IV drug use to inhalant drug use. Inhalant drug use, I. E. A crack pipe, is far less lethal than IV drug use, and it has less risk of infection. So some of it may be fueled by that, but we definitely are still seeing a high number of overdoses and overdose deaths. A lower percentage of them are from opiate. All right, and the last thing that is very clear to me, a priority of myself, of the department, of the state is around access to care. Health care transformation is something very near and dear to my heart, and this is certainly not something that is entirely owned by the health department, but it's something that I've been in healthcare for many years, and I've seen the challenges that we have. And I know the important work of this group and many, many others in helping with healthcare transformation and what that looks like. What I feel is very important is over the course of that transformation, we need to make sure we have access to her monitors. And that requires a lot of care and attention to make sure that these changes don't happen and patients get stuck in the cracks. We don't want So while health care is not public health, there's not 100% overlap. Access to health care absolutely can become that. So obstetric care, I think, is one that has been discussed a lot. And it's important that we continue to have access to birthing moms, both pre and postnatal, regardless of where you are in the state. Transportation is a huge challenge. As we talk about regionalization of health care, we need to have a rock solid transportation system. We don't have that right now. EMS does fall under the health department. And I've been working with our EMS team because that is absolutely something we want to help with to make sure that these efforts are going well. And then reproductive health care. This is a critical service, and it is protected by our constitution. And there is significant concern on the federal level that it's under attack. So we want to ensure that we have access to care for all Vermonters. I know for sure that change needs to happen. I can tell you firsthand that we have massive changes that need to occur. But in that change, we do need to ensure that we have access for our updates in the market. Any questions for me? Otherwise, I would hand it over to Megan. How many

[Allen "Penny" Demar (Member)]: more slides do we have left?

[Brian Cina (Member)]: Because I don't see it online and I'm trying to not answer, ask questions if I see it coming.

[Alyssa Black (Chair)]: This is basically the last, there's two more slides. I'm gonna

[Brian Cina (Member)]: wait and then I'll ask at the end, thank you. Take your time.

[Alyssa Black (Chair)]: I have a whole health question, which may not be now, but I think it's a vermantis guy of cardiovascular disease. So thinking about that and the approach towards that is something I'm interested in. So when it's appropriate to think about it and talk about it.

[Rick Hildebrandt (Vermont Department of Health)]: Yeah, chronic disease prevention.

[Alyssa Black (Chair)]: Yeah, prevention is moving upstream. And I don't want to take time right now.

[Rick Hildebrandt (Vermont Department of Health)]: No, I completely agree with you. Just learning about the budget of the health department, and when you look at the cost of a disease like diabetes versus how much we spend to try and prevent it, it makes me baffled. Because you're right, if you can prevent some of these illnesses, you can prevent massive costs. Now, it's an investment in decades, But it's still

[Alyssa Black (Chair)]: But it's very a conversation I'd love to have with you. Absolutely. Hello.

[Megan Pope (Financial Director, Vermont Department of Health)]: For the record, I'm Megan Pope, financial director at

[Alyssa Black (Chair)]: the department.

[Megan Pope (Financial Director, Vermont Department of Health)]: Thank all for having us. We're now into the numbers side of things. So our 2026 budget adjustment is rather small. We really only have two asks. The first you might have seen in other areas of AHS, it's just a transfer of general fund and federal fund from the agency central office to departments for increased costs for our agency and digital services agreement. So that's you may have seen that before. Really, the biggest piece of substance in our budget adjustment is a swap of funding due to the federal HR one bill. We're asking for $300,000 that was previously in our budget as global commitment investment to be funded as general fund because HR1 put restriction, a one year restriction on Medicaid funding to Planned Parenthood for family planning services. So that is really what the biggest piece of our budget adjustment. What was this

[Alyssa Black (Chair)]: for to plan parent? Yeah, a grant.

[Megan Pope (Financial Director, Vermont Department of Health)]: Have a it was a two year grant. It ends 06/30/2026. But usually, you know, it's we've historically given out this money annually. And it's the funding is intended to support the administration operations and outreach family planning services that they do.

[Alyssa Black (Chair)]: So I'm curious about the agency digital services. And I gather, I see that it's net neutral to HS, but not to you. Yes. I'm trying to understand how

[Megan Pope (Financial Director, Vermont Department of Health)]: Yep. The Agency of Human Services has the money. The way we budget for these costs is the agency gets the money and then distributes it out to different agent departments based on utilization. It's for things like nursing office support, those broader IT level services. So the agency kind of gets that initial pot of money and then distributes it to the departments based on.

[Alyssa Black (Chair)]: They charge you for it.

[Megan Pope (Financial Director, Vermont Department of Health)]: Well, we get charged for it, but the money is first appropriated to the agency and then it's divvied out to the department. So that's really what this is doing. AHS will have

[Alyssa Black (Chair)]: a down. We have an up, What would happen if that went away?

[Megan Pope (Financial Director, Vermont Department of Health)]: The agency of digital services.

[Alyssa Black (Chair)]: Yeah. Or the agency of digital services with that. I mean, that's a new department. Relatively newer. Let me ask him.

[Allen "Penny" Demar (Member)]: ADF is like our digital, it was rebranded, not new. Okay. And it's like basically the state IT department. You get rid of state IT department, must have get rid of our computer.

[Alyssa Black (Chair)]: Okay. Yeah, we'll

[Megan Pope (Financial Director, Vermont Department of Health)]: talk It's always been around, but didn't we make some changes since I've been here where more of the work that was being done maybe in the agencies, separate agencies are now all in ADS, which is why they're doing this. So now you all don't necessarily do the IT work. The IT staff are technically employed by the Yes. Okay. Thank you.

[Alyssa Black (Chair)]: Rent on the IT.

[Megan Pope (Financial Director, Vermont Department of Health)]: Yes, this is our portion of

[Alyssa Black (Chair)]: the state of IT support that we received. I I know the health department is largely federal grant funded. I can't remember what your budget, but it's a big percentage of

[Megan Pope (Financial Director, Vermont Department of Health)]: federal It's roughly, I haven't looked in a little while, but usually about 50% of our funding.

[Alyssa Black (Chair)]: So I'm curious as to, with things that, you know, we see in the news and stopping this and this grant cut out. How has any of this affected? These are grant funds, which means that they're not appropriated through the legislature.

[Megan Pope (Financial Director, Vermont Department of Health)]: Receive spending authority

[Alyssa Black (Chair)]: from the legislature. Authority. I'm wondering just how is it going? So

[Rick Hildebrandt (Vermont Department of Health)]: Mening can maybe speak to the specifics, but we really haven't seen that much in terms of grants not being continued, which is really, really good. Now, there are some grants that are coming up that are going to expire that we are worried about. They may not renew, but grant payments have come through, and really, we haven't seen much change. Now, that could all absolutely change, and we don't have a budget yet, obviously, so that could have a significant impact. We are hopeful that it's all posturing and not a whole lot of substance, but we don't know until we see it.

[Alyssa Black (Chair)]: I'm assuming you're not seeing a whole slew of new grant opportunities.

[Rick Hildebrandt (Vermont Department of Health)]: I mean, the only new grant opportunity is RHT, which is not a small grant, But outside of that, there's not new ones that we're seeing in the public health space.

[Alyssa Black (Chair)]: Well, do you know? Yes, go ahead, Brian. And then we're going to finish up, so we'll move it to the floor sometime.

[Brian Cina (Member)]: It's distantly related to the presentation today, and ultimately I'm hoping we can talk offline, but when Representative Demar asked about stimulants. You said that there was no MOUD. MOUD. Are you familiar with Ibogaine?

[Rick Hildebrandt (Vermont Department of Health)]: I'm not up to date research on many of those things. I've talked to some folks in the addiction field about what they are doing, and that's sort of the message that they gave me. It's not the same field. There's not a very clear everyone should be on this medication.

[Brian Cina (Member)]: Yeah, it's a one time medicine anyway. Can we find a time to talk offline about this? Because I have a lot of information to share. Okay, thank you. Absolutely.

[Alyssa Black (Chair)]: Did I see you hand up over to my peripheral vision?

[Allen "Penny" Demar (Member)]: No, I do have a request. Yes. New commissioner, I'd like to let her know where we're all from.

[Brian Cina (Member)]: Yeah. That'd be great. Sure. Sorry.

[Alyssa Black (Chair)]: Yes. Where are you really from? I'm so sorry. We wanted to end introductions with you. I thinking about introducing new members.

[Brian Cina (Member)]: Don't you start? Allen Debra,

[Allen "Penny" Demar (Member)]: I represent Ennisburg and Montgomery.

[Alyssa Black (Chair)]: Val Taylor, District Of Levene. Wendy Critchlow, and I represent Chester.

[Brian Cina (Member)]: Brian Cina, East District Of Burlington.

[Alyssa Black (Chair)]: Daisy Berbeco Wernuski. And Alyssa Black, Essex.

[Allen "Penny" Demar (Member)]: Harper McFaun and I'm from Barretown, represent Barretown, and Williamstown, part of it.

[Alyssa Black (Chair)]: Daisy Powers, I represent Waterford, Barnett and Red Gate. Karen Lueders, Lincoln, Bristol, Scottsdale, and Washington. Addison, four. Leslie Goldman, Rockingham, which is Bellis Falls, Westminster, and Brookline.

[Megan Pope (Financial Director, Vermont Department of Health)]: And Lori Houghton, City of S. Extension. You're welcome.

[Rick Hildebrandt (Vermont Department of Health)]: Thank you very much, appreciate

[Allen "Penny" Demar (Member)]: your time. Good luck.

[Rick Hildebrandt (Vermont Department of Health)]: It's been great so far.