Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Good afternoon. Today is Tuesday, January 13, we are doing just a flyover drive through, whatever we've decided to call it, of a bill that is currently in human services around immunization recommendations from the Department of Health. And they have jurisdiction over public health. So that is why it's in their committee. So we don't have We have no jurisdiction over this. We don't have to vote on this. We can certainly ask lots of questions and then make any recommendations that we have to human services as they move forward or not with this bill. So we have Katie to give us a walk through of the bill.

[Katie McLean (Office of Legislative Counsel)]: Good afternoon. Katie McLean, Office of Legislative Counsel. Let me pull up the document.

[Alyssa Black (Chair)]: Okay.

[Katie McLean (Office of Legislative Counsel)]: So this is H. Five forty five. This is draft 2.1. Human Services hasn't seen draft 2.1 yet, but Chair Wood said it was fine if we posted this version and walked through it because this is a reflection of their latest thinking after we've done some markup. So what this bill does, this bill changes the way that recommendations on immunization schedules for adults and children are made in Vermont. Right now, we have statutory language that the recommendation relies on the federal CDC's recommendations. What this does is it changes that process and instead has our Commissioner of Health, the Vermont Commissioner of Health, making those recommendations with input from a specific working group. And also looking at recommendations from a variety of professional organizations, including the CDC. So what does this do? There's already an immunization program in the state for the purchase of immunizations. This doesn't change that there's a program in place. This allows immunizations that are recommended in Vermont to be purchased at the lowest cost possible. This continues the existing insurance coverage, so it's cost neutral in that way. Right now, companies pay a surcharge for immunizations, and that will continue to be the case for those that are recommended in Vermont by the commissioner. And this language also would allow a pharmacist to administer an immunization that is recommended by the commissioner. So those are sort of the main things that this bill does. This bill looks very long. The reason it looks so long is because it sunsets. So this process with the commissioner making recommendations would be in place until 2031. And at that point, we revert back to the language that's currently in statute. In order to effectuate that in the bill, we had to show all of that language again as it currently is. So the bill looks to be almost twice as long as most of the substantive changes are. So I've tried to put very clear reader headings to show us where we are because it is very confusing when we're sunsetting language. So the first three sections are kind of the package of what I described, which is replacing the CDC recommendations for the Commissioner of Health recommendations. First, in this first section, eleven thirty in subdivision four, there's currently a definition of immunizations and it refers back to the CDC's Advisory Committee on Immunization Practices. So that language isn't struck. Instead, there's a new term that's created, which is recommended immunization. And this means a vaccine or other immunizing agent that provides protection against a particular disease or pathogen and the application of the immunization as recommended by the practice guidelines for children and adults established by the commissioner pursuant to eleven thirty a of this title. Eleven thirty a is a new section that we're going to look at next, And that is the process by which the commissioner can make recommendations. So it's referring to that process. So whenever you see the term in this bill recommended immunization, you'll know that it is referring to that process whereby the Commissioner of Health is making the recommendation in consultation with a special committee. Next, we have some small changes, mostly changing the use of vaccines recommended immunizations. But this section describes the current immunization program that the Department operates. So we have the Department of Health. We're just striking of health because it's already in Title 18, so it's already inferred that it's the department, is to administer an immunization program with the goals of ensuring universal access to recommended immunizations at no charge to the individual and reducing the cost at which the state may purchase recommended immunizations. The department shall purchase, provide for the distribution of and monitor the use of recommended immunizations as provided in this section. The cost of recommended immunizations and administrative surcharge shall be reimbursed by health insurers as provided in the following sections. So again, this is mostly existing law, but we're changing the term vaccines to recommended immunizations to reflect that definition change up above.

[Allen "Penny" Demar (Member)]: When we say health insurers, is that insurance company, Medicare, Medicaid? Is that

[Katie McLean (Office of Legislative Counsel)]: insurance, I believe, is paying for most of the vaccines. Medicaid is a question for the health department. I would assume yes.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: For adults, yes.

[Katie McLean (Office of Legislative Counsel)]: For adults. Okay.

[Alyssa Black (Chair)]: Thank you. Awesome. You. I wonder if you know where I went.

[Katie McLean (Office of Legislative Counsel)]: In Subdivision 2, the department is to solicit, facilitate and supervise the participation of health care professionals, health care facilities and health insurers in an immunization program in order to accomplish the state's goal of universal access to recommended immunizations at the lowest tractable cost to individuals, insurers, state health care programs, again, existing law. The department is to analyze and gather data regarding the immunization program for the purpose of ensuring quality and maximizing protection of Vermonters against preventable disease through immunization. In subsection C, the Department shall determine which recommended immunization shall be purchased under the program. The immunization program shall purchase recommended immunizations consistent with the goal of the program from CDC or another vendor at the lowest available cost. So currently the language just has permission for the state to purchase recommended vaccines from the CDC. So there's language here that they could be purchasing at another vendor if doing so is consistent with the goals of the program, one of which is to provide immunizations at the lowest possible cost. Striking through this sentence that the department shall determine annually which vaccines for adults shall be purchased under the program. In subsection B, the immunization program is to provide for distribution of recommended immunizations to health care professionals and health care facilities for administration to patients. In E, health insurers are to remit to the Department the cost of recommended immunizations as established by the Commissioner based on the recommendation of the Immunization Funding Advisory Committee, which we'll look at later in this section. The Department is to charge each health insurer a surcharge for costs and administration of the immunization program. The surcharge shall be deposited into an existing special fund and used solely for the purpose of administering the program. That's existing law and that doesn't change in this proposal. Subsection G. The Immunization Funding Advisory Committee. This is the first of two advisory committees we're going look at today. As established to provide the commissioner with an annual per member per month cost for recommended immunizations for the pediatric population and an annual per member per month cost for recommended immunizations for adult population. And a recommendation for the amount of the yearly immunization assessment. And then we have a list of who is in this committee. We have the Executive Officer of the Board of Pharmacy or designee, the Executive Director of the Green Mountain Care Board or designee, a representative appointed by the director of the Vermont Blueprint for Health. The committee, this language felt different than how we draft now. It had said nominated by the director of the Blueprint for Health and appointed by the commissioner. So now we just have the appointment by the director of Blueprint. Three representatives of health insurers, one each appointed by the state's largest three private health insurers as determined by the number of covered lives. E, a representative appointed by the Vermont Chapter of the American Academy of Pediatrics. A representative appointed by the Vermont Chapter of the American Academy of Family Medicine. And a representative of employers that self insure for health coverage appointed by the Commissioner of Health. That is the membership on that particular

[Alyssa Black (Chair)]: committee. Leslie?

[Leslie Goldman (Member)]: I'm just trying to understand the language. A lot of this is not underlined, but this is a new committee, right? This is not

[Alyssa Black (Chair)]: a new committee.

[Leslie Goldman (Member)]: Okay, so that's what I'm trying to understand. What did the committee do before and what's A

[Katie McLean (Office of Legislative Counsel)]: lot of it is the same. So they're the committee that's responsible for making funding recommendations to the commissioner for the purchase of immunizations. The only thing that's changing is who is recommending the immunizations that they're making their calculations based on.

[Leslie Goldman (Member)]: So the people that are on here are already, this whole establishment is already established. Well, and you get my point. Yes. This is

[Katie McLean (Office of Legislative Counsel)]: not new. This is not

[Leslie Goldman (Member)]: The membership is not new.

[Katie McLean (Office of Legislative Counsel)]: The language is cleaned up a little bit specifications of human services, but this committee exists with this membership.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: Got it. Thank you.

[Allen "Penny" Demar (Member)]: Go ahead, Allen. The per member per month cost, that's already been established?

[Katie McLean (Office of Legislative Counsel)]: Yes. The fact that they are doing that calculation, yes, already part of their purview. Okay.

[Alyssa Black (Chair)]: So this is just a board that already exists, that this cleaned up language, and this has to do with basically the funding of the immunization program.

[Katie McLean (Office of Legislative Counsel)]: Yes, they're making recommendations on

[Alyssa Black (Chair)]: the funding. Funding, yeah. Okay, not the actual immunizations. Correct.

[Katie McLean (Office of Legislative Counsel)]: But you will see another. I want to

[Alyssa Black (Chair)]: be clear what this does existing or not creating anything or changing anything.

[Leslie Goldman (Member)]: I'm just looking at the language which says is established, but that's old language. It's just confusing because it sounds like it's new when it says is established. That's from

[Alyssa Black (Chair)]: the beginning.

[Katie McLean (Office of Legislative Counsel)]: But it's not underlined, so it's existing.

[Alyssa Black (Chair)]: It's a

[Brian Cina (Member)]: case of statute.

[Debra Kildebrand (Commissioner of the Department of Health)]: I can see that's how it's worded though

[Leslie Goldman (Member)]: when it's statutized or whatever. That's a typical statutorily.

[Katie McLean (Office of Legislative Counsel)]: I think we typically do that, that we establish it that way, it's established. But yes, then it continues on and that's what it would look like if they amended it. Okay,

[Alyssa Black (Chair)]: I'm gonna wanna be clear for our two new members in case you haven't had a chance to sit with Jen Berbeco at all. That pretty much all these bills that we look at, they're 26 pages long, but the only changes that are really that we're making are things that are underlined. Or struck

[Brian Cina (Member)]: out, sometimes things are removed and

[Leslie Goldman (Member)]: And not the yellow is the new language.

[Katie McLean (Office of Legislative Counsel)]: Language, yes, the yellow is language that human services hasn't seen yet, or new since their last draft. So thank you. I should have said the significance of the yellow is. We have language in Subdivision 2 about how the committee selects its chair. That's the same Subdivision 3. By January 1 of each year, the committee is to provide the commissioner with an annual fiscal assessment of the per member per month cost for pediatric and adult immunizations, recommended immunizations based on the total number of covered lives by health insurers. And this is the same. We're just switching the defined term vaccines to the defined term recommended immunizations. And then in subsection H, if purchase requirements stuck through federal purchase requirements previous language opened it up to other vendors, not just the CDC, sub purchase requirements do not further the goal of ensuring universal access to recommended immunizations. For all, the commissioner may, following consultation of the funding advisory committee, discontinue the program with six months advance notice to health care professionals and insurers. Again, that's existing language, just changing the terminology around what is meant by recommended immunization. And then we have language about the adoption of rules. So I'm gonna switch over to section two now. Whereas in the last section, that was an existing section of law that we were amending mostly for the definition of recommended immunizations. Now this new section is all new. So this is new standalone section that will be sunset on 2031 under as as is drafted in this draft 2.1. So in subsection a, we list what the commissioner could make is to make recommendations on. So the Commissioner shall periodically issue recommendations regarding which immunizations children and adults are recommended to receive, the age at which each immunization is recommended to be given, the number of immunization doses that are recommended to be administered, the recommended amount of time between doses of an immunization, and any other recommendations regarding immunizations necessary to promote the maintenance of public health and disease prevention in the state. So you'll see that, well, it's highlighted in this draft that the committee next door had a conversation about wanting to highlight the fact that these are all recommendations and not requirements. And that's why a decision was made to add the recommended language in each line. And then in subsection B, we have sort of instructions about how the commissioner is to come to these recommendations for Vermont. So prior to issuing recommendations under subsection A, the commissioner is to first consult with the Vermont Immunization Advisory Council. We haven't seen that group yet. We'll see them next. And second, consider recommendations for immunizations issued by the CDC's Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and any other organizations the Commissioner may deem necessary. So the Commissioner is to look to all of those recommendations as well as consultation with the group that we haven't seen yet. Did the Human Services Committee discuss

[Daisy Berbeco (Ranking Member)]: the possibility of the CDC committee that is specified here of the stability of it? And is there any value in broadening that language?

[Katie McLean (Office of Legislative Counsel)]: I'm sure that's an issue you could raise with them. There's nothing in this language that requires the commissioner to take on any one of these groups recommendations. Instead, it's just a consider consider the recommendations. So it's asking them, the commissioner, to to look at all of these recommendations put out by these different groups.

[Daisy Berbeco (Ranking Member)]: Yeah, I'm just noticing all the other ones list entities, but that one was a specific committee added entity. Thanks, Katie.

[Alyssa Black (Chair)]: Is the CDC's ACIP, are they the only national

[Daisy Berbeco (Ranking Member)]: board of advisors

[Alyssa Black (Chair)]: around immunizations? There's nothing else?

[Francis "Topper" McFaun (Vice Chair)]: But

[Katie McLean (Office of Legislative Counsel)]: I think all of these groups are doing that work and doing their own research.

[Alyssa Black (Chair)]: I just didn't know if that was the one and only organization that specifically targets immunizations.

[Debra Kildebrand (Commissioner of the Department of Health)]: Okay,

[Katie McLean (Office of Legislative Counsel)]: thank you. And subsection C, this is immunity language. So I should just pause and say we have This language was taken from the existing statute on opioid antagonists for somebody who administers an opioid antagonist to an individual. So that's where I pulled this language from. But this says that a health care professional who prescribes, dispenses or administers an immunization in accordance with the recommendations issued pursuant to subsection A of this section shall be immune from civil and administrative liability for immunization caused adverse events unless the healthcare professional's actions regarding prescribing, dispensing or administering immunization constituted gross negligence, recklessness or intentional misconduct. In subsection D, the Commissioner is authorized to issue a standing order to health care professionals, including pharmacists, to prescribe, dispense or administer recommended immunizations for any combination thereof, to the extent that prescribing, dispensing or administering recommended immunizations is within the scope of the healthcare professional's scope of practice. So that's kind of duplicative. So again, this language was pulled from opioid antagonist, where there's also a standing order. I'm going to circle this before I lose it.

[Alyssa Black (Chair)]: What this is basically saying is that cannot be if you're a professional acting within your scope of practice, you cannot be held liable for any adverse events if you were doing what was recommended.

[Katie McLean (Office of Legislative Counsel)]: Yeah, that's what the subsection C is. Unless you're acting inappropriately, negligent, reckless, then if you're acting appropriately within the recommended immunizations, then there's immunity. Subsection E. The department shall prominently display information pertaining to recommended immunizations and other relevant information on its website, including how to access recommended immunizations. And secondly, any documents produced by the department about recommended immunizations shall include a disclosure if the recommended immunizations differ from the recommendations of the Vermont Immunization Advisory Council. So meaning that the commissioner must let me come back up here must consult with the Vermont Immunization Advisory Council, but there's no requirement to accept the recommendations of the Vermont Immunization Advisory Council. And so if the commissioner chose a different schedule that was different than what was recommended from the Vermont Immunization Advisory Council, documents about the schedule produced by the department would have to note that. And then we refer to the definitions in the previous sections. We've already looked at those definitions. Just to be clear, we're creating a new Vermont Immunization Advisory Council. The council already exists, but this expands what its responsibilities are.

[Alyssa Black (Chair)]: And the commissioner themselves, what is their saying is, can deviate from that?

[Katie McLean (Office of Legislative Counsel)]: The commissioner is responsible for coming up with the recommendations. There's guidance about how the commissioner comes up with those recommendations in terms of who they consult with and what recommendations they have to look at. But yes, the commissioner doesn't have to accept the Vermont Immunization Advisory Council's recommendations. And if the commissioner ends up recommending a schedule that does not match with the advisory council, it has to be noted on documents that are produced by the department on this topic.

[Alyssa Black (Chair)]: I guess I just want to be clear that there's all these things that the commissioner has to look at. One of them is the CDC's ACIP, new acronym of the day. ACIP. And if ACIP makes recommendations which are completely contrary to everyone else making recommendations, the commissioner in Vermont unilaterally can decide that's who I'm going with?

[Katie McLean (Office of Legislative Counsel)]: The commissioner would also have to consult with the Vermont Advisory Council. But at the end of the day, the commissioner who's putting forward the recommendations.

[Alyssa Black (Chair)]: Okay. All right. I'll be clear. Yeah, go ahead, Lee. Thank you. Thank you.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: So this does not change or broaden who can administer?

[Katie McLean (Office of Legislative Counsel)]: Not the who. You'll see language coming up about pharmacists. Right now, what pharmacists can administer is tied to the CDC, and this language decouples that so that they could administer the recommended immunizations as defined. So here is the Vermont Immunization Advisory Council that we have referenced several times. You'll see it's not underlined. So this is existing language. This is an existing advisory committee, But there are changes to the membership of the committee and to the charge of the committee. So let's go through that. In terms of who is on the committee, a representative of the Vermont Board of Medical Practice appointed by the governor, The executive officer of the Vermont Board of Nursing are designee. The executive officer of the Vermont Board of Pharmacy are designee. The Secretary of Human Services are designee. The Secretary of Education are designee. The State Epidemiologists are designee, the Department of Health's Immunization Program Manager are designee, a practicing pediatrician appointed by the governor, A healthcare professional as defined at 11:30 of this title who is not otherwise represented on the council. So this would open it up for somebody like an APRN to serve on this council. Two individuals who are professors, researchers or physicians or any combination of these individuals with expertise in infectious disease and human immunizations appointed by the governor. And a family or internal medicine physician appointed by the governor. A representative of public schools appointed by the governor had been both public and independent schools. And any other person deemed necessary by the commissioner. So that is who would be on the advisory council. And then in C, we have the charge of this group.

[Alyssa Black (Chair)]: I think Daisy had a question. Oh, I'm sorry.

[Daisy Berbeco (Ranking Member)]: Why is education the commissioner of education,

[Katie McLean (Office of Legislative Counsel)]: what was the thinking towards adding that person? Because the first charge of this group is to review and make recommendations regarding the state's immunization schedule for school We hadn't gotten there yet.

[Alyssa Black (Chair)]: How many people are

[Katie McLean (Office of Legislative Counsel)]: on this commission currently? Oh, I want to say about six or seven.

[Alyssa Black (Chair)]: And how many? 13. Okay, you couldn't do

[Katie McLean (Office of Legislative Counsel)]: the math. Yeah, don't quote me on

[Alyssa Black (Chair)]: the seven, but it's about seven. Which one? Ones that they added are the underlines?

[Leslie Goldman (Member)]: The yellow or the underline? Or the underline?

[Katie McLean (Office of Legislative Counsel)]: If we were in the yellow, it's the underlining are new.

[Alyssa Black (Chair)]: You didn't really notify

[Katie McLean (Office of Legislative Counsel)]: anybody other than the public school. The independent school.

[Alyssa Black (Chair)]: No one got one got winded off or crossed out. Correct. Okay. Okay. Alright.

[Katie McLean (Office of Legislative Counsel)]: So we just looked at the first duty of this group. The second duty is to provide any other advice and expertise requested by the commissioner, new language, including advice regarding recommended immunizations as defined in 11/30. So that is a new task that this group would perform. Under assistance, the council is to have the administrative and technical assistance of the department striking through legal meetings. The council shall convene at the call of the commissioner, but not less than once each year. The council shall select a chair from among its members at the first meeting who shall not be the commissioner. So there is some conversation that the recommendations go to the commissioner, so it doesn't make sense for the commissioner to chair. And then we have language about a quorum. Okay. Leslie?

[Alyssa Black (Chair)]: Is there some kind

[Leslie Goldman (Member)]: of time frame regarding that these have to be in place in terms of schools? I'm just thinking about you said meet twice a year. Is that sufficient to meet in terms of how it has to get distributed? If that's enough time, I feel

[Katie McLean (Office of Legislative Counsel)]: like that's an open question. The original proposal that Human Services had the health department asked to strike the language, but not less than one year. Mhmm. Human services felt that there should be a time frame in there, so they decided to retain the language. I don't know if they've gotten to the conversation yet about how many times. That's sufficient, yeah.

[Leslie Goldman (Member)]: Yeah, thank you. I appreciate that. Yeah. Thank you.

[Katie McLean (Office of Legislative Counsel)]: Okay. So we're starting to shift gears and now we're going to look at insurance coverage for recommended immunizations. So this, the next two sections are in effect from passage, because that takes effect on passage, and then through the 2031. So I'll just grab our notes.

[Alyssa Black (Chair)]: Daisy, do you have a question? I'm kind of thinking.

[Daisy Berbeco (Ranking Member)]: The group that we just went over, they were charged with just one additional task, that is to be able to advise the commissioner on recommended immunizations?

[Katie McLean (Office of Legislative Counsel)]: That is the new task, the new duty that was given to them.

[Daisy Berbeco (Ranking Member)]: Is there overlap on the membership of that committee and the first committee? I would suspect, yes.

[Katie McLean (Office of Legislative Counsel)]: Well, let me pull this up.

[Daisy Berbeco (Ranking Member)]: And my other thing that I'm waffling with is not everyone on this committee is a medical professional. There's education folks on here. So I'm just wondering whether the commissioner would be consulting or looking for the guidance of an educational professional on health matters.

[Alyssa Black (Chair)]: And it seems to be, as you explained, the only sole reason is because they make recommendations for schools. That makes sense.

[Daisy Berbeco (Ranking Member)]: But adding, I mean, the additional task of making recommendations about health should seemingly be by people who are qualified to do that. And in my opinion, I don't think a secretary of education is qualified to advise a health commissioner about health recommendations for my kids or anybody else's.

[Alyssa Black (Chair)]: Of the 13 members, do we have a breakdown on how many of them, because I'm assuming this is going to be a voting council, how many of them have medical research, practice, clinical experience and knowledge. We don't want to tilt it where there's like a I can't do the math right now. A seven is sick. 10

[Leslie Goldman (Member)]: medical and one education is what I'm seeing. That changed education. As a secretary, services. Is that still Because some of it is implementation.

[Daisy Berbeco (Ranking Member)]: To clarify, I'm not concerned about the effectiveness of the group or anything. I just want to know what is the intent of having someone without medical qualifications making those recommendations.

[Alyssa Black (Chair)]: We can ask human services.

[Allen "Penny" Demar (Member)]: It's only one person.

[Katie McLean (Office of Legislative Counsel)]: It would be two. The secretary. Okay.

[Leslie Goldman (Member)]: Should I move on? And if we want

[Alyssa Black (Chair)]: to make a recommendation in human services that we don't feel as though someone without any medical experience or background shouldn't be on there, then we can certainly make that recommendation if we

[Debra Kildebrand (Commissioner of the Department of Health)]: want.

[Alyssa Black (Chair)]: Sometimes we can't change this. I'm sorry

[Leslie Goldman (Member)]: we can ask the commissioner once we get to.

[Alyssa Black (Chair)]: Let's talk to him when he comes up to

[Leslie Goldman (Member)]: Yeah, so I don't mean now, I mean just because is it about implementation? Yep.

[Katie McLean (Office of Legislative Counsel)]: So I will keep moving. The next two sections have the heading insurance coverage for recommended immunizations in effect through passage of this bill through 07/01/2031, meaning we will undo this language on 2031 to go back to the existing language. So first, section four, forty, 42. This is group health plans generally. So we have language that there's no cost sharing for preventative services. The group insurance policy shall not impose any co payment, coinsurance or deductible requirements for recommended immunizations as defined in '18 VSA eleven thirty. What we're striking through is the reference to the recommendations created by the CDC. So this now refers to the Vermont recommendations. A similar change under section five, which is health insurance plans offered to the individual. Almost identical language, no cost sharing for preventative services. A health benefit plan shall not impose any co payment, co insurance or deductible requirements for recommended immunizations.

[Alyssa Black (Chair)]: Just so everybody's clear, that's the way it is now. It's just that it's the recommendations by the CDC. That's why we

[Katie McLean (Office of Legislative Counsel)]: have to change it here. Governs the coverage. Changing gears again. Pharmacists and pharmacy technician authority in effect on passage through 07/01/2031, again, because this would revert back or be amended to go back to this language as of 2031. This language has not been worked on at all by Human Services yet. This was pulled from the OPR miscellaneous bill as relevant to this topic. And so they pulled it in, but they are hearing testimony right now from OPR and they haven't really tinkered with what was in the OPR miscellaneous bill yet. So this language says that a pharmacist may prescribe in the following context. State protocol. A pharmacist may prescribe, order, administer in a manner consistent with valid state protocols that are approved by the Commissioner of Health after consultation with the Director of Professional Regulations and the Board and the ability for public comment. And then we have a list, multiple items. And then in Roman numerals VII and VIII, we have immunizations. The first one is for patients 18 years of age or older. For patients five years of age or older, influenza, COVID, and subsequent formulations or combinations of products thereof. Previously, obviously, the reference was to the CDC. Human Services had a number of questions as to why for under five, there are certain immunizations referenced, and I'm assuming they're getting answers to those questions now. So that hasn't been addressed yet. We have similar language for pharmacy technicians. Pharmacy technicians shall only administer immunizations to patients 18 years of age or older as established in the section we just looked at and in accordance with the state protocol. And again, this similar language to patients five years of age or older with regard to these specific immunizations. And then striking through language that would require the immunization to have to be recommended by the CDC. So that is in three. And then we have this language again in D that's being struck through. Pharmacy technician should administer only those that are recommended by the CDC. So that would be eliminated in this proposal.

[Francis "Topper" McFaun (Vice Chair)]: The pharmacy technician, they have to have any special training or anything?

[Leslie Goldman (Member)]: I'm sure they do, but I'm not prepared

[Alyssa Black (Chair)]: to talk about that. I'd have

[Katie McLean (Office of Legislative Counsel)]: to look into it or we'd have to have OPR in. Where is it? Trained to immunize. Wait, what a licensed pharmacist who is trained to immunize is present. Where are you reading this from?

[Daisy Berbeco (Ranking Member)]: Yeah, what you just read.

[Leslie Goldman (Member)]: That's not the technician.

[Katie McLean (Office of Legislative Counsel)]: That's the technician. Good question. I don't have an answer right now, but I could get back to you, or I hope you all, I'm sure, have an answer quickly. Okay. So that really is the the end of the bill substantively. But we're on page 14 of 26. So the rest of this bill is putting the statutes back in place as they are currently, maybe with a few little changes that are more technical, like striking of commissioner of health, because they're already covered in the definitions for this title. So we have the language, the immunization funding section that we looked at first. We have the section We jump to eleven thirty one. There's no eleven thirty a because that is being sunset. It was all new language, so we're just cutting it. And you'll see where that happens later on. So eleven thirty one is the advisory council that goes back to its current makeup and charge. Next, have the group insurance policies and the individual policy plan going back to the way it currently is. And then we have, again, restoring the current pharmacy and pharmacy technician authority to the way it is now on 07/01/2031. So that's what that language is. And then on page 25, section 14, this is the repeal of that one new section of law. So it goes away 07/01/2031. It just disappears. Nothing else comes in its place. And then effective dates are very important in this bill, as you would imagine. So this section, the effective date section, sections one through seven, which is the substance of what we went through, and section 14, which is the repeal, that all takes effect on passage. Eight through 13, which is all of the upping the language that is currently in existence now, that takes effect on 07/01/2031.

[Alyssa Black (Chair)]: Can I ask you a question? You may not know the answer to this, but I'm just wondering if you were in the conversations at all and know the intent and can convey the intent. Why are we sunsetting this whole thing in 2031? I

[Katie McLean (Office of Legislative Counsel)]: think that's a better question for the chair of human services.

[Leslie Goldman (Member)]: Leslie, this is more technical. So, when you have a sunset like this, what happens? Someone wakes up one morning and says, oops, it's going to sunset. We have to do something or how does that work?

[Katie McLean (Office of Legislative Counsel)]: So, if you Well, one, our office tracks it. So we have a chart so that we don't lose track of it. Automatically, the laws would go back. If this were adopted the way it is now, automatically on 07/01/2031, the laws that you passed giving the commissioner the authority to create a schedule goes away and the current laws come back into place. So if the legislature five years from now decides not to act at all, then that automatically would happen as this is drafted.

[Leslie Goldman (Member)]: So how soon before it might sunset does it get your office's attention?

[Katie McLean (Office of Legislative Counsel)]: When does it get our attention? Typically, I maintain a chart for all of the legislation that's going to sunset. Typically, two years prior to the sunset, I start sharing it with the attorneys of the subject matter. And it would be up to the attorney to have a conversation with their chairs. This is going to sunset. Would you like to do anything about it? So if the legislature five years from now really likes the new language and how the system is working with the commissioner making recommendations, there would have to be legislative action to get rid of the reversion to this current language.

[Alyssa Black (Chair)]: 07/01/2031, where are we now? Who's that? Five years from now?

[Debra Kildebrand (Commissioner of the Department of Health)]: Six years from now?

[Alyssa Black (Chair)]: Six, I think. Six. No, six.

[Allen "Penny" Demar (Member)]: This is '26.

[Katie McLean (Office of Legislative Counsel)]: This is '26. I'm thinking it's still '25. Six, 07/08,

[Brian Cina (Member)]: Five years and six months from now. Five years, five months and fourteen days from now.

[Allen "Penny" Demar (Member)]: Can I just add, I'm confused? What was the intent and the goal

[Alyssa Black (Chair)]: of this? Of the bill? I'm sure the

[Katie McLean (Office of Legislative Counsel)]: health department will be happy to talk more about it, but this replaces who can make recommendations about immunizations that

[Allen "Penny" Demar (Member)]: Taking away from the CDC. And what would be the reason for that?

[Katie McLean (Office of Legislative Counsel)]: If there was concern over what the CDC was proposing, then this would give an alternative way of adopting recommendations.

[Debra Kildebrand (Commissioner of the Department of Health)]: Okay.

[Francis "Topper" McFaun (Vice Chair)]: Getting back to that thing about the technicians, see here, we talked about the board. May.

[Katie McLean (Office of Legislative Counsel)]: Where? Can you tell me what date you're on?

[Francis "Topper" McFaun (Vice Chair)]: It's five.

[Katie McLean (Office of Legislative Counsel)]: Now

[Francis "Topper" McFaun (Vice Chair)]: is there a reason for the board to adopt

[Leslie Goldman (Member)]: as opposed

[Katie McLean (Office of Legislative Counsel)]: to shall. This is existing language. I don't know why when the language was originally enacted that they chose may versus shall. I don't know if somebody from OPR remembers or one of our attorneys at staffs OPR might remember, but I don't know.

[Alyssa Black (Chair)]: Just explain to me that I'm trying to trace back what enables the technician to be able to do these things. I think the statutory authority

[Katie McLean (Office of Legislative Counsel)]: is what allows them to administer. And then if OPR wants to create more nuance or specificity around the requirements, they have the authority to do so with that main language. But that is existing right now, that they have that authority if they would like. And I'm guessing there probably are rules. I have to double check.

[Alyssa Black (Chair)]: Unless it's a question on language or something, then we still want to get to the commissioner and maybe the commissioner can, I feel like, answer a lot of the questions that we're getting into?

[Leslie Goldman (Member)]: This is all legal. I was thinking back to when COVID came and we gave authority to pharmacists and others to give COVID vaccines, how does that authority intersect with this? I believe that the commissioner issued a standing order during COVID to be able to administer those. And I would look to the department to confirm that that is accurate. So it's pretty much it supports each other, I'm not sure

[Katie McLean (Office of Legislative Counsel)]: Well, what it right now, you'd be putting in statute.

[Leslie Goldman (Member)]: So it's not in statute now?

[Katie McLean (Office of Legislative Counsel)]: I don't believe so. I'm wondering how the standing authority was issued. I don't think it was statutory, but this is statutory. And the other place in statute where you have a standing order like that is the opioid antagonist.

[Leslie Goldman (Member)]: Thank you.

[Alyssa Black (Chair)]: All right. Thank you so much, Bee Bee. Yeah, you're welcome. Really appreciate you coming in. Doctor. Hillbryant says twice in I was going say twice in one week, but that was last

[Brian Cina (Member)]: Twice in less than seven days.

[Francis "Topper" McFaun (Vice Chair)]: Afternoon.

[Alyssa Black (Chair)]: Afternoon.

[Debra Kildebrand (Commissioner of the Department of Health)]: I'm Debra Kildebrand, Commissioner of the Department of Health, and I've got Meredith Flumpton with me, our immunization program manager.

[Alyssa Black (Chair)]: Thank you. So I think that in full disclosure, the Department of Health really was instrumental in putting this bill together. So why should we be doing this? Sure.

[Debra Kildebrand (Commissioner of the Department of Health)]: So I was listening to a number of the questions, and I can certainly answer and respond to many of those. But this has come at us pretty fast. We've seen some confusing statements coming out of Washington. We saw those many months ago, and it led us to help work on this bill. The main impact to date has been confusion. People are very confused about what they should be doing. I've heard that time and time again from pediatricians that patients are coming in and they have a lot of questions. Thankfully, for the most part, people are asking their pediatricians, which is the right source to ask. Some people aren't, though, and that's a concern that I have. Whenever there's confusion around what's the right thing to do, it's going to cause people to maybe not seek best medical care or evidence based medical care. So that's really been the big impetus for this. And we know that because of this, we had sought legislative change. To be fair, ACIP for decades has been the most reliable resource. It was founded in part with the American Association of Pediatrics. They have been an advisor to that committee every year except for this year. And it was a very reliable source of information for vaccination recommendation. It's no longer that, unfortunately. This year is a significant deviation from that practice, where they seem to be making changes that are not based on any scientific research that we can So the real impacts of this bill, there are a number. First, Vermont will have the flexibility to follow vaccination schedules that are not just what ACIP recommends, but those that are recommended by other professional organizations, like AAP, AFP, or ACOG, which are very reliable sources that we often

[Leslie Goldman (Member)]: those acronyms?

[Debra Kildebrand (Commissioner of the Department of Health)]: Yep. American Academy of Pediatrics, American Academy of Family Practice, and the American College of Obstetrics and Gynecology. So those three professional organizations oftentimes will give vaccine recommendations specifically. AAP and AAFP are very commonly referenced organizations for vaccine recommendations. And they have aligned with ACIP for decades. They do not as of today. So those are professional organizations that we often rely on. It allows us to use those and others to give vaccine recommendations to the state. The immunization program can still purchase vaccines. So that's another big concern is around the procurement of vaccines. So we get our vaccines from the CDC, from the Vaccine for Children program. That's at a lower cost. It's a group purchasing arrangement that we buy from them. They acquire it and distribute it to the practices around Vermont. If that were to no longer be available, we need to be able to buy it from somewhere else. We don't have that right now, that authority to do that right now. We are working on a backup plan to ensure that we can get vaccines at a low cost and have distribution, but we need the authority to be able to do that. We're working on the backup plan currently. It's not we have the ability to acquire from the CDC, but I don't know that that's always going be the case. Another one is to ensure that insurers continue to cover this with no cost to patients. We want to make sure that there is coverage for these vaccines. Now, insurers generally are very supportive of vaccines because they're usually cost savings, not cost generating. But we do want to make sure that that remains the case. Having access to people is really important. So the pharmacy and pharmacy tech availability to give the vaccine is really helpful to make sure anybody who wants a vaccine has access to get the vaccine from these sources around our community. They don't just have to go to the primary care visit, which can be challenging. You can't always get a primary care visit. So going to pharmacies is really helpful. Another thing is so that the commissioner of health can have a standing order for health professionals to administer the recommended vaccine schedule as opposed to just those that are recommended by ACIP and that there's liability protecting them from giving it with this set of recommendations. So generally in medicine, we follow best practice guidelines when we do things. We oftentimes will prescribe interventions that are off label. So they're not necessarily for the FDA indication, but they're within the practice guidance. This is very clear that, hey, this is within the practice guidance of giving these vaccines with this schedule. And then just to be clear, this is not a vaccination mandate. This is to ensure we preserve access to vaccines for Vermonters. So that's sort of the reason, the why behind this. And I know, again, there's a number of questions which I'm happy to field. I may not have all those answers, and I have my expert right next to me, who also has some prepared testimony she can share as well. Any questions?

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: Wendy, Karen,

[Alyssa Black (Chair)]: Sorry. I kind of looked over here and I'm like, Karen, sorry.

[Daisy Berbeco (Ranking Member)]: In two places, gives the commissioner the authority and any other authority, but is there a mechanism for that to appoint additional members of the two that that was raised to these? Just wondering about that language and the mechanism for who that would be or how that would happen.

[Debra Kildebrand (Commissioner of the Department of Health)]: Yeah, I can't necessarily foresee what that would look like. I think it's a catch all if there's a gap. So we've got a committee, and it's vacant a whatever, pediatric infectious disease doctor that would really be important to give influence, it would empower me to say, hey, we need this person on this committee because there's a gap related to the way the seats are appointed. That's the intent there.

[Leslie Goldman (Member)]: Leslie? Are there any required mandated immunizations for schools? And is there a way to not be required to do that? How does the law stand

[Alyssa Black (Chair)]: in that?

[Debra Kildebrand (Commissioner of the Department of Health)]: Is mandated school vaccinations? I am not the one to ask about the specifics of what those are. But yes, there are.

[Katie McLean (Office of Legislative Counsel)]: That's Who would

[Leslie Goldman (Member)]: be the person to ask?

[Debra Kildebrand (Commissioner of the Department of Health)]: So Meredith, probably know It's

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: posted on our website, and I can get you guys that I'd like to.

[Leslie Goldman (Member)]: Great. And there are exemptions. There's a way to exempt. Is that philosophical? No.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: There's a medical exemption and a religious exemption.

[Alyssa Black (Chair)]: Thank you.

[Debra Kildebrand (Commissioner of the Department of Health)]: Can

[Francis "Topper" McFaun (Vice Chair)]: you please explain under the impacts? Do it for large form.

[Alyssa Black (Chair)]: Standing order room?

[Allen "Penny" Demar (Member)]: Yeah.

[Debra Kildebrand (Commissioner of the Department of Health)]: So, the standing order authority is something that we've used in the past, which is, again, the example that was given was having pharmacists give a vaccine in that emergency during COVID. And a standing order is not something it's something that's done in medicine, oftentimes in things like the emergency department or other places where you have a situation where someone needs to act with an authority that they don't inherently have, but is important and vital with a set of parameters and when they can do it. So again, a common thing that I experience clinically is someone walks into the emergency department and they're having an emergency medical condition. You don't have to have a physician necessarily say, hey, please do this lifesaving intervention if these parameters are met, the nurses are empowered to do that. And that's a similar thing in this scenario for me. So I can give a standing order to health care professionals to say, hey, this is indicated in this instance and can be done. I don't know if you have a more nuanced way of saying that, Meredith, but

[Francis "Topper" McFaun (Vice Chair)]: I'm concerned about anybody given immunizations.

[Debra Kildebrand (Commissioner of the Department of Health)]: Sure, sure.

[Francis "Topper" McFaun (Vice Chair)]: And so the commissioner health will give a standing order.

[Debra Kildebrand (Commissioner of the Department of Health)]: I can't change someone's scope of practice. Okay, so there's a scope of practice issue as well. What I can say is, hey, pharmacist, you're now empowered to give this immunization, and here's a standing order to do so. They have to to do that. Correct, correct. I can't change someone's scope of practice with a wave of a wand. Doesn't work that way.

[Francis "Topper" McFaun (Vice Chair)]: So that answers my question. Why have we got May in this, the previous thing we just read?

[Debra Kildebrand (Commissioner of the Department of Health)]: Good.

[Francis "Topper" McFaun (Vice Chair)]: Sorry. They may have, they may set up, I think, rules for providing them with immunizations.

[Debra Kildebrand (Commissioner of the Department of Health)]: I will have to get back to you on that. Because I don't know how have the answer for you.

[Francis "Topper" McFaun (Vice Chair)]: I think it should be shall.

[Alyssa Black (Chair)]: Well, but if it's

[Daisy Berbeco (Ranking Member)]: a board, they need to vote on whether to do it. So I think you can't say they shall adopt this, because then you're forcing a board to do something in the board.

[Francis "Topper" McFaun (Vice Chair)]: But somebody's got to be responsible, in my opinion. Someone has to be responsible for training those people.

[Alyssa Black (Chair)]: Let's flag that and let's get a better understanding of it before we make any sort of recommendation.

[Leslie Goldman (Member)]: I just think the scope of practice concept, maybe you need to expand just thinking about that. Maybe OPR should be in the gutter instead. Go over there.

[Alyssa Black (Chair)]: Can jump in on their way by. Allen, did I see your hand up? I'm sorry. No. Okay. So I guess I have two questions first. Are you happy with the makeup, the expanded 13 members?

[Debra Kildebrand (Commissioner of the Department of Health)]: I know there's been a lot of discussion around who is the appropriate people to make up that commission. I gotta be honest, I'm not exactly sure where it lands right this moment because it's changed a number of times. We did submit, the bill has introduced a list of individuals that made sense. I think it's important to make sure that we don't have an unwieldy large group, so sort of 12 or 13 seems right. If we get to expand it to too much, it's challenging. I do like to have my general approach when making these things is to have a broad ability in terms of a category of an individual. So a pediatrician, which is a broad category that could include an MD, a DO, or an APP, is the right way. You have a good pool of people, and then you select the right candidate as opposed to being super specific in a particular thing. So the villas, as we had introduced, I think had a good slate of individuals. I know there's been some modifications.

[Leslie Goldman (Member)]: You said an APP, the

[Debra Kildebrand (Commissioner of the Department of Health)]: last APP, sorry, advanced practice provider.

[Leslie Goldman (Member)]: Thank you.

[Alyssa Black (Chair)]: My last question is, do you have any insight on the 2031? Because I was the lead sponsor of this bill, was in 2031.

[Debra Kildebrand (Commissioner of the Department of Health)]: Agreed. And I think the last recommendation is probably the right one to ask the other committee because that wasn't in the initial bill.

[Francis "Topper" McFaun (Vice Chair)]: Okay.

[Katie McLean (Office of Legislative Counsel)]: Lori, are there other states that have or are looking at

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: doing this that you know of?

[Debra Kildebrand (Commissioner of the Department of Health)]: Yeah, so a lot of other states are looking at this. Again, this isn't five years ago. No one would have conceived that we'd be having to do this, but necessity. Yes, the folks in the Northeast have been all looking at this type of legislation to ensure that they can continue to make the right recommendations. Great.

[Leslie Goldman (Member)]: And you're sitting here, so the administration supports this?

[Debra Kildebrand (Commissioner of the Department of Health)]: This is something that's very clear that we've discussed within the agency, and there's not been any connections. Listen, access to health care is important for us all. Absolutely, thank you. All

[Alyssa Black (Chair)]: right, thank you.

[Debra Kildebrand (Commissioner of the Department of Health)]: Meredith, did you want to Meredith has some prepared tests.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: Oh yes, I'm sorry. I just wanted to explain how our program works because I think that will help people. And then we'll leave enough time for Stephanie as well. So, the immunization program in Vermont, actually procures vaccines and supplies them to primary care providers across Vermont. We use, we currently use federal funding and private insurer funding. The way the statute is written right now, I think we reviewed that earlier, that we can only purchase those vaccines through CDC and we have to align with those ACIP recommendations. So what we're looking for is a little bit more flexibility. This slide shows you our bucket and how we get those funds in order to do that. So if you look on the right hand side, the VFC means Vaccines for Children. So that's a federal program that accounts for about fifty percent of the children in Vermont. And those vaccines are provided to us by the federal government. So we don't actually pay for those. It's children on Medicaid, children eligible for Medicaid, children who are uninsured. And then there's a couple of nuanced categories for American Indian and Alaskan Native children. On the right hand side, you're going to see a small bucket. It's a really odd name. It's called three seventeen funds. We use that primarily for uninsured adults so that if you are an uninsured adult, then you go to your primary care provider. Our program can still provide vaccines at no cost for you. And then the bubble on

[Alyssa Black (Chair)]: the

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: bottom is the private insurers. And Medicaid also pays in for adults in Vermont. The biggest nuance of the program itself right now is we provide vaccines birth through age 64. Medicare does not currently pay into our program. So we do not provide vaccines for 65 and older through our program. We are working federally to try and get that changed. It is a little bit of an uphill battle. Go ahead. A quick question

[Leslie Goldman (Member)]: on that three seventeen. If you're an unassured adult, can you go to your pharmacist to get a vaccine and have it be paid for?

[Stephanie Winters (Vermont Medical Society; AAP VT; Vermont Academy of Family Physicians)]: You have to go to primary

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: care. So pharmacies are allowed to enroll in our program. And if they are enrolled in our program, they can use our vaccine. But not very many pharmacies choose to enroll. Thank you. Pharmacies tend to purchase their own vaccine. They do.

[Alyssa Black (Chair)]: Can we go back one slide? I apologize. I need a refresher because I don't have my laptop with me today. So you purchased vaccines from the CDC. Are you still able to purchase vaccines from the CDC even if the CDC via ACIP no longer aligns, do they still make it available for you to purchase? Right now, yes.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: Okay. What we are worried about is if they start restricting the number that we can purchase or pulling vaccines completely off of their contract. Then we, as an immunization program, would not have the ability to purchase those vaccines the way that our statute is currently written.

[Alyssa Black (Chair)]: Currently though, even if they don't recommend something, you could still buy from

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: Currently. Currently, yes.

[Alyssa Black (Chair)]: Go ahead, Brian. Then I had about a

[Brian Cina (Member)]: the definition from way earlier, but I didn't ask it because I thought I should ask a doctor. It says, we are amending the statute from immunization to recommended immunization, and the definition being we are striking out vaccines and saying a vaccine or other immunizing agent that provides protection against a particular disease or pathogen. And I was curious what might be some examples of other immunizing agents beside a vaccine and what might be a pathogen you would give someone an immunizing agent for? Is that like if someone gets exposed to radiation perhaps, like an agent? You see what I'm saying? I'm trying to understand.

[Debra Kildebrand (Commissioner of the Department of Health)]: So the other agent is immunoglobulin. So vaccines are designed so that you make immunoglobulins against a thing, but that takes weeks. So there's sometimes like rabies, where if you have a bite, you need to have immediate immunity. So you give immunoglobulin against rabies to inactivate it. And we do that in some cases, such as in RSV. We'll give RSV? Immunoglobulin to make sure kids are protected against that. And then later you give the actual vaccine. So yes, you're right. The definition has changed a little bit because now we have this thing that we didn't have ten, fifteen years ago as an option in very specific cases where there's immunoglobulins that you can give to folks to help with immunity. And then pathogen is just a more generic term for an infectious disease. A thing that causes an infection.

[Brian Cina (Member)]: Do we have immunizing agents for radiation? In science fiction, like in Star Trek, they'll give them shots when they're going into high radiation areas. Do you have anything like that?

[Debra Kildebrand (Commissioner of the Department of Health)]: There's not

[Alyssa Black (Chair)]: redirect the committee because we are very, very short on time. And I want to make sure that we get to our next. So let's focus on the bill in front of us.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: So the one thing that I'll add to that is the RSV product was introduced three years ago. And the federal government actually voted and now includes it in the Vaccines for Children program. So it's included with vaccines, but they're calling it an immunization. It's still given via a shot. But it's reduced hospitalization in infants by over ninety percent. So it's a really, really great effective tool.

[Brian Cina (Member)]: So that's the only example you can give an immune My question was about immunizing agents. The only example is immunoglobulin.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: Correct. Right now, yes. There was a question, I think, from the other committee about how we communicate with providers. Providers or primary care providers in Vermont are our customers basically. And we communicate and support them in a variety of different ways. So we have a monthly newsletter that goes out. We have emails that are frequently sent out to providers. We offer webinars and then, we have a team of compliance people that actually go into the offices to make sure that those vaccines are being stored at the correct temperature so that when you go into your doctor's office and get a vaccine, it's viable. So, I don't, in the interest of time, I don't know if we need to go through all of the examples. I will say I'm going go to the childhood immunization schedule. So as Doctor. Hilbert said last week, there was a universal change made to the childhood immunization schedule and, they removed, we used to cover 17 different diseases with vaccines. And we're now down to 11 for their recommendation of what we should be offering children. So AAP still covers all 17. And that's what we want to continue to offer to parents and kids in Vermont. So if a parent wants their child immunized, we want them to be

[Alyssa Black (Chair)]: able to access these vaccines.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: Was there anything you have my slide deck.

[Alyssa Black (Chair)]: No. We're not even recommending influenza. No.

[Debra Kildebrand (Commissioner of the Department of Health)]: That one's a little shocking.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: In one of the worst flu seasons that we've seen in a long time.

[Debra Kildebrand (Commissioner of the Department of Health)]: I mean, for infants who have never been exposed to influenza before, flu can be very deadly. And that's a little shocking to me.

[Alyssa Black (Chair)]: I say this every year, and I will go on record. I had a son at five years old that almost died of the flu, and they did not think he was going to make it. It's

[Daisy Berbeco (Ranking Member)]: really serious.

[Alyssa Black (Chair)]: Flu kills

[Debra Kildebrand (Commissioner of the Department of Health)]: Anyways,

[Alyssa Black (Chair)]: go ahead. I'm sorry, Brian. Brian, you had a question?

[Brian Cina (Member)]: Well, how does this align with You said that these are what's recommended. I

[Debra Kildebrand (Commissioner of the Department of Health)]: ACE IT.

[Brian Cina (Member)]: How does that intersect with what is required in schools and things like that?

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: That's a great question. I don't want

[Brian Cina (Member)]: to distract this too much, but I'm curious because there's an intersection. If it's recommended but then required, there's a discrepancy if people don't have access.

[Meredith Flumpton (Immunization Program Manager, VT Dept. of Health)]: So each state makes their own vaccine requirements for childcare and school. And in Vermont, we want to maintain access to everything on this list, regardless of which box it's in. And I don't think we have any intention of

[Debra Kildebrand (Commissioner of the Department of Health)]: The required list is smaller than the recommended list,

[Alyssa Black (Chair)]: to be clear.

[Brian Cina (Member)]: It is. Yes. Okay.

[Stephanie Winters (Vermont Medical Society; AAP VT; Vermont Academy of Family Physicians)]: Yes.

[Katie McLean (Office of Legislative Counsel)]: Leslie, and then let's begin with,

[Leslie Goldman (Member)]: just say thank you. I mean, thank you really a lot. And I'm just gonna say hep B, saving a lot of lives with hep B immunization, and I just wanna reiterate that was flu.

[Alyssa Black (Chair)]: Thank you. Thank you guys very much. Stephanie? I suspect any

[Stephanie Winters (Vermont Medical Society; AAP VT; Vermont Academy of Family Physicians)]: Other part of me.

[Alyssa Black (Chair)]: Yeah. Was gonna say something, but you're not supposed to comment. I'm like, it's hard for you to be sure, But I will be sweet.

[Katie McLean (Office of Legislative Counsel)]: You are sweet. Thank

[Stephanie Winters (Vermont Medical Society; AAP VT; Vermont Academy of Family Physicians)]: you for having me here today, and I haven't been in here this year, so happy New Year, happy return. Welcome to your new committee members. Stephanie Winters, I am the Deputy Director of the Vermont Medical Society. I'm also the Executive Director for the American Academy of Pediatrics Vermont Chapter and the Vermont Academy of Family Physicians. So I represent physicians, physician assistants, and the AAP, the pediatricians also have registered nurses as members. So I am coming to you today on those clinical perspectives. We strongly support this bill, H545. In fact, I think we talked to a number of you at the beginning of last year when we kind of saw through a crystal ball what could happen and really wanted to protect Vermonters. And so we've been working with the health department for a long time on making sure we get this right and how to really do that the Vermont way. So we feel like H545 allows Vermont to uphold evidence based medical recommendations regarding vaccines and make sure that we have specific responsiveness. As you've heard, this bill aligns with trusted national bodies, such as the American Academy of Pediatrics, American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, and as well as the Advisory Committee on Immunization Practices. So if we get to a place of science and evidence, we can still look to that body. So just a couple of things. This bill will do the following. It will provide clarity and consistency for health professionals and patients. As you heard, there is a lot of confusion both from patients and from health care professionals. Who do we believe? Who do we trust? Will it all be accessible? Will it be paid for patients? And how do we do this? So there's confusion. We're hearing about it from our members. And it only will increase, and especially given the announcement from last week regarding the pediatric immunization schedule. So H545 establishes clear statutory authority for our commissioner to issue immunization recommendations, creating a single consistent framework. And I will say, Representative McFaun, your question about the standing order, I think a most recent example of that was when our federal government changed the COVID vaccine recommendations, and our commissioner issued a standing order so that our pediatricians could give COVID vaccines without risk of liability, lawsuits, because they were going against the federal government. So I think even in the next section, the immunity and the protection for healthcare professionals acting in good faith, as long as they are following Vermont recommendations, they will be protected. And I think that's really important because that is a risk. Everybody wants to do the right thing for their patients, but when your license or your livelihood and your ability to do that is threatened, that is harmful. That's harmful for patients, that's harmful for our healthcare professionals. And so this is really important to provide that essential civil and administrative liability protection. It will also strengthen the medical home and care coordination. So, as we talked about, it supports expanded access to immunization, so at the pharmacy. So both standing orders and team based care models, which include pharmacies and other licensed health professionals to provide those vaccines within their scope, while preserving the medical home as the central point for care coordination. The preservation of universal and no cost access to immunizations is really key. And this bill reinforces our longstanding commitment to that universal access and takes away financial barriers, which we know can be significant obstacles to preventive care. And it also ensures that vaccines remain free at the point of care. So this doesn't change. It just reaffirms that the vaccines that are recommended by our commissioner are then paid for in the same way that vaccines are paid for now. And then it supplies a stable supply of vaccines and reduces administrative burden. I think this committee in particular has talked a lot about administrative burden. Usually it has to do, sorry, with insurance companies and red tape, but this really allows for purchase of vaccine burden to the health department. They don't have to go through insurance companies for the purchase of vaccines. They magically appear, thanks to Meredith, in the practitioner's office, and they can give those vaccines. And so it's a seamless and great way to be able to have them. And then finally, I'll just say that the advisory committee really ensures that clinical expertise remains the central key to immunization policy in our state. We have a lot of experts here in the healthcare community. We have great pediatric infectious disease experts. We have a vaccine testing center. We have research that's happening here in our state and people who really care and are at the center of evidence and science, and so we should really use that expertise. So in conclusion, yes, we should do this. We should do this immediately. This is really integral. We don't know what is happening with science and evidence in our federal government, and we need to protect our state, and we need to protect those around us. And so we hope that although you guys don't get to vote on this, we hope that you will support this as a key driver of preventive care and protecting Vermonters. So

[Alyssa Black (Chair)]: thank you. Thank you, Sandy. Katie, just to This goes in effect on passage, right? Is it not a Okay. Right. Can we take a break? It's a process question. Yeah. Do we have the discussion and then have a discussion about it tomorrow and make any recommendations we wish to make to the Human Services Committee. Thank you. So