Vermont Legislature SmartTranscripts:

[Leslie Goldman (Member)]: All

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: right, good afternoon.

[Francis “Topper” McFaun (Vice Chair)]: Hello everybody. Good afternoon. This is the healthcare committee back again. This morning we were talking about hospital budgets. This afternoon we're gonna do the same thing and we have Sam Piche.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Piche, Piche, yeah, it's a tough one.

[Francis “Topper” McFaun (Vice Chair)]: From Vermont Legal Aid to start us off, and Mike Fisher from Vermont Legal Aid.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Thank you. I'm Mike Fisher.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: I'm Sam Pipes.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Good to be here. Well, I I think that this topic sort of builds on stuff that we have already talked to your committee about, but we thought it made sense to come in and give you just a little bit of our perspective on the hospital budget process and where we think we need to go and and just remind you a little bit about some of the tasks you have assigned to us.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Yeah. So this is kind of what we're hoping to do today and ask questions at any point. We hope we did introductions, talked about our role, some of the areas that we focused on at our office over the years with regard to hospital budgets. Maybe I should take a step back. I don't know if I'm the lead, but one of the leaders of the

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: office. Think I'm

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: the lead. Okay. Representing the HCA during hospital budget hearings before the Green Mountain Care Board. So we'll talk a little bit about that. And then recent history and some next steps at a high level. It's not gonna be a technical presentation. We're gonna keep it pretty high level for today.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Go ahead. Sam being lead on this, just a reminder, it's 14 or 15 Vermont hospitals, camp retreat.

[Allen “Penny” Demar (Member)]: It

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: is an immense amount of paper and documents, and it is a chunk of work. This enterprise of reviewing hospital budgets is a big chunk of work for the board and for the HCA and for the hospitals. Always wanna gotta remind you, we've got a big broad team. It's never who you see in front of you. It's always a whole team of people. Feel really proud. We've got a a very strong team. Yeah. Yep.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Really wish I wore pants for that photo.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Every

[Alyssa Black (Chair)]: time I

[Francis “Topper” McFaun (Vice Chair)]: see them.

[Alyssa Black (Chair)]: You use AI now.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: So it's a little bit detailed, but just so you all know about our role in hospital budget review and really kind of our rights in a way. So we get copies of all materials that are submitted to the board. So we have access to confidential materials. We get to ask questions of the board, ask questions of the hospitals. We participate in the hospital budget guidance development process along with the hospitals. So we make recommendations and we also make written recommendations after all the hearings have taken place. And we also have the opportunity to provide testimony during the hearings. Typically, we use that time to ask clarifying questions or highlight areas, particularly of public interest areas around affordability and access in alignment with our statutory obligation. Leslie, anything else? Yeah.

[Alyssa Black (Chair)]: Do have the right to go into executive session with them when they go in?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Often, we don't get the right to go into executive session when they're taking advice from legal counsel.

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

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: But there are plenty of times where hospitals ask for an executive session because the information would be damaging to them, and we get to attend those.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Yeah, and some of that's around competitive business information, like reimbursement rates, specifically each hospital, so that's usually confidential. I don't think this will be a surprise to most or all of you, but these are some, I wouldn't say this is exhaustive, but focus areas for us. We care a lot about data and data being high quality and transparent and standardized as much as we can. We care a lot about root causes. You've heard us talk a lot about hospital prices, barriers to access to care. We've been pretty outspoken, encouraging about directly putting pressure to reduce costs for Vermonters. Yeah, I'm sorry, you go ahead now. Yeah, no. Focus area for us is expanding access to patient financial assistance. Some people have heard of it as charity care and reducing bad debt, both of the hospitals, but also to patients. We heard a little bit about this from the board earlier, but we also support shifting away from regulating predominantly based on net patient revenue. Not that's not a metric we should ignore, but I think we need to focus a bit more on prices. And we can talk more about that later. And we also believe in regulating hospitals differently based on their location, their type. And I think you've heard Matt Sutter made a good example. And we actually coincidentally use the same one, like Grace Cottage is not the same as UBM. And Escutney is not the same as, say, Rutland. So we really believe that we need to recognize those differences when we're regulating.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: We've been at this for a long time. And so some of the things on this list, I would say, we have been shouting about for years. And, you know, data integrity, can we really trust the data that's coming to the board that hospitals are reporting in a consistent way across hospitals is an example of something we've been frustrated about for years. Raised the concern for years. We think we've made some ground on, but we still have concerns. And then I also want to sort of shout out a little bit more about bad debt. Sort of ratio of free care to bad debt or bad debt to free care is, I think, something that we've brought to the table in a particular way that others haven't and really push for there to be a focus on it. Uncompensated care is the combination of bad debt and free cash, I'll just simply say. And so the amount of uncompensated care that a hospital has, one hospital versus another hospital, okay, populations are different. It makes sense to me that one hospital might have more uncompensated care than another, given the demographics in their community. But of that uncompensated care, what proportion of people are eligible for free care? That gets, is an interesting question and one that we've pushed on a lot. It developed into a bill that you guys passed to to normalize, standardize free care. But it's been a focus for us for a long time.

[Alyssa Black (Chair)]: I got Leslie and then Allen.

[Leslie Goldman (Member)]: So the question came up about one auditor for the whole state this morning, and you mentioned that. Do you have an opinion yet, or something that we should know or not yet?

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Yeah, I don't know about one auditor. I mean, I need to spend more time with that, Bill. We definitely believe in the importance of looking at audited financial statements. I think that's been a focus area, well, I don't think. It has been a focus area of ours for the last couple of years as an important data piece for the board to consider. Hospitals each and Debbie, can correct me if I'm wrong. They use auditors as well. So I think that that data should be captured as well. I'm not sure about yeah. So I'm still kinda thinking about that.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: It is I guess my response is that it's not uncommon that we'll say, hey. Hospital a and hospital b, how come you did this differently? And they both say, our auditor signed off.

[Leslie Goldman (Member)]: That's right.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And, okay. Well, that's great that you both hospitals used an appropriate you know, that that was an appropriate way of of considering the data. But so would a single auditor help improve that? I'm gonna go back to data integrity. I don't know. But that's where my head shows too. It might be that that's also a way that could be addressed also by the board covering those details.

[Leslie Goldman (Member)]: Yeah. Creating a

[Captain Debra Munson (Vermont State Police)]: framework to tell you. Allen?

[Allen “Penny” Demar (Member)]: You just talked about free care. Okay. So if a person, a new person comes to Vermont, gets sick the first week, has to go to the hospital, does the hospital take the hit on no money? Or does the state pay it? Or where's somebody?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Yeah. How does that work? So all Vermont hospitals are nonprofit here in Vermont, and all nonprofit hospitals are required to have a free care policy. And Vermont took the step of normalizing that. And yes, Vermont has standards for residency and for eligibility for free care. And so a person who's here and is assessed, the test, they're unable to pay, the free care policy could cover it.

[Allen “Penny” Demar (Member)]: So when the hospitals at the end of the year,

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: they show that. Yes. And I guess I would say, you know, the question in my mind, you know, let's say, the question in my mind is, is that, the cost of that care going to be counted as bad debt? In other words, hospital didn't get paid, and they're writing it off because they're never gonna get paid. Or is it counted as charity care? Okay. We're recognizing this person can't pay. In both cases, the hospital didn't receive payment for the care. It's more complicated than that on the back end, but

[Alyssa Black (Chair)]: Do all hospitals report both bad debt and free care?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Yes. The board requires them, to actually have to report it in multiple different places, but yes.

[Alyssa Black (Chair)]: You think it's sufficient data, or do you want a little bit more discreet? I know that I I was the reporter of that bill. And the question becomes, is that being counted as bad debt when really that bad debt should have been part of the patient assistance free care and that they just didn't. Do you think that's still an issue or? Yeah,

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: I would say there's variance between what some hospitals report to the federal government in terms of I'm not saying anything nefarious, but there is unexplained variance between what they report on bad debt and free care for some hospitals and what's reported to the board. And better understanding why those numbers are different is an area of interest for us. It's a curiosity. And it has a real impact on people, right? Because if they have patient financial assistance, it looks very different in their lives than it does if they're incurring debt. I don't need to lecture about that. I know you all know that. And I just would add that there's different eligibility for different percentages. Like if you make a certain amount, you might qualify for less.

[Alyssa Black (Chair)]: Correlation, and I can't believe I'm asking this question, but I've been thinking about days in AR. Is there any correlation between a hospital's days in AR and their percentage of bad debt? Because we know that 15 hospitals have wildly different days in AR. What is AR, please? Oh, accounts receivable. Basically money, how many days something has been sitting on their books not collected.

[Allen “Penny” Demar (Member)]: That goes to another question. How did the bill we passed last year about reducing debt?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: We had a

[Francis “Topper” McFaun (Vice Chair)]: million dollars to reduce. So how

[Allen “Penny” Demar (Member)]: did that come into play?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: What has been the impact of that? It would be great to get a report back to see how that's going. I think this area of exactly how hospitals count the value of debt and free care, and in other words, are we looking at apples to apples comparison across the hospital system for a dollar of free care versus a dollar and a dollar a big bad debt. Those kinds of things we care about.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: That's an interesting question about if there's a correlation. I can look into that more. I don't wanna speculate without looking into it, but it's a good question.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And both of those are charts that are at our fingertips.

[Alyssa Black (Chair)]: Yeah, and the data that they present is a moment in time, And wonder if one would have affected the other such Can a way that

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I just jump in with a, should've started with this at the beginning. It's hard to run a hospital. I don't know how to run a hospital. Our hospital leaders know how to run hospitals, are running hospitals. And there is a great range of how different hospitals approach different problems. I think probably on every issue, there's schools from our standpoint that are doing a better job than others. And on this one, this goes back a long time ago, but on this one, when we spent some time traveling around the state and visiting with financial counseling offices at different hospitals, we saw a wrench. We saw hospitals where they were sort of almost in an activist way, really trying to partner with people who they knew were gonna have a hard time knew were going to have a complicated time given the nature of their insurance. Automobile accident patients have a different world of need a different world of support in order to get their medical bills paid, is one that we heard, for instance. Really, I think this is just an example of the lens that the HCA comes to as we're really being informed by our advocacy team that's hearing from Vermatra who's trying to struggling with medical debt, for instance.

[Karen Lueders (Member)]: Yeah, don't want to belabor this, but I understand that there's a difference for the patient if it's

[Wendy Critchlow (Member)]: bad debt or not,

[Karen Lueders (Member)]: but if there's a way to briefly summarize it, what is the difference in the hospital? Like, in terms of, yeah, all the stuff we're talking about.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I think it's complicated than that has to be the answer. I think it's different. I think it's certainly different for Medicare, bad debt.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Triple access hospital.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And it's different for different types of hospitals. Yeah.

[Leslie Goldman (Member)]: Oh, So. It's healthcare, it's complicated, just like home, of course.

[Francis “Topper” McFaun (Vice Chair)]: Didn't we define bad debt in

[Allen “Penny” Demar (Member)]: the bill?

[Alyssa Black (Chair)]: We define what it is, we know what it is, it's just categorize how

[Leslie Goldman (Member)]: it.

[Alyssa Black (Chair)]: I'm sorry, I got everybody all in a whole bad debt.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I did too.

[Alyssa Black (Chair)]: You owe us.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: I'm not going read through all these,

[Alyssa Black (Chair)]: Wendy, are you going to wait? I just

[Wendy Critchlow (Member)]: have a question on the last Yeah. And it's you don't have to answer it if you don't want it, but we've been talking

[Alyssa Black (Chair)]: a lot about those

[Wendy Critchlow (Member)]: three hospitals in New York, and I see that you actually, we heard a very plausible explanation today from Doctor. Lechner about why they're important to their network. I was wondering how you guys feel about it.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I think you would I think I don't wanna go too far into it now, but we raised this concern. I think you could find written statements from us about this in our in the record, which we're gonna, by the way, provide some links to, and have more concerns. So I I think I wanna both appreciate and understand what what Steve what doctor Leffler said and express a concern about Vermonters dollars and whether Vermonters dollars are standing in Vermont to care for Vermonters. Thank you.

[Leslie Goldman (Member)]: Anyway, yes, I think that's tricky. I mean, listening to him because his argument, if I got it right, was to sustain UVM, we need those dollars and those people coming this way. Do we as Vermonters, in order to have access to the academic medical center, have it sustained, accept that dollar, that we need to sustain them in order to I'm just thinking about this for the first time actually. How much money?

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: I think Chair Foster testified to this a bit. I believe he said potentially over $100,000,000 in the last several years.

[Leslie Goldman (Member)]: It went to New York.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: It went

[Leslie Goldman (Member)]: to New York. Yeah, it's huge. I get it.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I think it would be very interesting to look at the flow of patients from New York to Vermont hospitals before and after those hospitals became a part of the network.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: There's a question too about ownership too. Does the network need to own those hospitals in order for those patients to come here? And Nancy Cain, who's a consultant that we work with and I believe has presented for this committee before, I know that she has, the financial position of the network improves if they were not part of it. So that's just a data point, and that's from looking at audited financial results. There might be good reasons, but there are financial concerns about ownership of those hospitals. It might be.

[Alyssa Black (Chair)]: All right, let's move on.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I'm never going to get through this. Well,

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: won't read all these, but we do have a couple concerns. Don't know if miss is the right word, but maybe different theoretical approaches that we don't think have worked in recent years. And we encourage moving away from them in the future. I don't if you want to call it any of them in particular, but

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I think at first, too, about how to affect the change that we think we need and whether we have all lived through coalitions of the willing for a while. And I think it is I think from our perspective, we are at a level of crisis at a time where we're just gonna have to move to a much more prescriptive stance. I think that's what those two Yeah. You can look at them in your own life.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: And this is linked later, but I thought this was an interesting and informative graphic. I try to have as many graphics as possible. So this is from the Congressional Budget Office. They did an analysis a couple of years ago looking at what are the best ways to reduce costs, like objective analysis. And I put it up here because not to say we shouldn't do all these things, but to highlight the effect on prices. And you've heard from us, we're very concerned about high hospital prices in Vermont. I will say not every hospital in Vermont in our view is excessively priced. So there's some nuance there. But really, just to highlight, regulating prices paid to providers is the policy mechanism that's going to have the biggest impact. That isn't to say that we shouldn't have competition or we shouldn't promote price transparency. I think just want to orient the conversation that those have different impacts on price. System wide.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I totally understand why an individual might be very focused on price transparency so they can make a decision for their own care. Could have a big impact. System wide, it hasn't been shown to really bring down prices.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: So like I said, that link, the full report is in the rest of it. Yeah, so again, level, new path forward, maybe that's a little bit self righteous. We need to define what success looks like in terms of hospital prices. And what I mean by that, what we mean by that is what price is appropriate for each hospital. I don't think anyone's arguing that UVM should be priced lower than say a critical access hospital because they do different things. They're tertiary care hospital. And we also need to identify by what time we need to get these prices there? And B, to use your word, Mike, a bit more prescriptive than perhaps we've been in the past. Probably not as surprising to that from me as a researcher. We need ways to measure things and clear deadlines for accountability.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So I just wanna pause on this. We need to define where's the goalposts? Where are we trying to go? Sort of intentionally, we didn't say, hey, the legislature needs to do this or the board needs to do this. But I think it's an important question. Who who is setting the goalposts? Certainly, have tasked the the the board as the regulator to do a lot of, you know, the technical work every year for each hospital. But where are we trying to go as a system? I think I feel more and more motivated to say, I think there needs to be an honest policy discussion at tables like this that to define reference based pricing in and of itself. Reference based pricing is a tool. It doesn't even mean that you're gonna spend less. You could do reference based pricing and increase costs and payments. So where are we trying to go and how fast do we need to get there? So I think that's a theme you'll hear over and over from us.

[Alyssa Black (Chair)]: I appreciate that because with all the discussion, particularly that we had last year, we never really we never really set a goal. We just did a lot of things to try to move us towards a goal, and we didn't define what the goal actually was or what a global budget was. And

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: so, very short term, we didn't define a lot of things. What is our goal for '27? Longer term, where do we need to get to in the next three or five years? And how much do we need to do each year going forward?

[Alyssa Black (Chair)]: Or did you have a question? Oh, I thought I saw your hand up. Daisy, did I just see your hand up? I'm

[Daisy Berbeco (Ranking Member)]: just contemplating, like, the how realistic is it that we would be able to set a goal that we all agreed on? I don't know if that's realistic in this climate of our hospitals struggling with high costs of the work that they do, and then all of us have our points, but how realistic is that to say, let's set a goal of reaching this reduction?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Well, the language is way too obtuse, but the HCA has had the position for a number of hospital budget cycles that Vermont prices should be at the sixth decile. In other words, not a little bit more expensive than average given our rural nature, but nationally, compared to nationally, that we should be at the sixth decile. Not that ninth?

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Yeah. I mean, some hospitals are in the ninth and highest decile.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So representative Berbeco, I appreciate that it's really hard to do and that people it will and bringing up this topic will be upsetting to to people. And yet, if we don't, if somebody doesn't, then I just have a tremendous fear that we'll end up in the same place, but as a result of market forces.

[Alyssa Black (Chair)]: And,

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: the real affordability, the impacts of affordability concerns is that people sit out of the insurance marketplace. And I think we're seeing that significantly right now. And it ends up having the same.

[Alyssa Black (Chair)]: I see, Allen. Has anyone done an analysis on Chargemaster between the Vermont hospitals within the health network and the New York hospitals in the health network. Just a simple charge master, which of course, we know is sort of messy.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: They've done commercial prices, like amounts paid with the So actual that's what the RAND, which I know you're familiar with, builds out of that. So I can share what the commercial payments look like relative to those hospitals. That's linked here. There's an interactive tool that you can plug in any hospital and see where they rank in terms of price, commercial price.

[Alyssa Black (Chair)]: So the question of where do we want to be. I think I had a conversation with somebody about, from New Hampshire a few weeks ago, and they were lamenting the high cost of care at Dartmouth Hitchcock. And yet, if Vermont was priced at Dartmouth Hitchcock, we would be I mean, like It would

[Leslie Goldman (Member)]: be weird to assess the thought.

[Alyssa Black (Chair)]: We would be much less than what we are. Won't we be better? Yes, we would be better. So, you know, it goes to the defining where do we want to get to. Allen, sorry.

[Chris (Vermont Police Association representative)]: Well, I'll just read,

[Allen “Penny” Demar (Member)]: the new path forward for

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: your

[Allen “Penny” Demar (Member)]: organization, ACA, we're gonna talk to Doctor. Lueders, he put a path forward. We talked to the Green Mountain Fair Board, they've given us a path forward. Should we put you guys all in the room and not let you out until you come up with it? We

[Alyssa Black (Chair)]: sit in that room all the time.

[Allen “Penny” Demar (Member)]: But seriously, I think everybody's trying to do the same thing, but we're all taking a different path forward. And that kind of

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: boggles my mind. To some degree, I think in those three entities, you have a regulated entity, and you have a regulator, and you have a public advocate. Of course, we're going each come to it from different perspectives and want to push the envelope further from our perspective. And at the end of the day, it's the Green Men and Care Board's job to find what is reasonable for them. I guess I'm bringing that discussion to this table because I believe that the board needs direction about where we're trying to go. And that's a policy discussion that lives at a table

[Allen “Penny” Demar (Member)]: in place. So which one do we follow, doctor Leffler?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Know, that's a I guess Agree with us. Okay.

[Alyssa Black (Chair)]: Thank I

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: think as the session goes on, we may have my thoughts. So I think that's sort of stating at a high level that some decisions have to be made. So we have I say again, we have been doing this for a long time, and we just couldn't resist wanting to at least write down the last couple of years of comments as a resource slide for you. So you can, in your own time, take a look at the kinds of things we've been saying over the last couple of years. I don't think any of it will surprise you. We've been saying a lot of what you heard today for a long time, and we will probably keep saying it for a long time. But we want to make that available to you so that you can see what we have said to the board over the last couple of weeks.

[Alyssa Black (Chair)]: Any questions? Go ahead, Karen.

[Karen Lueders (Member)]: Well, if you are, I know that if you have to have a procedure done and UVM is the place you would normally go, you might find out if you go over to Plattsburgh, it's much smaller price. So let's say it's, I think it's fairly true, like $708,100 dollars at UVM and it's $175 over Plattsburgh. Is it circular that we're supporting the lower price over there by charging that? I don't quite know why they're experiencing such discrepancy. It's not even close. It's a huge, vast difference. And so that's sort of one question about how that works as a mechanism and how that could resolve itself systemically. And then the next question is the point that Doctor. Loeffler made about having a teaching hospital that supports expertise and who pays for that? I mean, it is incredible, maybe an incredible asset to the community, to the doctors that are learning there. But do Vermonters using their Blue Cross and Blue Shield insurance premiums need to pay for that? Or is there some other payment mechanism for that amazing, it is a great thing, but who pays for that? So they're kind of, I don't

[Leslie Goldman (Member)]: know if they're related, but they're kind of

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: in the same. Yeah, I mean, think paused yesterday, the other day when we were talking about mental health patients, mental health systems and telemedicine, could they get more revenue? Didn't decide not to say it, but I'm gonna say it now. Everybody wants more money. Everybody will come before you and say they need more money in order to make it. Some of them really do need more money in my in our opinion, and some of them don't, and it's really hard to figure out. It's really hard to figure that out. You need you need real metrics to make those decisions. But but I just I just can't help but notice, you know, like, okay, we need to give more money to primary care. We need to give more money to mental health. We need to give more money. Things I support. So for some reason, what you were just talking about evokes that in me. It's just a recognition that that it's that that you're always gonna get requests for more.

[Karen Lueders (Member)]: But the point Doctor. Lueders making is sort of educational. And yet it's our healthcare system. Somehow that was given,

[Leslie Goldman (Member)]: I don't

[Karen Lueders (Member)]: know, was a rationale that was given to us to have a more expensive healthcare system, even though we have very few people and now only one of this and one of that. So

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Sorry. I lost I lost the thread of what I was trying to say. And we should have more money, and we should have enough money to give the care. But at the end of the day, somebody has to pay. And when I sit with providers and they say we need more money, and I say, okay. Who? Do you think our small business community can do it? Do you think the taxpayer can do it? Do you think the ratepayer can do it? Nope. Nobody says yes to any of those questions. Do you think we're gonna get bailed out by the feds or the state has a pot of money that we can turn to or we can increase taxes? You know, run out of ideas. And so, you know, of course, there's always a subset of this conversation that's about efficiency. Maybe it's not need more money, but it's need to be able to do it in a more efficient way. But my fear over the last couple of years, and I've said it a lot of times that you haven't heard me say it, is not only that it's unaffordable, but that we're spending more than we're raised, that we are driving towards insolvency with what we're doing because there's a disconnect between what we raise and what we spend. So, yes, we need a good hospital. Yes, we need to support UVM to be the best hospital possible, and it needs to function in a way that the mattress can afford.

[Alyssa Black (Chair)]: Well, did you have a question?

[Debra Powers (Member)]: Yeah, but you don't have to answer it either, and I don't want to ruffle feathers. If you

[Alyssa Black (Chair)]: ask question to him He's gonna answer it.

[Leslie Goldman (Member)]: He might not want. So

[Debra Powers (Member)]: obviously, I've only been here for two weeks.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: It's amazing to you an expert.

[Debra Powers (Member)]: Right. So just come down to my level, go to kindergarten, and I'm hearing same words over and over. It's Medicaid, Medicaid, Medicaid. They can't pay. They can't pay. Who pays? Taxpayers. Trickle down? Taxpayers. Are we a magnet? I mean, is there any way, like, is just Vermont a magnet for let's go to Vermont because I don't have to pay, but Vermonters pay. That's frustrating.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So you guys have done studies about who comes to Vermont and what they and and there has been some analysis of that. I don't have it at my fingertips, but there has been some analysis of whether we're seeing people come to Vermont because they're seeking services or whether we're seeing like, what's the economic details of the people coming to Vermont? I think it has shown that it has not shown that there's an influx of people coming here to seek services. But but we have a tricky I I guess I I also just want to recognize, we have a tricky dynamic here. We are part of one country, and we have freedom to travel. And and people do want them to live here. They are Vermont residents. And And then there becomes this question of what do we do with them? What do they need?

[Alyssa Black (Chair)]: And our demographics, our aging demographics, additionally.

[Allen “Penny” Demar (Member)]: I'm going weigh in, I appreciate your question.

[Alyssa Black (Chair)]: I said aging demographics, and

[Allen “Penny” Demar (Member)]: I'm then add some weight not that old. No, I appreciate your question, because I think we skirt that question. And I would like to see a study that that's happened. Like I say, I deal with my whole Montgomery Heathensburg, we're elderly, and there's a lot of animosity there. And the thing is, I'm sure I'll get a phone call tomorrow or an email that says, Okay, guess what? I can't get this help, but these people get the help. Could you explain that to me? How do I explain it to them? Older people at home aren't feeling they get anywhere near the care. And that's hard for me to explain. So, next question they say, we want working people to come here. Are we getting working people here? Are we getting the young families that will get into our school and get jobs? I think it's an issue that we haven't tackled, and I think we're all afraid of it.

[Wendy Critchlow (Member)]: And you're a nice welcoming community.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Mean, is a question too that some benefits are difficult to access. So I think there is an inherent complexity, if I could find a kind of consensus view. Like, if we have statutory protections, Vermonters should be able to access what they are afforded to by the law. So I think part of our job is to ensure that folks that are eligible actually get the services that they deserve.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I won't go there.

[Allen “Penny” Demar (Member)]: Yeah. Okay.

[Alyssa Black (Chair)]: I'm sorry, I'm Can we remember that the lowest reimbursed insurer, other than Medicaid in many cases, is Medicare. So the argument can be made that, I mean, that is why they always talk about why is healthcare in Vermont so expensive? Our demographics are aging, which means we have more people on Medicare, which the only way that hospitals and providers can sustain themselves, because Medicare doesn't cover the cost of care in many instances, is being subsidized by the younger insured, commercially insured, which is why the rates are going up so dramatically for the commercial insurance and everybody else is paying more because Medicare doesn't keep up with the cost of care. I'm sorry, but I'm not going to let it go unchecked that it's somehow other people's outsider's fault. It's a combination of things, it's a million things, but our aging demographics are not on our side. And it's getting worse.

[Allen “Penny” Demar (Member)]: We put 17,000 new people on Medicaid last year. We did that, remember? We had a bill. We added 17,000 MSPs.

[Alyssa Black (Chair)]: 17,000.

[Allen “Penny” Demar (Member)]: Yeah, no, no, that was Medicaid.

[Alyssa Black (Chair)]: Medicaid for Medicare recipients.

[Leslie Goldman (Member)]: All of them?

[Alyssa Black (Chair)]: Yes. That's where the MSP is.

[Allen “Penny” Demar (Member)]: Okay, so if you turn 65, alright, I'm on Medicare. When I turn 65, I'm on Medicare. So, come out of my So, how did we put Medicare people on Medicaid?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: These are very low income people. Exactly.

[Wendy Critchlow (Member)]: They're very old people.

[Leslie Goldman (Member)]: They're your constituents.

[Allen “Penny” Demar (Member)]: Most of those constituents worked all their lives to get social security.

[Alyssa Black (Chair)]: Yes, and they deserve it. So, can I just say

[Allen “Penny” Demar (Member)]: So, they worked all their lives, why didn't they stay on Medicare?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Why did they stay on Medicaid? Because there's earnings over their lifetime, give them a social security payment that is par.

[Allen “Penny” Demar (Member)]: That's insufficient. All 17,000?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: There's economic eligibility for this program, every single one has become eligible.

[Allen “Penny” Demar (Member)]: Oh, I'm sure they all become eligible.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Because of their very low income,

[Allen “Penny” Demar (Member)]: very low But I don't think we 17,000 elderly that was on Medicare and all went. I'd like to see those.

[Alyssa Black (Chair)]: We expanded the eligibility for Medicare Savings Program, which is a program offered through Medicaid for very low income Vermonters on Medicare, and we just expanded the income eligibility to capture more of people who were on Medicare who had no supplemental coverage. I do understand that.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: But you know, I Maybe we move on. Maybe we should move on and come back to Yeah.

[Alyssa Black (Chair)]: It's an open question. I

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: actually Let's not talk about it more right here right now, but I do want to say to the members with this concern, I I am not afraid of this conversation. I think it's a good good one that I'm happy to talk more about. And, you know, people have these questions, and we need to think about, What is going on in our community, and what's the right thing to do about it?

[Wendy Critchlow (Member)]: Can I just say one more thing about this? I promise this, then it'll be over, because I don't want to leave it like this for anyone who's watching, is that MSP, all it does is pay for your Part B Medicare. It's $185 if you're making $1,200 and what?

[Alyssa Black (Chair)]: No, it's enough. Yeah, whatever. $2.02 $0,102 now. I'm just saying if your

[Wendy Critchlow (Member)]: social security is qualified for dollars and you didn't qualify for it, getting that $185 in your monthly paycheck is huge. It really makes a difference in people's lives. I know this firsthand. So I just, I don't want to leave it like that. I think we did a great thing, I think.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And we should go forward.

[Leslie Goldman (Member)]: Yes, well dad.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: If I'm

[Allen “Penny” Demar (Member)]: giving you the staff, I'll agree with you.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: All right, I'll come on Monday with the stat,

[Alyssa Black (Chair)]: Tuesday with the stat. I just, I want to put accurate information out there.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Okay. Thank you. We wish for a little bit more than half an hour, and I apologize for the next

[Alyssa Black (Chair)]: No, that's a question. That applies to our next gift, witnesses. I always call people gas. I mean, witnesses sound I so like the answers. You're a guest.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: We have a

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: question for each other.

[Alyssa Black (Chair)]: Thank you. Hashtag can you just tell me who's online? It's just Brian. Okay, just Brian. Okay, so we have Bob.

[Leslie Goldman (Member)]: Other two witnesses after the fall, we weren't supposed to be here

[Alyssa Black (Chair)]: in person so much. Oh, okay. All right. Hi. Hi, Arnell. Nice to meet you. Nice to meet you.

[Bobby Arnell (Invest EAP)]: As well. Yeah. Thank you. So my name is Bobby Arnell. I work for Invest DAP, which is an employee assistance program that serves the majority of Vermonters throughout the state. I'm a state employee. The EAP is a quasi hybrid governmental nonprofit hybrid. And so we serve the state of Vermont workforce, but we also obtain subscriptions from private enterprise in order to provide employee assistance services, which, for those who may not be aware of that, are what they call short term solution focused counseling. It provides short term counseling services that doesn't go through an insurance carrier, and it's paid for by the employer. I believe I'm here today in my capacity as the director of a peer support program in regards to H270, which is the confidentiality protections that would be afforded to peer to peer communications. And so part of my role at EAP is I oversee a statewide peer support program for first responders called Secure, which is an acronym that stands for Skills and Experience for Calling Up Resiliency. I kind of regret not bringing a laptop, but if you wanted to learn more information, there is a website called securepeer.org that lays out a little more information about the origins of the program, how it works. And there's even a peer map where you can see where some of our peers are located, in which people can reach out directly to a peer to obtain assistance from them. So secure, I guess maybe I'll just explain a little bit about what the program does, and then you can maybe ask some questions about how it relates to the the proposed bill. So secure began around 2021 through a grant that the EAP wrote and obtained from the Department of Justice through the Law Enforcement Mental Health and Wellness Act. The idea was to create a peer support network of first responders that could act as mentors within their respective departments and create those links with colleagues, other first responders that are struggling, provide in the moment support, and then if needed, refer them on to an EAP counselor for counseling services. So that's one part of it. The other part of what we do with that network is that there is a subset of peers that deliver critical incident stress debriefings. And so what that is is that if there is a traumatic incident within Vermont and first responders respond to that, and they will request some additional support afterwards, we have a team of peers that will go in with a counselor to deliver a debriefing for all of those first responders that were impacted by that incident with the hopes that by doing a group debriefing together like that and processing the events as a group, that they will ultimately reduce symptoms of an onset of PTSD. It's a proactive measure in the generally forty eight to seventy two hours after a traumatic incident that's provided in the hopes that we'll be proactively preventing PTSD or other psychological impacts of a trauma like that. And so our peers that we manage go in and do that work for departments that request it as well. So at this point, we started this in 2021. We now have approximately a little over 60 peers that are part of the statewide network. And I should say, too, part of what we do is we provide training to those peers that apply to the program. So they apply through the website, we review the application, and then if accepted, we use our funding to provide them with peer skills training. And the training that we provide is generally the training we provide is through an industry recognized organization called the International Critical Stress Foundation. And they've received skills on noticing the signs and symptoms of someone in crisis, someone that may be suicidal, what type of questions they can ask, how to proceed with that conversation, and then ultimately, if needed, how to refer them to another resource, such as mental health counseling in that room. We also provide the training for how to connect themselves and how to lead a CISD, a group debriefing, for those departments that request it. And so we've been doing this since about 2021 through some seed money through the Department of Justice. And now we've been continuing this work through putting together some other federal grants, like a CDC suicide prevention grant and also a SAMHSA grant that's allowing us to continue this work in the years ahead. So I just put a lot out there. I guess maybe what I'll say is it's a new program, and it's one of the few that it's statewide. We partner with other organizations to provide that support. It was the original grant was written in a way that recognized that a lot of the smaller communities, smaller rural communities that didn't have the larger budgets for mental health services, there was a gap in that psychological health services. And so we wrote this grant to help those folks and also volunteer fire departments that would otherwise have access to services through the town. So all of this is in an effort to fill in those gaps and provide a level of psychological assistance in the aftermath of a trauma or when someone within a department is experiencing a need for some sort of help or intervention.

[Leslie Goldman (Member)]: Are there any

[Alyssa Black (Chair)]: questions? Go ahead, Leslie.

[Leslie Goldman (Member)]: I don't know if we're a quasi nonprofit, state funded, like that sounded really mysterious to me.

[Bobby Arnell (Invest EAP)]: Well, so the EAP is located within the Department of Disabilities Aging and Dependent Living.

[Alyssa Black (Chair)]: That's an employee assistance program.

[Bobby Arnell (Invest EAP)]: The employee assistance program.

[Alyssa Black (Chair)]: For all employees.

[Bobby Arnell (Invest EAP)]: For all state employees, but then not all of our employees are state employees, and I think part of that reasoning is that some of our funding comes from private subscriptions, so private employers will contract with us so that we provide those employee assistance services to those businesses as well.

[Leslie Goldman (Member)]: So your funding comes there's state funds and then funds, donated funds, or grant funds, or

[Bobby Arnell (Invest EAP)]: Private contracts. Private contracts. With private employers. And so because of that, we service the state of Vermont workforce, of course, but we also service the municipal employees as well, the teachers as well. And I think that we have about, I don't know exactly how many, but over 200 private contracts with other employers located throughout the state of Vermont. So who's in charge? So the director of the EAP is Mark Adams, and he reports to Diane Dalmas, who is the hireability director, and she reports to the commissioners.

[Alyssa Black (Chair)]: You don't have a board

[Leslie Goldman (Member)]: or anything, you're going through the state of Vermont?

[Allen “Penny” Demar (Member)]: I'm going

[Bobby Arnell (Invest EAP)]: through the state of yeah.

[Alyssa Black (Chair)]: Fascinating, I had no idea that it's like That was a very interesting point. Yeah, and when you were in Dale. I still think we put things in Dale all the time. Doesn't seem like they're have

[Leslie Goldman (Member)]: a wastebasket there. Put them on Dale.

[Alyssa Black (Chair)]: Any other questions? I have a question, but

[Wendy Critchlow (Member)]: Just a quick question, so yesterday we heard testimony that it appear that you train, but they have no liability insurance.

[Bobby Arnell (Invest EAP)]: Correct. Yeah, it's a volunteer, so it's a volunteer based service. So they don't have any liability insurance. The counselors that work with them do, The peers themselves don't, since it's completely volunteer. Yeah, so I think it's You

[Wendy Critchlow (Member)]: worried about that? Mean, it's just a Sue happy world we live in right now.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Yeah, I mean,

[Bobby Arnell (Invest EAP)]: it is a concern, I think. We also, part of that training that we provide to the peers stresses the importance of the role as a peer as opposed to a mental health counselor and maintaining that distinction and the boundaries. And so we're always, if we feel like, we always proactively support getting them connected to a counselor of course, the consent of the person involved. But yeah, think having that boundary and that distinction, I think, helps mitigate some of that risk when it comes to the lack of liability insurance from a Okay,

[Alyssa Black (Chair)]: thank

[Francis “Topper” McFaun (Vice Chair)]: you. Do you have any connection with the peer counselors for drug abuse or alcohol abuse that are located in maybe a designated agency in the community like Washington County Mental Health?

[Bobby Arnell (Invest EAP)]: Peers? No. We work with other peers. The group of first responders that we work with that we're calling secure peers are really just first responders that are focused on supporting other first responders. And so there isn't necessarily a specialty peer training when it comes to alcohol or substance use, but the counselors that we work with at the EAP, we do have licensed alcohol and drug counselors. So if there was a need for that kind of intervention or service, then we make that referral to that counselor.

[Alyssa Black (Chair)]: So the purpose of this bill, H. Two seventy, is because these are not technically HIPAA covered entities and these peer support within Secure are not licensed and covered under HIPAA either, that we need to be extending confidentiality. Do you think that the lack of expectation of confidentiality is stopping people from taking advantage of these services within our first responder, our emergency service providers. Do you think this bill is a good bill? I guess I'm asking.

[Leslie Goldman (Member)]: Well, why do we need it?

[Alyssa Black (Chair)]: And do we need it? Yeah, why do we need it?

[Bobby Arnell (Invest EAP)]: Yeah, know, that's a really good question. Know, I think, I'm coming from this a little bit as an outsider, because I'm not a first responder myself. I've taken that training just to be aware of the kind of education that we're providing to peers. But I think the idea, we want to encourage more people to seek out assistance when they're struggling. And I think sometimes, under the best of circumstances, there can be a stigma associated with reaching out for help. I think that can be maybe even more so within certain first responder communities. If we can allay some of those concerns even just a little bit and make it a little more likely that someone's going to reach out, I think that's a good thing. And I think of it from from two the from two ways in which this could work is one is just we have a peer. Generally, some departments have their own peer team, or they have one of our peers stationed in their department. And if somebody's more likely to reach out to them knowing that their communication is privileged and protected, I think that that could open up some doors for people who have concerns about, is this going to reach my chief? Is this going to affect my job? So anecdotally, I think it could be a really good thing. The other part of the other kind of communication, I think, that this bill would be implicated in is those group debriefings. And so I think, just anecdotally, from what I hear from other counselors and the research that I've read around those group briefings, it really only work if people are upfront and just open and communicating what they're feeling in that moment. I think that's the nature of the support. And so if people are worried about what they're saying in a group there about it getting out or if it's going to affect their job or what if this kind of what if this, what I say here, gets out into the newspaper? I think people are going to clam up. And I think if that happens, then they're not really receiving the service that they're supposed to be getting in being able to honestly process some of that trauma that they've experienced.

[Alyssa Black (Chair)]: Thank you. Any other questions?

[Leslie Goldman (Member)]: Yes. Yeah, go ahead. We had testimony that there were some potential suggested changes to the bill as it was introduced, It was around the wording counselor. I'm curious if there's any national requirement that EAP keep the word peer counselor. This is related to Topper's question about there being certified peer specialists and recovery counselors approaches.

[Captain Debra Munson (Vermont State Police)]: So I'm just wondering, if tweak anything in that language, is

[Leslie Goldman (Member)]: that going to be problematic for you?

[Bobby Arnell (Invest EAP)]: Is it to call the first responder peer a peer counselor, or is the counselor language associated with the mental health counselor that works with the peer?

[Leslie Goldman (Member)]: So we want to clarify that these are not counselors. And it sounds like that's exactly what you stated also, is that these are folks that listen and help connect folks to resources and you have the ability to connect people to licensed counselors. So I think the individual making the recommendation was just trying to be sure that the bill language is really clear in that sense, that we're really clear that these are not providing counseling services to their peers.

[Bobby Arnell (Invest EAP)]: Yeah, having that clarification, I think, from my perspective, is important. Don't necessarily want regardless as to how much training we give a peer, we don't necessarily want them pulling themselves out as a mental health counselor and talking to somebody with the expectation that they have that same kind of level of training when it comes to addressing some acute psychological need. And so purely speaking, just from my own point of view, I think having that being clear and that differentiation, I think makes sense.

[Leslie Goldman (Member)]: And then EAP, I know I've worked at other organizations where we had EAP. There's no national requirements around language that you use or terminology around this, right?

[Bobby Arnell (Invest EAP)]: Not that I'm aware

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: of. Okay.

[Leslie Goldman (Member)]: Let us know if there is. Can get back to

[Bobby Arnell (Invest EAP)]: us. Okay. Okay. Yeah. I mean, I think it's pretty novel in the sense, too, I'm not aware of, maybe other folks are, of a statewide peer support team. I think generally, the peer support around the country are department specific. Like the MAT team with the state police, that's an internal peer support group. So the secure network is a little bit of an outlier in the sense that it's statewide and composed of folks across different departments and different disciplines as well. So we try to keep an open have an open a large umbrella to include police, law enforcement, sheriffs, firefighters, EMTs, ski patrol. I think that's fairly novel in that regard.

[Alyssa Black (Chair)]: Well, thank you, thank you so much, and we appreciate your patience. We know we were running late. No problem, thank you for coming in. Next we have Debra Munson. Do I call you commander?

[Leslie Goldman (Member)]: My name is just fine. Okay.

[Alyssa Black (Chair)]: Well welcome, and thanks for coming in.

[Leslie Goldman (Member)]: Thanks very much. There are many within my organization that go unfranked and be identified. I'm perfectly fine with Deb. Okay. I'm Alyssa.

[Wendy Critchlow (Member)]: Nice to meet Trishma.

[Captain Debra Munson (Vermont State Police)]: Thank you very much for having me. As she stated, I'm Captain Debra Munson with the state police. I come with fifteen years of experience with the state police. I began my career over in the Northeast Kingdom out of the Derby Barracks. And I moved up through the ranks becoming a patrol commander there, then becoming a station commander. I transferred over to Williston and became the station commander over in Williston. And then I got promoted into my current rank of captain. And I oversaw our Special Operations Division, which oversees all the commanders of our special teams, our Marine unit, and then our traffic safety unit. And then most recently in 2025, early twenty twenty five, I transferred over to my current position where I oversee the Northern Half Barracks. So in the Field Force Division, I oversee all of the lieutenants of the Northern Barracks. Along with that, I command our peer support team. We call it our members' assistance team. That team has been in existence for numerous years. I couldn't even find records back dating when it actually began. We are overseen by a clinician, and our team is made up of 20 members. We do have a contracted clinician associated with our peer support team. And in addition to that, we have two additional licensed counselors along with her that provide support to us as well. One is also a chaplain. Prior to VSP, my history is I have an educational background in social work. I have my BSW. And then I don't want to say regretfully stop my education with my final year of my mental health counseling degree, but I jumped ship and came over to VSP. So my educational background is in the mental health field. So I do have a vast knowledge, if you will, and understanding of mental health and wellness. And then I've kind of bridged that gap and brought it over to the state police. I took command of the members assistance team back in 2020. So I'm going on year six, heading up that team, we have come miles since then. So I know there were some questions that people wanted to know with the state police. I'd like to first maybe answer your question, ma'am, you had for the last speaker. There is no national standard when it comes to a protocol for first responders and peer support. However, there are programs that are climbing towards that recognition. And it's more of unofficial. So I can speak on behalf of New England and the New England State Police and what framework we follow in terms of all of New England. And that is, as the gentleman mentioned, ICISF, which is the International Crisis Intervention Program. And so we do follow everything ICISF. And our clinician is a licensed teacher of that. So she teaches and she provides the training for ICISF, and she trains all of us. She has even recently trained up the state of Maine state police peer support team following that model. And like I said, that particular model does define things such as a peer support member, what a crisis intervention is. It does define that we are not with first responders in mind and for first responders is kind of how that program was built. So it's very specific to first responders, if that helps. I know someone testified the other day about confidentiality statutes within New England. And there are four out of the six states that currently have a confidentiality statute. And of those, two specifically state ICISF as being a model that is acceptable to follow. So it's showing that that is, yes, growing out of those states in Bloomington, two of them recognize it via a statute even. Yeah, so I just threw a lot at you with that. Does that answer a little bit of your question?

[Leslie Goldman (Member)]: Yeah, it does. Okay, thank you.

[Captain Debra Munson (Vermont State Police)]: I know there was the question thrown out of why do we need this? Do we actually need this? And if you think about what a first responder actually sees and does and the role of a first responder is a first intervention. That's the first person on scene. We're the ones that run to the problem instead of running away from it, right? The goal of the first responders to act first and get there first before all the other stuff kind of comes in. This would help that first intervention amongst peers. And the research shows that, especially it's displayed through ICISF, that the first intervention to prevent mental health illness and PTSD is an intervention from a peer, from someone who understands. If that is just something as a, Hey, how are you? Or, How are you feeling? Did you sleep last night? Can I get you some water? I know what you just went through was rough. And someone to really understand what peers see when they enter these incidents and have that be protected. Because they are the first ones that can prevent something such as a PTSD incident or diagnosis in somebody and really help people move forward with their lives. So yes, I do think it is very important. It's a stigma that most of us do feel in the first responder industry. Coming from a wellness and mental health specific background, when I entered law enforcement, it was very, people were very hesitant to say how you felt. I came from I spilled my guts when I when I came in, you know? I was like, oh, yeah. That was scary. And people looked at me sideways. Like, you're a cop and you're scared. Like, do we really want her next to us? Like And that was really different for me. It was almost like a culture shock coming in. And now we've kind of built our program to know and understand that you should be scared. That's normal. If you're not, we're probably looking at something else. It's probably an issue. But I say that very loosely because that is a wall that has to be broken down. That is something that is very hard for a first responder to say, yeah, that was scary. Yeah, I see that when I sleep. I woke up five times last night seeing the same pictures over and over. I keep hearing this voice. I keep seeing this picture. Those are things that are really hard for anyone, whether it be a police officer, firefighter, an EMT, to go through. And it's becoming more and more recognized that once people personalize some of the things that they see when they go into these incidents, the more likelihood of PTSD coming in because now they've personalized it. Now they make that connection with something that really means something to them. And being able to express that to someone who also understands is imperative for someone to feel that safety in doing so. And to say whether or not I support the bill, I can't speak to my support nor my opposition, but I can tell you where the research kind of goes and how important these first interventions from a peer really are and how they can change potentially the rest of someone's life. And it's very hard to put into research just how many peer support interventions have changed the course of someone's life, have prevented a suicide, have saved a career, because we did it. Preventative. So it's very hard to put that into writing. Well, exactly how many, have we saved in that? I'd like to answer some questions if you have any, or I can expand a little bit more on, what other states have for their statutes or what that kind of looks like or trying to frame out what you would like to know. First

[Alyssa Black (Chair)]: of all, thank you very much for your testimony. I won't. I was going say, man, she's impressive. I don't say that about a lot of witnesses. You had a chance to look at the bill as introduced. And I believe that this bill was brought to us by the Vermont Police Association, which you're part of the Vermont Police. And is the Vermont State Police separate from the Vermont Police Association? You have one state, one's more municipal. Did you have a chance to look at the language of the original bill and then the language that was presented to us the other day? And are you Do you feel as though it's sufficient language for what we're trying to accomplish?

[Captain Debra Munson (Vermont State Police)]: It has improved significantly from what was originally submitted. And I can only make that comparison seeing what other states kind of have, as well as my background and very much deciphering who a peer member is, is imperative because we are not counselors. And the first draft of this bill, I believe that was introduced, did call, I'm gonna use the word us, the and as that brings in, we're not we don't have insurance for that. We don't have the educational background. Despite every bit of my education, I wouldn't call myself a counselor. I wouldn't want that title either. And nor do I want to bear that responsibility for my peer and have that expectation of a peer either. So I think that making those definitions out there very clear is imperative for a bill to have. And that ICISF model does give out definitions of such things.

[Alyssa Black (Chair)]: Any other questions?

[Leslie Goldman (Member)]: Not a question, but just a comment. Mean, Alyssa said she's impressed. I am just in awe at the fact that we have you here in Vermont, and the quality of work that you're doing for your peers and for your field is it makes such a huge difference. Knowing that we have folks like you out there who understand what the folks who they show up to help might be experiencing is just thank you so much.

[Captain Debra Munson (Vermont State Police)]: Thank you, I appreciate that.

[Francis “Topper” McFaun (Vice Chair)]: Great to have you here. I asked a question about drug and alcohol abuse a little earlier, and people might've been saying, what the hell is he asking that kind of question? At least from the information that I have read, first responders, police, fire, drink a lot.

[Wendy Critchlow (Member)]: You're not wrong.

[Francis “Topper” McFaun (Vice Chair)]: And that's why I asked the question of the other person, how are you coordinating with professional counselors and peers that are being paid, because they're trained in doing that. And the other gentleman said, we can handle that ourself, We have people in there. And that one's great to hear. What happens? Because sometimes you gotta get through that barrier before you can have an impact on what the core problem is.

[Captain Debra Munson (Vermont State Police)]: I'm going take a long way around answering that question. And that ties into where confidentiality, I think, comes in is, because no, we don't have anyone that is a licensed alcohol and drug counselor. We don't. And we're not trained in it either. We are trained to see where people have a problem. And then we resource out. So that's where we have our clinician tied directly in. And our clinician is not a drug and alcohol counselor either. Not that she couldn't talk to someone about those issues, but then she would also probably refer out. But where confidentiality ties into that is that very person that is suffering from drug and alcohol addiction, it is very hard for them to reach out in that first responder world to say, I need help with these things because I could lose my job over it. And so they're not willing to actually reach out or accept that help. Or what happens to my job when I have to go into a facility for twenty eight days? Does someone really want me to jump on a fire truck when I come back from that because they don't know if I will relapse or if I've been using or what stigma is associated with that? Or do you want that person carrying a gun in your state and being the first one to arrive and intervene in a domestic violence situation when they have a drug or alcohol problem. Those are real, real problems to address, and they affect people. And it's really hard for someone to say, I need help Because I'm going spiraling down and I'm doing these things. And it's even harder for someone to step in and say, I'm noticing this. Can you talk to me about what's going on? I'm noticing something's not right, but someone's walls are up because of that stigma that they don't feel that they can safely say, Yeah, I need some help. And that's where the confidentiality statute comes in, because someone can say, Yes, I need help. How do I do it? And that peer member says, I'm here for you. I hear you. Let's get you in the right direction.

[Alyssa Black (Chair)]: Yes. And

[Captain Debra Munson (Vermont State Police)]: that protects that discussion, that communication with a peer that your chief can't come to you and say, Is Joey going to drug and alcohol? What did he say to you? Is he drinking? Is he doing it? That protects those communications. I hope that answers That's a a little bit long question.

[Francis “Topper” McFaun (Vice Chair)]: I make sure that something's being done, a referral thing to get help.

[Captain Debra Munson (Vermont State Police)]: Absolutely, that is what we're trained to do. We're trained to hear, to see, to understand the problem or the feelings that are behind it and how someone's doing and support them through and getting them to make that call or continue with that resource into that help.

[Alyssa Black (Chair)]: Other questions? Thank you. And thanks so much for coming in.

[Captain Debra Munson (Vermont State Police)]: You're very welcome. If you have any questions that you think of that I may be able to answer for you, please don't hesitate to reach out. I Thank would provide

[Leslie Goldman (Member)]: you. Thank you for your work. Thank you very much, mom. Yeah, you are kicking that.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Thank

[Alyssa Black (Chair)]: you. And we have Chris Horse.

[Chris (Vermont Police Association representative)]: Good afternoon.

[Leslie Goldman (Member)]: Thank you for coming in.

[Alyssa Black (Chair)]: So it is my understanding, and it actually took us a little bit of time to figure out, we weren't quite sure where this bill came from. Sure. So, and I understand it came from your organization.

[Chris (Vermont Police Association representative)]: Absolutely. It

[Alyssa Black (Chair)]: was championed

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: by your organization.

[Chris (Vermont Police Association representative)]: Yeah, and you've had some phenomenal testimony already. Far more experience than even myself. But what I can say and what I can testify to is the importance of this bill. Some of the previous testimony you've had, I've already kind of crossed that in mind. But first responders, they are. They're two to three times more the substance use disorder rate among the general population. So that's a huge, huge issue. And then in Vermont, there's an average of two to three people per week who end choose their own lives, each resulting in massive ripple effects on families, schools, communities, other first responders and healthcare providers, just to name a few of the stakeholders that would obviously be affected by something like that. One example coming to this committee that I thought would be meaningful was if a healthcare provider were to lose a nurse who was experiencing a mental health crisis, what is the physical costs to that? Not only in the ripple effects to their family, the community, all those different things. It's no different. When we talk about first responders and critical incidences, which is kind of how we refer to them in profession, clinicians with the immediate confidentiality needed, they're not always readily available, especially in the immediate aftermath of that critical incident. Myself, you know, I am oftentimes very close to a lot of those critical incidences for the capacity of what I do. And one of the really good examples was the tragic death of the relevant police officer Jessica Ebbenhuisen. The acute response from peer support networks like the Vermont State Police's MAT team was significantly greater than clinicians themselves. So that alone also lends to the importance of this confidentiality, the need for that because those people are readily available and able to mobilize and respond to a critical incident that it's not planned. It's a matter of when, not if. So as it relates to the confidentiality in and of itself, it builds trust and safety needed in order to have vulnerable conversations. Once those occur and if we didn't have that protection, individuals would be, as was already mentioned, you know, fear of judgment or retribution which would hinder their participation in an important program such as this to help get them the assistance that they need. Having confidentially would foster psychological safety, making peers feel secure to explore the deep challenges and finding a sense of belonging amongst finding a sense of belonging amongst your peers. I don't think it's any secret that being a first responder is an extremely difficult job. If it were easy we wouldn't be having a statewide staffing crisis as it is. So at some point, every single one of them is going to feel this enormous weight of a traumatic experience on their shoulders. First responders unfortunately see a lot of traumatic experiences. Some will be faced with more traumatic incidents than someone from the general population likely in their lifetime. There was a Vermont doctor, Doctor. Friedman, out of White River Junction who did a lot of work about Instead of calling it PTSD for first responders, they referred to it as cumulative career traumatic stress. And it's because a lot of times people, veterans who experience PTSD oftentimes can look at a specific time or a specific incident that caused the stress Whereas first responders more often sometimes didn't, wasn't pointing to one specific time, was pointing to a longer period of time in multiple traumatic experiences. On average, one hundred and eighty four police officers end their own lives annually. Conversely, on average, sixty four police officers are feloniously killed in the line of duty annually.

[Allen “Penny” Demar (Member)]: This

[Chris (Vermont Police Association representative)]: is sixty five percent less than the number of suicides per year. So, this legislation removing those, I would call it a roadblock for first responders when considering seeking mental wellness resources that are clearly already available to them By providing this confidentiality to peer support professionals, our state's first responders will be more supported in seeking help in addressing any potential crisis they may experience. And in turn be healthier and better prepared to serve and protect their communities. That's sort of the remaining gist of the stuff that I had to say and share.

[Alyssa Black (Chair)]: Thank you. Thank you. And it's very difficult to hear, but thank you for reminding us. Thank you for reminding us why we're doing this.

[Chris (Vermont Police Association representative)]: Absolutely. I appreciate every one of you for taking this up and giving the time.

[Alyssa Black (Chair)]: Do you have any concerns over the language change between what was originally submitted and the recommendations?

[Chris (Vermont Police Association representative)]: I haven't looked at it myself and I'm of a language person, so I can certainly take the look, but by the sounds of it, there's some people that are working on it that have some great experience and knowledge on what

[Alyssa Black (Chair)]: they're Just taking out the word counseling and counselor to ensure that

[Chris (Vermont Police Association representative)]: we're I think something being more clear and less ambiguous is always a good thing.

[Allen “Penny” Demar (Member)]: I don't know if it's a question for you or Ralph, but when we talk about confidentiality, and again, if I went through a depressing moment doing something and I'm looking for some peer support, we're just passing the bill of confidentiality. How many individuals or groups or organization will have access to that? If I'm talking to a peer supporter, you might send me to your other one.

[Alyssa Black (Chair)]: That's the whole point of this bill.

[Allen “Penny” Demar (Member)]: I know, okay.

[Alyssa Black (Chair)]: Just to make sure that no one else has access.

[Allen “Penny” Demar (Member)]: No one but the ones involved. So if I'm a peer supporter and I think you need more, I can send you to another one, that type of thing. Or

[Alyssa Black (Chair)]: a professional. A professional,

[Allen “Penny” Demar (Member)]: and that's okay. So it's the whole gamut. Yeah. Okay.

[Chris (Vermont Police Association representative)]: I think the importance of the peer support is to, those people have relationships with one another. With the confidentiality and the protection, the safety, it can open the door, that gateway to having those difficult conversations and then usher them to an individual that is prepared to help them further along the way.

[Alyssa Black (Chair)]: Thank you. Thank you so much for coming in.

[Sam Piché (Office of the Health Care Advocate, Vermont Legal Aid)]: Really

[Alyssa Black (Chair)]: quickly, committee, let me just ask, and then we'll end for the day. This was all testimony that I intended to take on this bill. Is there is anyone feeling as though they might need to hear more or if they would like to hear from someone else we could reach out to?

[Allen “Penny” Demar (Member)]: Do we see the updated draft?

[Alyssa Black (Chair)]: Well, we don't have an updated draft yet. That was my next question.

[Allen “Penny” Demar (Member)]: I have

[Leslie Goldman (Member)]: a question.

[Alyssa Black (Chair)]: Yes, go ahead, Brian. Sorry.

[Brian Cina (Member)]: I still would like to hear from a lawyer about the HIPAA issue that was brought up the other day. It was never clarified.

[Alyssa Black (Chair)]: Would we like to hear from a lawyer or our lawyer legislative counsel?

[Brian Cina (Member)]: I think legislative counsel is probably best. And specifically, was the issue of when a witness said that crisis responders didn't need it because HIPAA covers them, but then couldn't give evidence in the law to back that. And I looked it up and I can't find any evidence that people working in a designated agency who did mobile crisis, for example, their peer communications would be covered by HIPAA just because their employer is a healthcare provider. I think I'd like to clarify that.

[Alyssa Black (Chair)]: I'd like to clarify that as well. So let's ask Hailey if she can clarify that. Is everyone additionally, so I have this on schedule for next Thursday for markup and possible vote. Is everybody in agreement that we should ask Haley to incorporate the difference in the draft that we were presented into H-two 70 so that when she does come in, can have it prepared and ready for us.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Yes. With yellow. Okay.

[Brian Cina (Member)]: If we include anyone else. But regardless of that, I feel like the case has been made why we should move forward. Just don't want to delay us unnecessarily either.

[Leslie Goldman (Member)]: Sorry, could you remind me, is it on passage or

[Alyssa Black (Chair)]: effectiveness? Oh, believe it's on passage.

[Leslie Goldman (Member)]: I just wanted it to be that, but we can move on.

[Francis “Topper” McFaun (Vice Chair)]: It would say July 1.

[Leslie Goldman (Member)]: Oh, if it's July 1?

[Alyssa Black (Chair)]: Well, actually we'll change that, because remember it was effective July '20

[Leslie Goldman (Member)]: that she said. Oh, it wasn't her fulfillment. Oh, no.

[Alyssa Black (Chair)]: We'll we'll ask Katie to make it I'll have her put it on passage. Alright? Unless there's for some particular reason why it would have to be July 1. We'll do that. So I'll get with Katie over the weekend or before next week and ask her to incorporate those changes so she'll have a fresh draft for us Thursday and we can finish marking it up and possibly vote it out on Thursday. And we can go off of live.

[Brian Cina (Member)]: Alright. Thanks.