Vermont Legislature SmartTranscripts:

[Alyssa Black, Chair]: You're not stealing them. They are there for the needs of everyone. It means money. Yes.

[Megan Houghton, Financial Director, Vermont Department of Health]: Sorry,

[Alyssa Black, Chair]: we're clarifying a paperclip situation

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: here.

[Alyssa Black, Chair]: So we're back and we have Doctor. Elframp from Vermont Department of Health with us and we're starting to go over budget and Governor's budget recommends. So

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: we're to

[Alyssa Black, Chair]: start with you. You're the first person in.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Great. This is a two for two in the house with being in that seat, so great.

[Owen Foster, Chair, Green Mountain Care Board]: For the

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: record, Kilibrand, Commissioner Department of Health. Thank you all for having me. I'm gonna be sharing this presentation with Megan, who will much more of the in-depth financial information that I have, and

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: I will give

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: initial introduction and high level review. So our mission and vision and values, again, present these here, and I I wanna keep these on a lot of our slides just to, again, reconfirm our commitment to Vermonters, that we stand by them in this changing landscape despite whatever happens on the political landscape, both federally and locally. Our departmental structure, we have six sixteen positions across our central office, 12 district offices, the chief medical examiner, the warehouse, our lab. Again, a reminder to myself and to us all that we have a wide range of things that we do. Some of them are very much public health and looking at where we live our lives and the health of our environments. And other ones are very clinical, like the Office of the Chief Medical Examiner, the nursing home visits, laboratory testing, and the like. We have experts in all these fields that I rely on heavily because having been in the seat for less than four months, I am not the expert in all these areas, but I've been getting rapidly up to speed. And I'm very thankful for having that. Another thing we do, we do love data. We provide a lot of data and reports to the legislature and other places, including the state health improvement plan, state health assessment, Health and Remarks 2030 dashboard, and many, many, many others. These are mostly links for your reference and just to say, hey, there's other things that we do besides the programmatic work around data. So our budget process this year, we did very differently. It was my first time doing it, but it was done very, very differently than the years past. Instead of looking individually at our own departments, we looked at an entire agency at the amount of money the agency spends, where it's going. It was a very interesting process, and frankly, helped me rapidly not only make very close connections, but also understand the programs in the various departments within the Agency of Human Services. It was challenging, too, because we knew it was going to be a tight financial year. This year, we were looking at a $75,000,000 deficit within the Agency of Human Services. And when you look at the landscape of all the things that we do, there are some that are very important that we have to look very critically at, including services to Vermonters, occupational therapy for people with disabilities, things that you do not want to let go of. So in the grand scheme, when we're looking at that, keep that in mind when we're talking about some of the cuts that are in the Department of Health, because we did have to weigh those against everything within the agency.

[Alyssa Black, Chair]: May I interrupt?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Yeah, of course, anytime.

[Alyssa Black, Chair]: Within AHS, dollars 75,000,000 cuts. That's not Is that federal money?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: It's the entire budget, not just federal money.

[Alyssa Black, Chair]: Yeah. Did you say cuts or deficit? G

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: f. G I'm sorry. G f. I apologize.

[Alyssa Black, Chair]: What's the deficit?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: We'll let Megan go into the details of In all the places. It's not all programmatic cuts, okay, just to be clear. It's reductions in the budget.

[Alyssa Black, Chair]: Here

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: is our pie chart of where all our funding is coming from. Again, the majority of our funds is from federal funds. The budget for the health department is $221,000,000 this year, which is a 1.2 overall decrease from fiscal year 'twenty six. Again, federal funding is the largest source. General funds only account for 11% of our total budget. And the general fund share of the budget plus the state share of global commitment is 22% of our budget. We have a $5,000,000 lower budget request this year than last year, and our federal receipts are projected to be $1,100,000 less.

[Alyssa Black, Chair]: I'm sorry, 1.1 less?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: 1,100,000.0 lower for federal receipts and 5,000,000 less in global commitment budget.

[Megan Houghton, Financial Director, Vermont Department of Health]: Okay. Lori, can you explain the difference between federal fund and global commitment?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: I can. I promise you, Megan, we'll give you a better answer. But global commitment is through the eleven fifteen waiver from Medicaid that we share with the state roughly sixtyforty split between federal and state funds, whereas federal funds come a lot through grants. We have a lot of grant funding that we get directly to the department for a variety of programs, Like, I heard the news last weekend, the FIG funding, the Public Health Infrastructure Grant, which is very important to us, comes from the Fed.

[Megan Houghton, Financial Director, Vermont Department of Health]: And I'm sorry, can

[Lori Houghton, Member]: you I know the Chair Black already asked this, but can you clarify those numbers again? Yes. So

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: $5,000,000 lower global commitment budget and $1,100,000 lower federal receipts.

[Alyssa Black, Chair]: General fund remaining the same?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: General fund is lower.

[Megan Houghton, Financial Director, Vermont Department of Health]: General fund is also lower.

[Alyssa Black, Chair]: Yes.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: The record, no land will direct this file, because it gets confusing, but it shows up it's matched in the HS central office. So that's where the general fund and the federal fund, people find it in the departments. That's why it's global credit. So to the commissioner's point, most of that federal fund that they get directed to your grants, Sometimes departments do have direct federal funding from other things, but most of the global people use grants and that's why it shows up as the gross.

[Lori Houghton, Member]: So by reducing state funding, we're obviously reducing any global commitment.

[Alyssa Black, Chair]: Mental

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: where it's abuse problem. That's Megan question.

[Lori Houghton, Member]: Okay, so we can we'll let you keep going in the poll question. Okay, thanks.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: And the main thing that I, again, I do want to present is the programmatic cuts that we are proposing, okay, because those are ones that are meaningful and speechless. So three program heavy cuts. Two are in the workforce training bucket, one through the AHEC program support and another one through health professional educational assistance, VSAC, and then discontinuing the efforts to implement the unused drug repository program. I will go into all of those high level on the unused drug repository program. We got no bites when we tried to do this. It wasn't enough funding really to do the program. I don't actually think the amount of money that if we were to actually fund it fully, I think we would make less money than what we would get out of the drugs we just bought them. It's just a very expensive process to go through unused drugs, sort them, repackage them, and distribute them to people. So we didn't get any bites.

[Alyssa Black, Chair]: Are we gonna get into that a little bit more further? Leslie, do you wanna hold your question? I think he's just giving us a preview slide.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Yeah, and again, the next three slides are on those three individual programmatic reductions we're looking at. So the first one, the proposed budget would end the health care professional educational assistance programs through University of Vermont statewide area health education centers and Vermont's Student Assistance Corporation. This is a UVM program that is funding basically tuition reimbursement for health care professionals. It's not the only source of funding for VSAC, but it is a chunk of money. And the reasoning behind this, there's a couple of reasons. Again, the prioritization of the funds throughout all of AHS. There were other programs, again, service line programs that were felt more important. But the other piece is the Rural Health Transformation Program has a significant amount of funding that's going to be funneled into workforce development. More than twice this amount of funding, we're going to be looking at investing in workforce development. And we would like to reimagine that program, how we're doing it, to get outcomes that basically encourage and have outcomes that show people go into healthcare in Vermont, healthcare. That's what we want to do. The outcomes of these programs are not horrible, but they're just not where we want them to be. And we think if we rebuild this program, we can have better outcomes. And frankly, expand the programs to have the right service professionals in our state. As an example, yesterday I was doing a tour in community health centers in Burlington, and they've got a wonderful practice there. And part of it is a dental practice that is really great. They don't have any dental hygienists at all. They can't find anyone. So they're not able to service many people. Things like that would be great to look at when we're rebuilding these kinds of programs to make sure we're training and providing the right health care professionals. Anyway, so we see this as an opportunity to reimagine the way we're providing tuition reimbursement to Not tuition reimbursement, excuse me, tuition assistance to students that

[Owen Foster, Chair, Green Mountain Care Board]: build healthcare.

[Alyssa Black, Chair]: Yeah. No, Lori, did you go first?

[Lori Houghton, Member]: Is there more on that?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: The next one, which is related, is around AHEC, which is a supportive program to that. But this is the phone.

[Lori Houghton, Member]: Okay, so I'm going wait for AHEC.

[Alyssa Black, Chair]: I think my question is, we know that the Rural Health Transformation funds come particularly around the workforce development, that it comes with a lot of strings attached and how and who it can be dispersed to, that it can't ever pay tuition that has already been incurred, it's not a loan forgiveness. How does the very narrow way we can use those funds, how does that differ from what VSAC and AHAC currently, their model, and are we leaving a big gap?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Yeah, that's a great question. I can't give you a full answer because I don't know the full answer of that, because it has been challenging for her, but to find all the exact strings associated with it. The big one I do know, we cannot use it for two things. Can't replace something with vertigo. So we can't just say, we're going to just replace this with federal funds. It's great. And we can't use it for specifically tuition reimbursement. We can use it for tuition scholarship programs. So you can pay someone scholarship while they're in school. You can have the strings attached to those monies, which you absolutely need to do. I am confident we can build this program in a way that serves Vermonters and frankly, has better outcomes than what we have now. The retention rates being better, the outcomes I'm looking at. How many people stay in Vermont for how long in the right fields? But you're right, there are strings attached to it. 100% agree with that. And it's a different program than this. And there's no way to say that. It's true.

[Alyssa Black, Chair]: The the money that we invest currently in these programs Yes. Do they have a federal match to them? And are we going to lose that federal match if we are not putting in state dollars?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: I do not believe so, but

[Megan Houghton, Financial Director, Vermont Department of Health]: So for the record, you might be called the financial director. We'll definitely get into this when we go look at ups and downs, but yes, some of the programs are globally funded. So the cut includes both state, as Nolan was saying, the state funds and the federal share.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: I think also, correct me if I'm wrong, we're not decreasing the amount of drawdown of global commitment funds. It's not like we are taking less funds from the government in totality in the state of Vermont. It's just not coming from this program. We're reallocating it somewhere. Correct, correct. And that process that we were looking at within AHS is where should we be spending this money? And it's lessened here and a bit more here.

[Megan Houghton, Financial Director, Vermont Department of Health]: Ahead, I'm going to have questions. So a couple of ones, just

[Lori Houghton, Member]: on that, I'm going to hope that when AHS comes into the central office, they will show us that re

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: They show all of that plus highlights on specific programs like this across the entire agency.

[Lori Houghton, Member]: Okay. And if we're reducing, if the recommendation is to not have these programs anymore, what's happening to the people who are currently receiving money?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: You're absolutely right. That's a gap. I mean, again, this

[Lori Houghton, Member]: is They're just gonna be the money that they've been told they were gonna have?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: So the specifics of the program, I believe it's not a you are guaranteed this money for x number of years. It's more of a you apply for it and get this reimbursement for this year. So there wouldn't be any more money into the program, so they wouldn't have funds next year, as an example. So there are people who are currently receiving tuition reimbursement from old loans that wouldn't be able to have it next year.

[Lori Houghton, Member]: Okay. So can we get the data? You said outcomes aren't great. So can we get the outcome data? And can we find out the parameters of when people The sign hooks? And then my other question is, and I could be completely wrong about this, but correct me, but I believe this budget was made before we received the Rural Health Care Transformation. So this decision was made before that, I believe. And if so, are you already creating a plan as to how to replace this as of July 1?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: So the application Was submitted. Right, so we had submitted an application for tuition reimbursement. You're right, it was a gamble because we weren't guaranteed that we were gonna get 195,000,000, but there was confidence in the front, and this is some before I was that we would get some money for workforce development. And frankly, I think we got more than we thought we would. Our hope was we were gonna have similar amounts of funding within this bucket. But again, I stepped into it a little bit midway here. But my understanding was there was an acknowledgment that we were hoping to get money, just by

[Megan Houghton, Financial Director, Vermont Department of Health]: pointing And out to I'm going to admit on record that I have

[Lori Houghton, Member]: not read the World Health Care Transformation Plan. So could you also send us the piece that talks about what the plan will be for workforce in that?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Yes, I can. And to be clear, information about this is rapidly evolving at this time. So we'll send you what we got now. But I to might send you some next week too and maybe the week after, because it could absolutely change in those intervals of time with more specifics, budgets and things of that nature.

[Alyssa Black, Chair]: I just want to say, we'll probably talk to VSAC, AHEC. I want to be clear though, we're not replacing.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: We're not replacing.

[Alyssa Black, Chair]: We're replacing. Replacing.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: And people will be affected by this. It's true. People will be affected by this in a negative way and in a positive way. Having more funds sounds great, but it's not going to necessarily go to the same people. Again, my hope is, yes, this is a change, and this will be hard for many folks, myself included. I'm hopeful that we can build a system that is better at the other side.

[Lori Houghton, Member]: But we haven't done that.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: We have not done that yet.

[Alyssa Black, Chair]: Have we started?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: So again, the health transformation

[Alyssa Black, Chair]: You just cut the money.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: And that's the thing. The rural health transformation work has really just started. It started in earnest really, really, really recently. So I am very acutely aware of the timeframe on this, and I have been talking with my folks and with the secretary about making sure that we can build this quickly, because you're right, we're got the time. We're against

[Alyssa Black, Chair]: Oh, Allen.

[Allen "Penny" Demar, Member]: Can you just kind of explain to us this transformation money? It's going to the agency of human resources. Did all the agencies get what their wants and So

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: high level, in the application, we submitted a number of proposals for things that we wanted to do. And there's, I don't know, more than two dozen. They're not all within one program. There is certain things within the application that says, here's the things we will do. You can sign up for that in that sort of way. So as an example, within the health department I'll speak to myself because it's what I know there are things within mobile integrated health, within community paramedicine that we apply for and we've received positive. So working on building that system, redeveloping that system. Things in education are another one, and another one in recovery residences. Those are sort of some of the buckets that fall into our shop. There's a whole lot, a whole lot that is central office, and then there's pieces within other departments as well. So it's not like I get to ask for things. It's the application has things in it that make sense for us to apply for.

[Alyssa Black, Chair]: Alright.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: So again, in the same sphere, AHEC, which is a supportive program through UVM, our recommended budget would end the Global Commitment Fund grant, which is $500,000 which provides operating support for the state area health education centers, which is to promote health care on local college, high school, and middle school students, and a $50,000 annual grant to AHEC to recruit UVM medical students and medical residents to work in Vermont. Again, same thing. These are really challenging discussions and choices. But our hope is that we can rebuild a system that is stronger on the other side. Yes. Could

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: you speak a little bit louder when you

[Owen Foster, Chair, Green Mountain Care Board]: you you tail off. I'm very sorry.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Probably because I'm not as excited about this as I am about other things, to be frank. But just so the the budget would end the the global commitment funded grant education, which is $500,000 that provides ongoing support for the state area health education centers. The focus of those centers is promoting careers in health care among the local college, high school, and middle school students. We'd also end a $50,000 annual grant to UVM's AHEC for a program that recruit UVM medical students and medical residents to work in Vermont. So those are the sort of specific programs that we are recommending to know. And then the last one is the state prescription drug repository program. Again, this is one I briefly touched on. This is a program that was designed to collect unused prescriptions, resort them, package them, and provide them to Vermonters who need them, which is a great idea, I think, on paper. I think when it came to actually doing it, it was just too costly. And the amount of funds that was appropriated to it, we just could not get any bites off it.

[Alyssa Black, Chair]: You said bites a couple

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: of RFP, had no one to take up our RFP. No one submitted an application.

[Alyssa Black, Chair]: In Iowa, mean, were other states that have- Go ahead. Because I know this was your bill. It was. I remember this was your bill. It was very exciting at the time. Yep. Yeah. And there are other states that are very successful in this So what's the problem?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: I can't say for sure, but my I can say the problem is the funding amount. That's what it boils down to, is it the amount of money that was in the appropriation. It's not viewed by people in Vermont anyway. It's something that they could do. And I don't know for sure why that is. I suspect strongly it has to do with the resources in Vermont, and that is a real challenge that we struggle with, is just having enough health care workers in different fields. So in the realm of pharmacy, having worked as a physician, know we are short on pharmacists. We are short on pharmacy techs. Those are resources that are challenging to come up. If I were to venture a guess, that's what it is. But I don't know the specifics other than it's funding. It's not funding at a high level.

[Alyssa Black, Chair]: So all the problems that this was supposed to address, which were a lot, are just going to go up in smoke

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: wish early. That we could get a partner to say, yes, we can do this for this amount of money.

[Alyssa Black, Chair]: But why not ask for more money? I mean, if we believe at the

[Emily Brown, Executive Director, Green Mountain Care Board]: time, we believe Yep.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Again, we could certainly do that. We could appropriate more money. My strong guess is if we just bought $400,000 worth of medications, it would be more than the amount of money that we're the pills that we're throwing away, because the value of the meds themselves matter. So if we just bought, if we spent this money, we just bought money What's the amount?

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Sorry, I didn't

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: think 3 and $55,000

[Alyssa Black, Chair]: What year was and what did we appropriate in that

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: '25 was the was the appropriation year.

[Alyssa Black, Chair]: Okay. So it was in FY. We passed it in '24.

[Owen Foster, Chair, Green Mountain Care Board]: So it

[Alyssa Black, Chair]: was in FY so '20 how much did we appropriate in FY '25?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: It's $355

[Alyssa Black, Chair]: 300. Okay.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: It's been out for our fees since then.

[Alyssa Black, Chair]: So it's just been sitting in a bank account and now you're giving the back?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Not been funded.

[Alyssa Black, Chair]: Was it in base? I believe it was general funds,

[Megan Houghton, Financial Director, Vermont Department of Health]: so we have it in tops and downs. We'll go through it in focus. And just again, this was the agency wide budget process as they were looking at all programs across all departments. This was one that was not currently implemented. So the agency executive leadership team figured it out less of an impact on

[Alyssa Black, Chair]: it. A great idea, but it would cost more to administer it than it would be to just buy these drugs. That is my

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: guess, and looking at the funds here. I know that it's not enough that someone's willing to take up the program. And again, to Megan's point, one of the things we did look at is, hey, what hasn't been implemented or what has been underutilized when we're looking at where we can trim. So

[Alyssa Black, Chair]: if you may ask, how much of it ever was actually put into it?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: I can't speak to that.

[Alyssa Black, Chair]: How do we know?

[Megan Houghton, Financial Director, Vermont Department of Health]: Do know the,

[Alyssa Black, Chair]: I mean, Brendan, I'll just say, Brendan, Edward and I worked together on this, this is before we moved up to the latter, but he was pretty excited about it at the time.

[Megan Houghton, Financial Director, Vermont Department of Health]: We posted an RFP. I do know the division that was working on this within the health department posted an RFP to get interest to see what vendors were available. I don't know the exact results of the RFPs or responses, but there was effort put into trying to find a vendor. Certainly no one ever came

[Alyssa Black, Chair]: back and said, this is enough money to incorporate the gate. Even though it had value and came

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: from you. Correct. I don't deny that there's a lot of merits just doing something of this nature. Think it's a financial problem in terms of how money that it's costing versus what someone is going to charge to do it. And frankly, think, again, as I said, I think the value of meds themselves.

[Alyssa Black, Chair]: It's better to just incinerate them, which is what's happening now.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: As horrible as it is to say, because I don't like to make waste ever, as a Vermonter, Financially, that's probably true. And I'll say it's restricted. And then it's

[Alyssa Black, Chair]: going into air. I I know.

[Owen Foster, Chair, Green Mountain Care Board]: I know. And I'm

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: not there's a whole bunch of other pieces with it that say, right, have costs associated with that. Was saying dollars and cents, though. I think there's a challenge there.

[Alyssa Black, Chair]: Any

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: other questions initially before I pass it over to Megan? Again, I know that none of these are programs I frankly want. I don't. I like them all, and this has not been pleasant, I don't think, for anyone, certainly not for me stepping into this. It's always hard to talk about budget reductions. I know the team did their absolute darnedest to try and minimize the impact of the moderators,

[Owen Foster, Chair, Green Mountain Care Board]: and I can see that both

[Alyssa Black, Chair]: here. My initial question is we had a joint hearing with Senate Health and Welfare and Human Services, just Human Services, I'm sorry, getting my around restructuring of the AHS. And one of the identified things was, and we just had a witness who, you know, the co occurring substance use and mental health and the highest recommendation was just to alleviate and we were having a conversation. I should plan three minutes where everybody can just get all their sounds out. So I'm curious, I don't see anything reflected in the budget on sort of more of a sharing services between DMH and VDH, because I thought we were trying to come together on some of our programming.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Yeah. So as it pertains to Act 119, my understanding is we would need a legislative change before we would do it would be in the following fiscal year if that were to go through. I can speak to the work that we've done, because I've heard feedback from the designee of the agencies around this. I've experienced it myself. There are absolutely a lot of folks in our state who have co occurring illness, And I have worked diligently with Commissioner Hawes to make sure that whatever gaps currently exist, whether it's challenges in operations or legislations or just teams coming together, we've worked very hard on that. We've actually done a lot of great work to make sure, regardless of what happens, structural change, we're not. We're going to meet the needs of Vermonters who have co occurring illness and the agencies who are delivering those services who have been struggling. So the financing of that, I believe, would not be until the next year. But again, right now, I'm not going to wait for that to make sure we have a great system of care for these folks. Alright. I'm gonna pass it off to Megan.

[Alyssa Black, Chair]: And I will still be here

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: if there's anything, of course, that I can't describe.

[Alyssa Black, Chair]: Ups and downs, which we all understand a 100%. No one gave us a tutorial.

[Megan Houghton, Financial Director, Vermont Department of Health]: Again, for the record, Megan Houghton, Financial Director of Vermont Department of Health. I believe you've all gotten a copy of the full AHS ups and downs, but in the event you didn't. No, I'm sorry. We have that's why. I threw them in as an appendix. The last kind of or the first three slides of our appendix is kind of that full, lovely spreadsheet. But I do have once AHS gets those to you, we have reference numbers per pages. So just as a brief review, the health department has three different appropriations. Our admin and support appropriation, which includes the commissioner's office, our office of health equity, our public health appropriation, which is our largest. You can see all the many divisions within public health and then our substance use program appropriation. Oh, yeah. See, no one's got it. No. The public health appropriation, this slide represents, this is the changes in our gross salary range costs from fiscal year twenty twenty six to 2027. So again, all of these lines here represent gross changes to position costs from year to year. And I'm happy to take questions as you've got them or I can just keep barreling through. Can I just verify that it is actual fiscal year twenty six or is

[Alyssa Black, Chair]: it budgeted fiscal year? Budgeted fiscal year '26.

[Megan Houghton, Financial Director, Vermont Department of Health]: This is '27, but the comparison is to '26. Budget. Yeah. Budget's a budget. Yep. No actual central bank. Correct. I'll keep going on then. This next slide shows one last change to our personal services section, the workers' compensation insurance that the state pays for. And then the operating expenses, you'll see these are changes in our internal service funds. So fee for space, our buildings, other employee insurances, our ADS costs. You'll see that line is rather large. That's the $1,500,000 change. Our understanding is it's a change in the way ADS is going to be billing costs to the agency and departments compared to this current year we're in. There's going to be less cost billed to the AHS level. So, our BAA, we have that ABS allocated service charge that usually fluctuates. The intent is for less of that and more of the billing to go straight to the departments. So, AHS will have fewer costs, the departments have higher costs, and then we just won't have to do that transfer mid year. That's the intent.

[Alyssa Black, Chair]: Go ahead, Lori.

[Lori Houghton, Member]: The intent, so when will that start?

[Megan Houghton, Financial Director, Vermont Department of Health]: Fiscal year twenty seven is

[Lori Houghton, Member]: my Okay, underlying so right now you're saying that it's all at

[Megan Houghton, Financial Director, Vermont Department of Health]: the AHS level? There's a mix. A majority of our billing is to that AHS level and then AHS allocates out to departments. We do have some direct costs to ADS based on if there's a health department specific project or we have ADS staff working on very health specific things. Those get billed directly to the department, but these are kind of those broader charges like support desk services, Microsoft Office licenses type, the very broad general IT support. So do you as a department get

[Daisy Berbeco, Ranking Member]: summary a or a I'm not sure what I'm

[Lori Houghton, Member]: trying to say like a data sheet that says what you're being charged for, that

[Megan Houghton, Financial Director, Vermont Department of Health]: you know that these are all things ADX has. Right now, that broad summary for this ADX allocated charge goes to agency services. So because that's how it's been dealt with in the past, that summary will go to them. My assumption is now that we are budgeting for it directly to the health department, that

[Alyssa Black, Chair]: will jump.

[Lori Houghton, Member]: And so do you know if the charges that they're sending down to the departments now are truly based on the department's charges? Or is

[Megan Houghton, Financial Director, Vermont Department of Health]: it kind of like we have five departments, we're trying to be equal? I believe AHS a does review of that and then an allocation based on usage or staff. I admittedly can't speak to exactly how the AHS office then allocates it, but thanks. Other questions on this?

[Alyssa Black, Chair]: Brian?

[Brian Cina, Member]: I don't know if you're going to get to this later. So if you are, we can wait. But I was just curious if you could say more about increases related to people going back to work and having to pay for spaces that we weren't paying for before.

[Megan Houghton, Financial Director, Vermont Department of Health]: So the health department budget does not have These are just increases in fee for space and rent that are just general for spaces that the health department has already occupied, no impact.

[Brian Cina, Member]: It's like the COLA or whatever.

[Megan Houghton, Financial Director, Vermont Department of Health]: Yeah, yeah. The 3% rent increase that BGS is anticipating for currently owned or currently occupied. Does that fee

[Alyssa Black, Chair]: for space also include things like paper towels, toilet paper? No. It does not. That reflected anyway?

[Megan Houghton, Financial Director, Vermont Department of Health]: No. Right now, this is assuming When we built this budget, it was the current level of staffing that the health department has at our various locations. So district offices, our public health lab, our central office, which will be expanding in Waterbury. But for right now, this was our current occupancy

[Brian Cina, Member]: before we're done. When you say it's expanding, do you mean you anticipate people returning to the office or are you moving into a new space or is there construction?

[Megan Houghton, Financial Director, Vermont Department of Health]: The health department is anticipating a larger footprint at the Waterbury facility.

[Brian Cina, Member]: Within the facility? Yeah. See. Space is gonna be reallocated. Yes. Okay, thank you.

[Alyssa Black, Chair]: I think that's when Diva had to move out. PAH is taking their desks.

[Brian Cina, Member]: You gentrified Diva? Okay. Thank you for laughing and understanding.

[Megan Houghton, Financial Director, Vermont Department of Health]: Be Sorry, my lap isn't perfect.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: These are ups and downs, not bays. If you wonder how much they spend on paper towels, that exists in a bigger budget book for the allocations, how much we have this, that, and that thing. What this is saying is we don't plan on buying more paper towels than we did in the room to do, just to kind of use that in a

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: raffle way.

[Brian Cina, Member]: Even though more people are there.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: And I'll advise adjustment, then I'll say we need more toilet paper towels. Yeah.

[Brian Cina, Member]: Or like those new fangled devices that dry your hands.

[Lori Houghton, Member]: All right,

[Alyssa Black, Chair]: move on.

[Megan Houghton, Financial Director, Vermont Department of Health]: This last section in our public health, or I'm sorry, our admin appropriation is the grants changes. So the first three lines you'll see here reflect the move of our rural health and primary care program activities from our admin appropriation into public health. So, those three lines were not program service eliminations. We're just reorganizing where the work is done within the health department. And you'll see corresponding, when we get to the public health section, you'll see corresponding increases or ups in those. And funding levels are, as I said, unchanged. It's kind of a net neutral.

[Alyssa Black, Chair]: Lori, I'm sorry. Leslie, could you just talk about the quality improvement prescribing program? Know it's net neutral, but what is it?

[Megan Houghton, Financial Director, Vermont Department of Health]: The Quality Improvement Prescribing Program, that's a budget for two grants to the Statewide Area Health Education Center for academic detailing and education programs for healthcare professionals. That is funded with our Evidence Based Education and Advertising Special Fund. And it was, I believe, established The program was authorized by '18 BSA 4622.

[Alyssa Black, Chair]: So, what does that mean?

[Megan Houghton, Financial Director, Vermont Department of Health]: Yeah. The academic detailing program is a university based prescriber education and support program. Faculty reviews clinical topics focusing on the latest evidence, lifestyle changes, generic medications, and new drug releases. And it's shared with healthcare teams across the state.

[Alyssa Black, Chair]: So, is there any data about the impact of the program? How many people participated, changes in prescribing as a result of the program?

[Megan Houghton, Financial Director, Vermont Department of Health]: I'm sure there is, and we could get

[Alyssa Black, Chair]: that to you if you would like it. Yeah.

[Megan Houghton, Financial Director, Vermont Department of Health]: Over the first three lines that are, again, programs moving into our public health appropriation, the next two lines, the Area Health Education Center and Educate Loan Repayment, those are the two programs that Doctor. Hildebrandt mentioned are proposed for elimination.

[Alyssa Black, Chair]: I want to be clear, these two, I'm looking at them together, but the one is really just administrative support. The five fifty is administrative support for AHEC? I believe it is a combination of administrative support and

[Megan Houghton, Financial Director, Vermont Department of Health]: the small program to help recruit

[Alyssa Black, Chair]: residencies. It's not

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: task to commission. It's not what? It's not a task to commission. It's not a tuition fee.

[Alyssa Black, Chair]: How else is the AHAC funded? Will they go away? It should happen.

[Megan Houghton, Financial Director, Vermont Department of Health]: And then the last line, again, improvement prescribing. He talked about it a little bit, but that's another program that is just moving out of the commissioner's office and will be going into our public.

[Alyssa Black, Chair]: Yeah, I've got Nolan in clap for us.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Go ahead Nolan. I might be getting a habit, I see you have the educational loan repayment, you're taking $2.50 out of the federal fund, but on 03/12 you're adding it back. Yep. Is that, I see this but neutral on the federal piece, but does that mean you're still funding the program?

[Megan Houghton, Financial Director, Vermont Department of Health]: Yes, so.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: With classic federal.

[Megan Houghton, Financial Director, Vermont Department of Health]: Yep, thank And

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: still leaving some money for the.

[Megan Houghton, Financial Director, Vermont Department of Health]: Yes, so our state loan repayment grant comes, I believe, from HRSA. That program is still maintained by the federal government. So that aspect of this broader program will remain. It's the global commitment funded part of the AHEC program, the education loan repayment that we're proposing to. Did you have details

[Alyssa Black, Chair]: on that somewhere? Sorry. It's showing amount. So

[Megan Houghton, Financial Director, Vermont Department of Health]: what is staying versus Yes. What is staying is the $250,000 state loan repayment grant. And in our detailed budget book, you can see that's a federal receipt or an anticipated federal receipt.

[Lori Houghton, Member]: So, I'm sorry. I didn't realize you had a detailed budget book.

[Megan Houghton, Financial Director, Vermont Department of Health]: Can you

[Alyssa Black, Chair]: say that again?

[Megan Houghton, Financial Director, Vermont Department of Health]: We haven't posted it yet. We're getting it ready for appropriation. So that's Yes, I apologize. But it should be ready soon.

[Alyssa Black, Chair]: I mean, I realize that we're still in negotiations developing things. Is the intent to hopefully use a HEC as the administrator of whatever

[Emily Brown, Executive Director, Green Mountain Care Board]: loan

[Alyssa Black, Chair]: assistance program is developed using the RHT money?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: VSAC is probably the primary mechanism of loan distribution. I think that's TBD in a way, but VSAC is, they get the lion's share of the funding that we have for this loan forgiveness program, so they're a large one. Okay.

[Megan Houghton, Financial Director, Vermont Department of Health]: But I think it's too early to say exactly where

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: I asked that very specific question

[Owen Foster, Chair, Green Mountain Care Board]: as well about, hey, can this RHGP stuff become bigger?

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Should it be beneficial? That

[Alyssa Black, Chair]: would be I think you stepped out of the room.

[Megan Houghton, Financial Director, Vermont Department of Health]: Last change in our admin appropriation. So moving on to public health, This is very similar to what you saw in administration. These are salary and fringe changes, net, for the coming fiscal year. Let me know if there's any questions on these. Absorb the numbers here. Yep. I will say just in general, you will see we had a There's a rather large interdepartmental transfer reduction there. That reflects changes in the way the precinct development grant is being administered throughout the agency of human services. In the current year and the year before, VDH did a lot of work. That grant is held by the Department of Children and Families, and they provided a good amount of funding to the health department to do specific work and activities. The way that grant is being operated within the agency is just changing a little bit in the coming year. We, the health anticipate doing a little less work, but DCF is continuing most of those programs and activities. So, that's why you'll see a rather large decrease in the interdepartmental transfer fund at the health department.

[Alyssa Black, Chair]: This is an aside, but it's just the childcare contribution. If state employees, I I know that there's an option for employers to pay 100% of it, or it's like a 70 five-twenty five split if you want as an employer. Does the state of Vermont pay 100% of the childcare contribution? I know that off the top of my head. I

[Megan Houghton, Financial Director, Vermont Department of Health]: believe employees pay a bit, but I would need to get back to you on that.

[Alyssa Black, Chair]: Then

[Megan Houghton, Financial Director, Vermont Department of Health]: the last change in kind of the personal services section, again, Doctor. Hildebrandt mentioned, is the removal of the unused drug repository program from our global commitment budget. Then we have two lines for changes in operating expenses. Again, fee for space, that's our cost of our district offices and the public health laboratory. And then this medical and lab supply line, that is a transfer of a program of a Narcan distribution program from our public health appropriation into our substance use appropriation. So again, no funding changes for that. We're just reorganizing within the department where that program is maintained. Sorry. It seems like every time

[Alyssa Black, Chair]: is a general question, every time people come

[Megan Houghton, Financial Director, Vermont Department of Health]: to do the budget, there's always

[Alyssa Black, Chair]: these transfers. Why,

[Megan Houghton, Financial Director, Vermont Department of Health]: like, is it because you're looking at things and you're like, oh, this doesn't make sense? Or just curious what the rationale is. Things constantly are moving. So I can't speak for every department, but for the health department, this past year, we did the health department leadership kind of took a look at where programs were being housed and run, and it made sense to move some of those programs out of our administration division Corporations, sorry, and into either public health or, in this case, moving our NARCAN, which is largely treatment of substance use disorder, preventing overdoses, it made more sense to have that program run out of our substance use appropriation. So, some of them are just those kinds of internal moves within departments sometimes, and we have a few of these ourselves. When we're building the budget, we find areas where the budget isn't really true to how we actually fund a program. So, there's some of those shifts as well. The format of the ups and downs makes it so you see any. Yeah, right. Yeah, no, it's interesting.

[Alyssa Black, Chair]: Okay, thank you. I have a question about it. I mean, feels as though if we're moving the money around, we're recognizing that things should be incorporated in different areas, which would imply a level of efficiency. And why don't we ever see, why do we always see net neutral? Why don't we ever see increased efficiency? That's a good question.

[Megan Houghton, Financial Director, Vermont Department of Health]: Admittedly, now, these programs, needed the We whole needed all of the money to continue the program within our substance use division. We might see efficiencies as this move comes, but we didn't want to move the program into a different unit and then also at the same time, short them. We wanted to keep the program whole and allow the new division to help to implement that.

[Alyssa Black, Chair]: More of a philosophical We never seem to see increased efficiency

[Megan Houghton, Financial Director, Vermont Department of Health]: and down. I do believe, and I don't know the AHS wide presentation, but there are some program efficiencies in the AHS wide budget this year. As again, we've looked at the whole of the agency rather than just department by department, I believe they were able to find some program efficiencies that they were able to book some savings on.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: That's that.

[Owen Foster, Chair, Green Mountain Care Board]: That's valid. And you're actually right. There is some examples of that

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: with open air funding or emergency support that we had that funding away statute. That's something that I've been asking very hard questions about

[Owen Foster, Chair, Green Mountain Care Board]: with my programs, because there are some countries we

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: haven't criticized appropriately, and if that funding either goes away or the world has changed, should I be looking at reducing back to the wages for a

[Owen Foster, Chair, Green Mountain Care Board]: back index? So you're absolutely right. It's something that is absolutely on my plate and

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: it's open to help looking at it very It's a challenging question, if you were, when I'm looking at it more.

[Alyssa Black, Chair]: Leslie? So you've obviously been immersed in this budget for months. You're now seeing it for the first moment. Are you planning to give us a narrative? I mean, you're explaining a lot of stuff, but I'm not following, I'm not keeping up, I must admit. So I'm wondering if there is a narrative that you could support these recommendations, changes, whatever, to help us understand your thinking. Yes. Again, we

[Megan Houghton, Financial Director, Vermont Department of Health]: are working on some supplemental materials as was requested through the Joint Fiscal Office and the Appropriations Committees. We are preparing those supplemental materials that will hopefully complement and help explain the changes in our budget.

[Alyssa Black, Chair]: And then you'll come back when we have that? We could

[Megan Houghton, Financial Director, Vermont Department of Health]: come back. It should be posted to the It'll be posted.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: We'll come back whenever he passes.

[Megan Houghton, Financial Director, Vermont Department of Health]: I was gonna say, if he would like us to come back, yes, we

[Alyssa Black, Chair]: can come back. It's also simply hard to take out for me, I'm saying, Oh yeah, to take this in and be a responsible person, not stealing that opportunity right now.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: To be fair, I do think we have a chance to see the entirety of the AAS and all these divisions that may also be inspiring.

[Alyssa Black, Chair]: I mean, you won our votes, right? That's a lot of

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: the truth of my work. We want you to understand it.

[Alyssa Black, Chair]: Doctor, go ahead.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: This is just an information question. Suboxone. Is Suboxone an opiate?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: How about I answer that?

[Megan Houghton, Financial Director, Vermont Department of Health]: Was gonna say, was defer to you. So

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Suboxone is a combination of two different medicines. One of them is an opiate called buprenorphine, and the other one is an opiate blocker. And the rationale behind that is that if you just lose an opiate, people can use it as a drug abuse. By pairing it with a potent opiate blocker, if someone were to do things like crush it and try and inject it, it would block the effect of that opiate. Now in practice, people still, to some extent, do that. But there are huge benefits with Suboxone. Obviously we've seen those in the introduction of opioid related deaths. You can't overdose with Suboxone. That's one of the biggest advantages of the medication. Are there people who are using these medications in ways that are not the intended prescription? Of course. But the benefits of these medications just so far outweigh the negative effects. We've seen that not only here but across the country. But that's sort of the rationale behind this, and it's been very effective. But yes, buprenorphine, which is part of Suboxone, is an issue.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: And you've become addicted to Suboxone. So it's dystopia,

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: so absolutely. Ethiopians can be addicted, for sure. And there are definitely humans on this planet who that is the way they entered into addiction. Again, my clinical experience that I see far more commonly these are used as medicine as a bridge to sobriety. The point is valid. There are people on this planet who have found pills and use them as a substance abuse. I appreciate that. I

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: thought that's what it was, but I want to make sure. Because we're using it in the treatment program, we use it

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: a lot. Yeah, that's true. We use it as replacement. Again, clinically what happens with Suboxone, we are getting very far away from our budget. I promise

[Owen Foster, Chair, Green Mountain Care Board]: you I'll wrap up very quickly. Lori, actually,

[Alyssa Black, Chair]: it's about to go into the substance use.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: It is a stabilization effort. When someone is using drugs injecting IV opioids, the brain chemistry becomes very, very dysregulated.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: When you

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: have someone on Suboxone, a daily dose that's set and measured by a physician, the brain chemistry regulates and that thinking can become very much normalized and you can then engage someone in truth. I think the philosophy and what we've seen in practice with this medication it is an opiate. It is addictive. It is, in some cases, abused.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Wanted to make sure I was invited.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Did you take

[Alyssa Black, Chair]: it in the argument or did you lose it?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: I'll try next time.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: It was It was neutral.

[Megan Houghton, Financial Director, Vermont Department of Health]: This is the last slide for our public health appropriation. And again, you'll see these were a lot of the programs that we had kind of reorganized within the health department itself. So the move of those rural health system improvements, clinical development and support, and the healthcare quality assurance out administration into public health. This education loan repayment line, that is the state loan repayment grant federal funds that is remaining. And then our quality improvement prescribing. So all four by four of those items that were taken out of administration and put back into.

[Alyssa Black, Chair]: Oh, I lied.

[Megan Houghton, Financial Director, Vermont Department of Health]: I have more on public health. Sorry. The next slide This is Yeah, there's a two parter. Had a lot of grant. Our immunization program. So this budget line item represents a requested increase of 7.5 in vaccine costs for the Vermont Vaccine Purchasing Program. As I'm sure you're probably familiar, the program ensures universal access to vaccines for all people in Vermont at no charge to the individual. And the program helps reduce the total cost of vaccine by using large purchasing contracts. Program Sorry, program costs are funded with an assessment to health insurers, is deposited into a special fund. And that is our requested increase in the special fund. We anticipate vaccine costs to be about 7.5% higher next fiscal year.

[Alyssa Black, Chair]: Can I ask you a question on Nolan here real quick? How do we assess insurers to go into that special fund? Do you know?

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Which special fund is it?

[Megan Houghton, Financial Director, Vermont Department of Health]: The The immunization. I believe it's a per member per month rate that people I will briefly speak to it, but we can get you more information. But we assess every year, there's a committee that reviews how many Oh, actually, that's funny. Reviews entire All the drugs, not drugs, immunizations that we're recommending, we estimate the cost of purchasing those, and then each insurer is charged the per member per month rate based on their covered lives.

[Alyssa Black, Chair]: So if we're increasing this by almost $2,000,000 are we using residual money that's in that special fund or are we increasing the per member per month that insurers pay into it? This would be an increase in the per member per month rate that's charged to insurers.

[Megan Houghton, Financial Director, Vermont Department of Health]: Insurers are on the committee that reviews the assessments and approves. The No. I'm sorry. So is this state money or is this money from the church? Is this money from

[Owen Foster, Chair, Green Mountain Care Board]: a church?

[Lori Houghton, Member]: That's coming in as revenue. Yeah. Okay. Thank you. Mhmm.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: That fund was created by this committee.

[Alyssa Black, Chair]: Oh good. It's a great I'm just trying to figure out, it's a great

[Megan Houghton, Financial Director, Vermont Department of Health]: It is,

[Alyssa Black, Chair]: yeah. And it's great company. And And let's forget that the insurers are then not paying for that immunization if it's state supplied.

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: They

[Alyssa Black, Chair]: get all claims to their member. Okay.

[Megan Houghton, Financial Director, Vermont Department of Health]: The next line is yet another internal health department reorganizational change. This was related to our Syringe Service Program that was previously part of our HIVAIDS program. We're again kind of moving it into our Substance Use Programs appropriation just because it makes a little more sense for that program to be run out of that division. Is

[Brian Cina, Member]: that because of the policy changes over the last many years? Because originally it used to be that CDC money for HIV was funding the harm reduction efforts. Is that changed now? Is it coming from different sources?

[Megan Houghton, Financial Director, Vermont Department of Health]: Is specifically syringe service program. So we could never use federal money for syringe service programs. So this very specific portion, our HIV AIDS program is still living within the public health appropriation, but this is just very specifically-

[Brian Cina, Member]: Oh, you mean like giving out of needles versus the bleach kits and the condoms? Yes. Okay.

[Alyssa Black, Chair]: So, I'm sorry, where is that

[Megan Houghton, Financial Director, Vermont Department of Health]: going now? Substance use preparation. The next two lines you'll see are changes to our maternal and child health programs. The very first line, this down in the interdepartmental transfer of $2,400,000 that is the, as I mentioned previously, the changes in the PDG grant. Again, a little less money is coming to the coming to health department and more of those programs being operated directly by DCF. I'm sorry, preschool development.

[Alyssa Black, Chair]: Thank you. Yep. So we would find an up in DCF's budget?

[Megan Houghton, Financial Director, Vermont Department of Health]: I believe so, but it would show up in their side as federal funds just because of the way it's So we don't count federal funds twice. It shows up in DCF's budget as federal and ours as interdepartmental transfer. And this next line under maternal and child health programs is the school Medicaid administration claiming is moving to the Department of Vermont Health Access. Then after Actually, I realize we're short on time. Do you want me to

[Alyssa Black, Chair]: keep going? Yeah. Okay. Let's hit the highlights.

[Megan Houghton, Financial Director, Vermont Department of Health]: So this next change in our tobacco control program is a We are better reflecting how the budget is appropriated and how we spend it. And then the very last change in the emergency medical services, that is an increase of $300,000 in special fund. The source of that revenue is a transfer from the fire safety fund. Back in 2024, there was an increase to the annual amount of the transfer to the health department from that funds. This is where we're just kind of cleaning up to ask for that additional funding. Finally, our substance use programs appropriation, these net salary fringe changes. The biggest change you'll see here, and I apologize, I meant to mention it when we were in public health because you would have seen it there, but there were 11 positions that were in the substance use programs appropriation that worked out of our district offices. Those positions have been moved into the public health appropriation. They still work out of the district offices. They still do substance misuse prevention work. Again, it's kind of an internal alignment shift in the health department as to where they were funded. So that is the large federal

[Alyssa Black, Chair]: So they're in the central office of VDH, not the central office of AHS?

[Megan Houghton, Financial Director, Vermont Department of Health]: They are VDH employees. They used to be they're out in the district offices, but we used to fund them out of the substance misuse appropriation. We've moved them to the public health because that's where our district offices.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Okay, got And

[Megan Houghton, Financial Director, Vermont Department of Health]: again, this medical lab supplies line, this is the up, this is the NARPAN program that is out of public health into substance use. And then finally, we have changes to our grants appropriation and the substance use prevention account code, you'll see an increase in the annual appropriation. The special fund is from the substance misuse prevention fund. And that is the 30% cannabis excise tax that is transferred into the fund by finance. The administration is estimating that the amount of revenue available in 2027 will be 9,500,000.0. So, our current budget, this is again where it's sometimes helpful to see that larger big budget book. Our current budget is roughly 6,900,000.0. So, to get us to that estimated 9.5, we've asked for an additional 2, a little over 2,000,000.

[Alyssa Black, Chair]: Are we losing federal or is it?

[Megan Houghton, Financial Director, Vermont Department of Health]: The total, it's a combination of a few things in this particular line. We anticipated additional special fund. And then our federal is, really trying to true up the funding for that kind of program to how it's actually spent. We are not necessarily losing federal grant money. It's just we had more federal in the budget than we actually really use in that particular line. Substance use intervention. This is the new kind of what is the SSP program. So, that syringe service program that was moving out of public health and into. It just has a different label now that it's in public, substance use. And then our substance use treatment account code, we again change in the kind of general funding mix of our programs. No overall change in funding levels, but we're trying to, again, better reflect how funds are going to be spent out program. Of So, there's a decrease in general fund and investment global commitment, but we are anticipating being able to claim more of our substance use block grant in that for the treatment. And then very last item, and then I'll open it up to questions, is a transfer to the Department of Mental Health for certified community based integrated health centers. So, were previously providers that the health department paid as Medicaid fee for service. They are transitioning to that community integrated health model, and that was held within DMH. And I believe they get a flat rate per member per month payment by DMH.

[Daisy Berbeco, Ranking Member]: What did you just say about your block grant?

[Megan Houghton, Financial Director, Vermont Department of Health]: Yeah, so the substance abuse treatment line, we're not getting more block grant. It's not an increase in our block grant, at least not that we're anticipating. It's we're across this program, we're seeing trends where we're able to spend more of our block grant on substance use treatment. And therefore we can kind of true up our funding and spend less on treatment from our Medicaid investment.

[Alyssa Black, Chair]: Or we could just spend more. That

[Megan Houghton, Financial Director, Vermont Department of Health]: is the end of our budget.

[Alyssa Black, Chair]: Any questions? Okay, and again we'll invite both Veesak and Ahak in regarding the loan stuff? Go ahead, Brian.

[Brian Cina, Member]: Would you say that that loan change is the greatest change that you presented today out of everything? It seems like it stands out to me, but is that the biggest change in terms of funding and policy that you're

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: proposing? Okay, thank you. That's why I do it.

[Brian Cina, Member]: If it's that? Well,

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: thank you. Thank you.

[Alyssa Black, Chair]: Actually, I do have a question about that. Did you sort of I don't know if you directly said this, or maybe I just felt like you alluded to it. We've put a lot of money over the years into, particularly AHEF, or I I know every single year that I've been here. Have we seen results in terms of workforce, particularly physician? Have we gotten good bang for the buck or?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: That's question. I can get you outcomes on some of the tuition reimbursement and retention. Again, I think we have an opportunity because if I go around to the primary care offices and say, hey, do you have enough primary care docs? I can't imagine a single person saying yes. Now that's not blaming anyone for not, but I think we have an opportunity with this funding that we're having from the Fed is to say, is there a way we can do better? Because I don't think we've fixed it. I think we have an opportunity to maybe not fix it, but work towards that. And that's my hope and my goal. So the extent to which AHEC, I'm sure that they can provide you specific granularity of what an impact they've made. But I think we can do.

[Alyssa Black, Chair]: What does mean? What does do better mean? Because obviously, the implementation, you have five years of funding, and then it goes away. So what does doing better mean?

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Decrease the workforce shortage in Vermont. Ultimately, that's what we're trying to do, trying to decrease the shortage amongst the myriad of workforce in health care that we have, whether

[Alyssa Black, Chair]: it's What needs to different than what's been done. Well, what do think? We really need to move on because we're ten minutes late for our next series of sessions, our next witnesses. You. Absolutely. Thank you very much. I feel like I haven't taken a break. You know what, if anybody needs a break, they can get up and go take their own break. I mean, you're adults. Figure it out.

[Brian Cina, Member]: You can always jump on YouTube or Zoom and keep listening like I do.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Has anyone, I had copies of the up and down made?

[Alyssa Black, Chair]: Oh, wow. Not. Know.

[Megan Houghton, Financial Director, Vermont Department of Health]: Health department starts on page 10.

[Alyssa Black, Chair]: Prohibiting age to age five eighty five, which is what we were doing yesterday. Does somebody want to invite our next witnesses in? Because I saw the only one, and I know that they're out in the hallway.

[Brian Cina, Member]: Yeah, so they don't come in and escape. Maybe they're like scooped away by the healthcare advocate.

[Alyssa Black, Chair]: Hi, and we are live, just to let you know.

[Megan Houghton, Financial Director, Vermont Department of Health]: Anyone else have a copy of that?

[Alyssa Black, Chair]: Earthquake! Oh wow. You guys can come out of the house anyway. Not taking a break, making people work through. So again, we're pivoting back to '5 85, and we've asked the Green Mountain Care Board to speak on some of the areas that we heard on yesterday within that bill.

[Owen Foster, Chair, Green Mountain Care Board]: Thank you for having us. For the record, my name is Dylan Foster, I'm Preppy Green Mountain Care Board.

[Emily Brown, Executive Director, Green Mountain Care Board]: And I'm Emily Brown, I'm the executive director at the Greens Mountain Care Board.

[Owen Foster, Chair, Green Mountain Care Board]: Would you like us to just provide an overview? Ms. Brian and I will divide up some of our comments, and I'll try and go through it sequentially. The first section that I want to address is the board of directors and the changes to the composition of the board of directors.

[Alyssa Black, Chair]: We actually were so intrigued by all the other sections yesterday that we never got to the board of That doesn't sound familiar. Or you can just speak to it in general.

[Owen Foster, Chair, Green Mountain Care Board]: Great. This is my favorite section.

[Alyssa Black, Chair]: There's an exception on board

[Owen Foster, Chair, Green Mountain Care Board]: of directors. Board of directors the domestic insurance company. 4513A. So,

[Alyssa Black, Chair]: yeah, here's This is a section one. Section one, this is the board of directors for essentially Blue Cross Blue Shield of Vermont, only domiciled.

[Owen Foster, Chair, Green Mountain Care Board]: Correct. The change that this bill introduces on the board of directors is it changes the composition of who is on the board of directors. That's a fundamental change. Section c in this bill, representatives of the public, c one, holds for two voting members of the board, but no less than one sixth of the board to be representatives of the public appointed by the governor. So this would add a layer of remove it just from self selection of the board or of the board's management and who is on the actual. Why I think this is important is because it will create more diversity on the board. It'll make it so that people are not just selecting friends and colleagues. It'll add a layer of transparency because it's people who are appointed literally by the political branch. I also believe that what we've seen in some of the governance issues across providers and insurance companies are unsatisfactory. My main gripe with the board oversight that's existed in Vermont is it has not been consistent with the state's goals in health care. What I mean by that, Leslie Goldman, is we're seeing a lot of really large bonuses and executive compensation increases at a time when the state's healthcare system is literally failed. And I struggle with why are the executives of our largest nonprofit systems receiving enormous bonuses while the rest of the state is really, really struggling and suffering? And I understand it. It's because of their process. Their process is, here are the benchmarks, here's what we do, approve it. And it's considering really just what's happening with that one organization, not what's happening to the entire state. So let's go to UVM, the easiest example. UVM CEO, like two years ago, got a $600,000 bonus. Well, they did so in part because they had really good financials that year. From that organization's perspective, that CEO had done an outstanding job. They did really well. They made a lot of money. That lot of money came at the cost of a lot of other people paying a lot of money and a lot of other people not being able to get enough money for the services they provide. And I'm talking about community providers and primary care providers. So I think that we need to change how the board is looking at and evaluating its management. I think this provision does that. You need to consider the state's healthcare goals, not just how your entity is performing. My other concern here, and the reason why I support it, is we're all well aware of some Blue Cross' financial challenges that they had in the last couple of years. Their finances were truly nosediving. At the time that their finances were nosediving, the top executives had enormous compensation increases. In the Green Mountain Care Board's budget rate review order for Blue Cross, we noted, I believe, the amount was a 40% increase in the CEO's compensation. Keep in mind, the Blue Cross insurance premiums are really high, the increases were exceedingly high, and the finances were nosediving. I do not understand why an executive would get a 40% pay increase over two years in that dynamic. It makes no sense. What I believe is correct is if the insurance company does a great job, rates are kept low, their solvency is good, that's a situation where you might say, Hey, you're doing a good job. Let's pay this person more. I'm not necessarily against high compensation. It's maybe a necessary evil at times, but it doesn't make sense to me when the system is really, really struggling. I think these changes allow us to have a little bit better oversight and input on that at the board level.

[Alyssa Black, Chair]: This says that the governor gets to pick two. Should the governor get to pick one and the legislature pick one? Don't.

[Owen Foster, Chair, Green Mountain Care Board]: It could be the governor picks two, the legislature picks two. Well, so I support the way the Green Mountain Care Board nominating committee has done. I think it's two from the governor, two from legislature, maybe two from the business community, something like that. That's exactly what it is, but it's different assortment of people making selections.

[Alyssa Black, Chair]: I think it's different. And then the nominating committee makes the decision on who to send up to the governor, and he may pick from amongst those choices.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Correct,

[Owen Foster, Chair, Green Mountain Care Board]: yep. No, I would have no objection to the legislature having appointments as well. I think diversifying these groups is really beneficial.

[Brian Cina, Member]: Go ahead, Brian. Besides wanting them to be members of the public, are there any other guidelines that you might recommend? For example, there has been talk in the past about having a healthcare provider on the Green Mountain Care Board and there's been bills saying that at least one of the members should be a healthcare provider. Might we want a healthcare provider on the board? Might we want a patient? Are there any other perspectives you might suggest we weave into these community based appointments or appointees?

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, I think that is healthy, and at the Care Board, we do have a provider on the board and a physical therapist, and we have pretty good diversity now of professional backgrounds. I think it is really, really beneficial. If you look at section B, also speaks to the composition of the board. At least three fourths of the board of directors shall be composed of subscribers and members of the public. The remainder may be providers. So it gives them some discretion there.

[Brian Cina, Member]: Which section was that? I'm sorry, missed it.

[Alyssa Black, Chair]: Yeah, and I know it's hard because we didn't walk through this.

[Brian Cina, Member]: We didn't.

[Alyssa Black, Chair]: Yeah, bottom of page three. When we invited our guests in, the intent was that we had already gone through this.

[Owen Foster, Chair, Green Mountain Care Board]: So I go by the statute numbers, but if it's so it's 4513A, section B, and then section C. Section B is the one I just referred to that talks about three quarters of the board must be members of the public, including subscribers. And then section C is the governor's appointment.

[Alyssa Black, Chair]: Thank you.

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: All hospitals have the same amount of board members?

[Owen Foster, Chair, Green Mountain Care Board]: No. And this feels just as to the insurance company. Okay.

[Alyssa Black, Chair]: Anything on that? Do you want to talk about executive compensation? Sure. Okay, unless you don't have any thoughts on it.

[Owen Foster, Chair, Green Mountain Care Board]: No, my second favorite section. So this goes to my point I made earlier about incorporating the statewide view when boards are deciding executive compensation. So this is 4513. Section E starts with guiding principles from representatives of the public. Page

[Alyssa Black, Chair]: five. Page seven. Page seven. 4five Number 13. Page seven.

[Brian Cina, Member]: If it's page seven, line 13, I'm looking

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: at the right spot. Thank you. So

[Owen Foster, Chair, Green Mountain Care Board]: this I put this section because there's additional transparency in how executive compensation decisions are being made. So here, it has a provision that requires the benchmarks that are used and the compensation surveys that are used be provided to the Department of Financial Regulation so they can actually review them and say, hey, does this make sense? Not all of the surveys are they're very different. There's a lot of different surveys that have different peer groups and different considerations. You can, I'm not suggesting they are because I don't know, but you can cherry pick which surveys you like the best, and you can have a mismatch. So for example, I'm making this up, but do these surveys include consideration of the financial performance of the insurance company? Did the surveys that were used when the executives had very large increases the last two years consider other companies that had the same financial trajectory? Do they consider that the rates were really, really high and the premium increases were high? I'm going to guess probably not, but this allows a layer of transparency for people to consider that and just take a more holistic view as to what we are doing on the executive because it does matter. Executives are rightfully motivated by their incentives, and they want to do the right thing, so we need to make sure that we're incentivizing them towards the right thing for the state. That's the key for me. And then it provides page eight, line 18, that the commissioner of DFR may require the insurer to modify who the peer groups are and can change it if they think that it's inappropriate. I think that's just a good oversight. It keeps everybody on the same page. We're skip ahead to the age rating.

[Alyssa Black, Chair]: I'm waiting, this is my favorite I'm sure, favorite. Before we get to that. Oh, did you, I'm sorry, you You were

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: mentioned, when you were talking about the board, the two public members. They have to be on compensation committee, which I think is important.

[Owen Foster, Chair, Green Mountain Care Board]: That is correct. The compensation committee can have other people, but those members of the public must have Have to be on. Correct.

[Megan Houghton, Financial Director, Vermont Department of Health]: Are we on page 11?

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: You should vote that.

[Alyssa Black, Chair]: Section six. Wait. Page Page reading.

[Brian Cina, Member]: Oh, skipped ahead, okay, I'm sorry.

[Owen Foster, Chair, Green Mountain Care Board]: I thought we were still talking about the

[Brian Cina, Member]: I was still stuck on salaries.

[Alyssa Black, Chair]: Okay. Age rating.

[Owen Foster, Chair, Green Mountain Care Board]: Age rating. Right now, Vermont does not allow age rating, which effectively ends up meaning that people who are really, really healthy tend to pay more for insurance, and people that are sicker or older may pay less, which, sugar is older people who use more health services or may be more ill, get a good, better deal, and people on the younger spectrum and healthier get a worse deal. That's effectively what happens with this policy direction. What DFR, I believe, is proposing this bill is to allow a small change to allow some age rating to happen. I believe they put a threshold of it can't be more than a 5% change that would happen. I do support this, and the reason I support it is because you have if it's more expensive for the younger people, the pool of people gets sicker because those healthy people drop out, and that actually makes it more expensive for everyone that's in the pool. You want to make sure you're encouraging and keeping those younger lives in the pool. And when we see people dropping this year with the loss of the enhanced subsidies and our really high costs, we're losing those lives. So when the board gets a rate every year, one of the biggest drivers, if not the biggest driver, is how sick that pool is. So a lot of people think, well, board do a better job on the hospital budgets, and that's where we're gonna find affordability. But that's not really true. I mean, is a degree of that. But also you can't do anything about how sick the pool is. They need services, they cost a lot of money. If you don't have those healthy lives to balance out those sick lives, it's really, really expensive. I think last year, the morbidity adjustment, which is how sick the pool is, was 7%. A 7% increase just because how ill the pool was. So if the board keeps the hospitals, we can cut the hospitals all day, and that won't change that the base increase was 7%. And then last year, the CTR, the contributions to Blue Cross' reserves, how much they're gonna put back in the bank for safety really, that was also a 7% request. That means before we do our work, we're at 14% increase with nothing we can do about it, really.

[Alyssa Black, Chair]: Do you think 5% either way is incentive enough to actually change

[Owen Foster, Chair, Green Mountain Care Board]: That the would be caveat I have with this is I don't think I've seen or heard of any data suggesting that this will actually change the behavior. So if you're considering this, I would ask for what's the data and the actuarial analysis that shows how much this will drive change. So should it be 10%? Should it be zero? Not going to drive change. Why are we doing it? So I would want to see that.

[Alyssa Black, Chair]: Yeah. Think I'm struggling, and I see you, Brian. I think I'm really struggling with thinking about, okay, 5% if you're a little bit older, you're going to probably pay more than the benchmark by the rate that you set. 5% if you're younger, less if you're younger. But I'm also struggling with how the subsidies are affecting the younger and if we hurt one, help another, I can make those decisions of who am I going to help, who am I going to hurt. But if I'm looking at the one that we think we're helping and it actually we aren't maybe helping them, then we're not helping somebody and hurting somebody else. So I'm really struggling with this.

[Owen Foster, Chair, Green Mountain Care Board]: Exactly the caveat that I would have is I would want to see the actuarial analysis of what that does.

[Emily Brown, Executive Director, Green Mountain Care Board]: I think if you could show that this policy change would bring more uninsured younger folks into the market, and then you could see, to your point about the subsidies and who they would be impacting with this policy change, I think those are all questions that should be answered. But again, if it has the intended impact of bringing more young individuals, healthier individuals into the market, and then with the subsidy coverage has a minimal impact on those older folks, then you might be able to justify it. But again, I think there needs to be an analysis showing how in Vermont this policy would actually impact individuals who are currently covered in

[Alyssa Black, Chair]: the QHP market. Brian, and then Leslie. So

[Brian Cina, Member]: It sounds like the point of age rating would be to incentivize participation in the marketplace, we

[Owen Foster, Chair, Green Mountain Care Board]: want to call it that, I don't

[Brian Cina, Member]: think Paul means that, but it is, by younger people to reduce the risk or reduce utilization, the risk pool, their share. Are there other policy levers we might be considering that would achieve the same goal? For example, just going to throw it out there, like a small tax on all income earners that goes into a pool and then we all just get primary care. So then it's incentivizing people using primary care at all ages, which then reduces spending on the Versus these high deductible The incentive is, oh, you get 5% less on a plan that you have to spend $12 on before you even get the benefits. That doesn't seem very appealing as a young to middle aged person, yet I'm doing it because of the subsidies. I don't know what that difference is going to make when you still have a $12,000 deductible before it even kicks in.

[Alyssa Black, Chair]: Or increase Vermont premium assistance.

[Owen Foster, Chair, Green Mountain Care Board]: I these think are all good policy discussions to have, but I would say, there is a number of other policy levers you can use. The QHP plans have the market has gotten shrunk quite a bit. We've seen a lot of people go to level funded plans and to the employer sponsored plans. That's decreased the pool. It's cannibalized the pool, and the pool that's left have been the healthier lives. If you wanted to create a healthier pool, you could require them to be in the QHP plans. That would make a bigger market. It would have more healthy, younger lives in it. The downside to that is those folks that are in those other plans now are getting a relatively better deal than the people in this pool. So you're gonna be making a trade off where those people would have fewer options that might be cheaper, but for that other pool, it would be better for the whole. And your point about primary care, there are a couple primary care bills. There are some things the board is working on with site neutral billing and with reference based pricing. We're doing some things towards trying to ensure we get better primary care access. Also ties in well with the rural health funds and some of the work AHS is doing there to bolster primary care. Certainly, I think improving our preventative care and overall health will drastically improve the quality of the pool in terms of health. Emily, do you have anything to add?

[Alyssa Black, Chair]: No, that's great. Oh, Leslie. I don't know if you're gonna get to association health plans, and maybe you will, but yesterday when we heard from the BFR, there's this tension between the association health plans in terms of where lives go and the age rating. And you mentioned actuarial analysis. Do we do that? What's the order of operations here in order to think about this? Because I feel like we're being asked to think about this with no data and no analysis. So what comes first? So

[Emily Brown, Executive Director, Green Mountain Care Board]: again, this is not our piece of impacts the QHP market rates, which we regulate. But I do believe understanding the Vermont market and the impact of this policy on Vermont. I heard yesterday in testimony, I know that a lot of other states do this. I think Vermont and New York are one of the two states who don't allow age rating. But again, we are different and smaller than a lot of other states. So I think, again, understanding how this policy would specifically impact Vermont based on our uninsured rate, based on our subsidy levels, based on our existing exchange population. All those questions are important to have answered before you decide if age rating actually the 5% limit is actually going to, as Chair Foster said, change that behavior, bring more folks in the market, and what the actual impact on people will be.

[Alyssa Black, Chair]: Does that make sense to me because I've spoken to that. So thank you.

[Owen Foster, Chair, Green Mountain Care Board]: We can move to the association health plans if that's my second favorite. So this is a similar discussion. Our view is also similar. I wouldn't say that we're necessarily for or against this as a policy lever, but the thing I would say is we should really consider what the pros and cons are. One, it will hurt the pool and the QHP, and that's I think sort of the point, is that you're providing a more affordable set of options to the people in the QHP plan. So some people who can leave will leave, and they'll have a better, more affordable option potentially. The people that don't have that option and are left in the pool will see increased morbidity and illness, and that makes it more expensive. So again, it's a trade off. Are you gonna provide options for some? It's like the level funded plan, same thing. Or are you going to have the pool larger and overall more affordable for the group? That's really what you're deciding.

[Alyssa Black, Chair]: Shouldn't our focus be I mean, we know we want to grow the pool. We've got one age rating, which we think, oh, it'll grow the pool. And then we've got association plan followed up, which is going shrink the pool. So there are complete odds to what the goal is. But I think the goal is we want to grow the pool. Because the more lives we can get into the pool, the more it's spread across, the risk is spread across more people. Shouldn't we be concentrating on how do we grow the pool? And how do we make that pool the pool that people want to be in? What can we I don't know. Are you asking philosophical Oh. Yeah. What are we doing to make that pool be attractive? Think if your

[Emily Brown, Executive Director, Green Mountain Care Board]: goal is to make the pool stronger, more folks in it, as chair Foster said, association health plans would allow some employers other options. It would take small employers out of the QHP pool and put them in a separate plan. So that would shrink the pool. So if the goal is to grow the exchange market, grow the small employer group market, this AHP option, while it would provide some employers a less expensive option, if the intent is to grow the pool,

[Owen Foster, Chair, Green Mountain Care Board]: it would not do that. There's another consideration I throw out, which is what is the pool we're trying to grow? I think from the policy perspective here, it could be we're trying to grow the pool in Vermont of more young people and having more affordable other options like AHPs. While it might hurt the QHP pool, might help the overall Vermont demographic pool. But again, I think the point is the same. I would want to see the data on how much this will help or hurt, same with the age rating. Like, how much do we actually anticipate? Because the actuaries do a really good job of giving pretty good numbers that show what this will do. I do think that overall growing the pool, right now it's a pool of last resort, and that's what

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: it is. It's a pool

[Owen Foster, Chair, Green Mountain Care Board]: of last resort, and that's really tricky. You have to think about who's in that pool. It's a lot of carpenters, it's a lot of trades people, right? It's people that don't have another option, and that's a really important pool to make sure they can afford healthcare, because one, a lot of people, they have health needs, and second, they're really important Vermonters.

[Alyssa Black, Chair]: And it's small businesses. Yeah,

[Owen Foster, Chair, Green Mountain Care Board]: exactly. Restaurants, nonprofits, love the backbone of our main streets.

[Alyssa Black, Chair]: Thank you.

[Megan Houghton, Financial Director, Vermont Department of Health]: So what would be the projected time frame where we may see a result of

[Owen Foster, Chair, Green Mountain Care Board]: I think that would be better asked to DFR. They would be the ones that would have better granularity on that. I don't really know.

[Emily Brown, Executive Director, Green Mountain Care Board]: And so you can only enroll in the QHP once a year. So if this change was implemented for rates for 2027 plan year, you would expect there to be some impact. Yeah, it would probably be gradual impact. But again, I agree. I think DFR would be the better entity to answer those questions.

[Megan Houghton, Financial Director, Vermont Department of Health]: And if it was positive, would you increase that number, 5% eventually? Is that how it Positive. Would If the 5% made the pool larger.

[Alyssa Black, Chair]: The cost change, cost Yeah, increase. You also have to think about, if it's 5% good for one, it's 5% bad for another. So if you're gonna make it 10% great for somebody, it's going to then get 10% worse for somebody else.

[Emily Brown, Executive Director, Green Mountain Care Board]: And I think that's what a team analysis could show you. You could measure different thresholds of premium increases. And then what the actuaries can do is they can actually model not necessarily to 100% accuracy, but they can show you what the projected impact would be. We did yesterday ask for a timeline from DFR of all of these proposals. I'm hoping they bring that forward.

[Megan Houghton, Financial Director, Vermont Department of Health]: Sorry, Jennifer.

[Alyssa Black, Chair]: Jennifer, did you have a question?

[Nolan Langweil, Joint Fiscal Office (Health Policy Analyst)]: Daisy, did I just gotta say, in order to do that, you're gonna have to change the bill, because right now it limits it.

[Emily Brown, Executive Director, Green Mountain Care Board]: Right.

[Megan Houghton, Financial Director, Vermont Department of Health]: I

[Alyssa Black, Chair]: sort of got the feeling as we were going through this yesterday, that a lot of this stuff is theoretical and I don't know if anybody else was a little frustrated with, well, we're not sure. A lot of probable, maybe. Maybe, probable. And you've actually mentioned this in your testimony today that we need better numbers. I hate to throw this out here because it seems to be one of the things the legislature does best.

[Owen Foster, Chair, Green Mountain Care Board]: Okay. I know where we're going.

[Alyssa Black, Chair]: Should we perhaps I mean, I'm not making the recommendation now, but it's a thought swirling in my head. Would you be supportive of let's look at it, let's come back with an analysis? My response to

[Owen Foster, Chair, Green Mountain Care Board]: that would be, let's see if we can get any better information now. I I do think that there is quite a bit of urgency to all these issues. I think this is one where it's possible to have

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: the actuaries get on it pretty quickly. What's quick?

[Owen Foster, Chair, Green Mountain Care Board]: I mean, when we work with our actuaries on these types of issues,

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: get it two to four weeks.

[Alyssa Black, Chair]: Yeah, we crossover.

[Emily Brown, Executive Director, Green Mountain Care Board]: So I think the age rating question is a quicker response time because we have data on our exchange right now. We know who's enrolled. We can measure that. I think for the impact I heard yesterday, the impact of the AHPs and the short term limited duration is a lot more harder, if impossible, to measure because you don't know who or which employers in the market would want to pursue that option. It would also involve a rule change. We have a rule right now that is fairly restrictive towards AHPs. So that, I think, would be harder to measure as far as impact on which employers are going to choose that option. There are already some AHPs right now. There's beta, which was mentioned yesterday. But there's also other options for small employers who have healthier lives that they've already taken. There's the Blue Edge program, which exists right now, that has taken that some small employers have the option to pursue. So it's hard to understand what other option for AHPs, because of the ERISA requirements around how those can be formed, what impact that would have in Vermont. And maybe DFR has had interest, and so maybe know of some potential associations that want to form. I have no idea, but I think that would be harder to measure the impact because you just don't know who is going to be successful in the pursuit of an association. Just to let everyone know,

[Alyssa Black, Chair]: for timing's sake, we're going to reschedule a Blue Cross Blue Shield because we want to make sure they have a lot of time as well. We're going until Daisy?

[Daisy Berbeco, Ranking Member]: You said something about urgency, and that's always something I really look to you for is how urgent is this? We did a lot of regulatory changes last year. And I have heard from some providers, let this dust settle. Let us implement some of these changes. They're huge. We need to catch up. So do you have any concerns about anything in this bill adding it to the things that we're doing around health care reform and hospital transformation, and whether that would muddy the water or?

[Owen Foster, Chair, Green Mountain Care Board]: Well, as to this bill, I don't really see this having too much impact on the provider side. It's really focused on the insurer side. There's one provision actually, two provisions we can talk about that are more focused on providers. But in terms of the provider concern of moving parts, I don't see that as being an overwhelming concern in this bill. Mean, if you change to a limited age rating, that won't really impact the providers. It won't add any red tape or any burden to that. It'll change something for the insurance company.

[Alyssa Black, Chair]: I don't think site neutral billing would have a We'll get to that later.

[Owen Foster, Chair, Green Mountain Care Board]: There are two sections I

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: do think impact the providers more.

[Emily Brown, Executive Director, Green Mountain Care Board]: And then I think to address that question specifically to the AHPs and the short term limited duration, I think it depends on how those policies are enacted. So if we're thinking about short term limited duration, for instance, right now, short term limited duration plan in Vermont can only be offered for three months. The benefits need to be similar to those for the essential health benefits, which are similar to the QHP market. This policy, I'm understanding, would expand the availability of those products. There is a rule also. So it depends largely on how these policies and how these rules sugar off in the future. If the benefits are the same as they are now, you would expect then when a consumer buys one of these products and then goes to their doctor, they would have similar coverage. I think what I think about is if the short term limited duration benefits end up being less than what they are now, how does that impact access to care? Meaning you then don't have insurance coverage when you go to hospital for certain benefits that right now, under the existing short term limited duration policy, you would have. So those are the downstream impacts that are unknown. There's not an answer because they're not in place right now. So I think it's hard to answer what the impact would be on our hospital on our health care system, rather, at large without knowing more details. I don't know if that

[Daisy Berbeco, Ranking Member]: is Yeah, I'm really listening for a sense of you need to implement some of these changes now, because that was the message all last session, is the house is

[Emily Brown, Executive Director, Green Mountain Care Board]: on fire. So the house is on fire, meaning our health care costs too high. Legislation passed last year, a lot of authority given to the Grey Mountain Care Board to AHS was intended to try to control those costs. What I view largely is these options doing is creating more options, creating more alternative coverage options for individuals who, because the enhanced subsidies went away, for instance, they now maybe want an option to buy a short term limited duration, or maybe an employer says, I can't afford the exchange. I want to do an association health plan. So this creates more coverage options. I don't see it addressing the underlying health care cost issue that a lot of legislation last year that was passed is meant to address. And Chair Foster, please chime in if

[Owen Foster, Chair, Green Mountain Care Board]: I Yeah. I totally agree. Two things. One, I think the bills you passed last year were house on fire bills, and they were immediate. The drug price gap was immediate. The four eighty two bill passed on this committee to provide for insurance protections for downside. Yeah. Immediate. Those allowed us to immediately last year reduce the rates of insurance. They were hugely impactful in our ability to reduce the QHP increases. These do not do that. These are more longer term structural things. I don't view these as necessarily like going to solve a house on fire problem, but they do help with the longer term solutions.

[Daisy Berbeco, Ranking Member]: They may help individuals' houses that are on fire because they can't buy groceries because their premiums are so darn high.

[Owen Foster, Chair, Green Mountain Care Board]: Well, maybe in a year. They're not necessarily going to do it this year potentially, but people have to get on, they have to sign up. It's a whole process before that would actually happen as opposed to immediately reducing the price of the service.

[Megan Houghton, Financial Director, Vermont Department of Health]: And some of them were hurting others. Correct.

[Alyssa Black, Chair]: I think I'm asking this question I might be asking this question maybe more to Emily because I know you have experience in this. We're sitting here with a DFR bill and we're talking about the house on fire. Again, yesterday, I just kept getting the feeling of we got to throw something at it, so let's just throw all these things at it, without really any evidence that they would do anything. But again, I keep thinking about how do we make it more attractive for more people to get into the pool? And from the regulatory side, is there something with our benefits we could do? I mean, we very few choices of plan options and you were talking about it gives people more options. Is there something that we can do within our QHP market to actually provide more affordable options? Are there some levers that we can push in that regard to actually make them more attractive and give more options?

[Emily Brown, Executive Director, Green Mountain Care Board]: So there are a few things that come to mind. Right now in our QHP market, and Diva would probably be the best to speak to this. There are nonstandard and standardized plans. The nonstandardized plan, it's my understanding, are designed in a way to try to be attractive to folks maybe with certain health conditions or guide them towards less expensive care to try to mitigate some of those high cost services that they would maybe have to use if they weren't accessing preventive care. So I know there are options there. And again, that's a policy decision that I would defer to Dev on. I think in our existing statutes, we have a lot of health insurance mandates. So we require insurance companies who want to operate in the regulated insurance market in Vermont. That's the fully insured market. So when you think of QHPs, they have to offer certain benefits and those are all outlined in Title VIII. I'm speaking with my former hat on right now. So I know from my time at DFR and previous legislative sessions, there has been an interest in looking at the whole environment of all of our benefit mandates and understanding the cost impact of those mandates. And then also not only the cost impact, but then actually are they designed in a way to be guiding people towards the preventative care, the lower cost services? What is the actual benefit or the impact of the cost of that benefit? And then is it actually designed in a way that's making people healthier? That's the goal. You want to ensure that people are having access to services that are balancing cost and the actual usefulness of that benefit. So I think looking at our state mandated benefits and understanding the cost impact of those on our QHP and fully insured business would be a worthwhile exercise, that could be one thing you could look at.

[Lori Houghton, Member]: I guess a second question, something you said made me think of when I was looking at the QHP market this year and trying to plan. It's so hard to understand.

[Megan Houghton, Financial Director, Vermont Department of Health]: So do you think people are even in the right plan for themselves? I don't. I can't answer that. I have no idea. Because I mean, yeah. So there's so many options, and it's like,

[Alyssa Black, Chair]: I don't know which one

[Megan Houghton, Financial Director, Vermont Department of Health]: is better for me. Yeah.

[Alyssa Black, Chair]: All right, thanks. Karen, did you have a question?

[Megan Houghton, Financial Director, Vermont Department of Health]: Yes, when you talk about the mandated benefits, are

[Daisy Berbeco, Ranking Member]: you just talking about the

[Megan Houghton, Financial Director, Vermont Department of Health]: THPs now, are you talking about all of Vermont's insured in No, all different

[Emily Brown, Executive Director, Green Mountain Care Board]: so there's what's called a regulated market in Vermont. And so in Title VIII, there's a chapter which outlays all of the mandated benefits that if you want to offer coverage in Vermont, you have to offer. So it's system wide. Correct, except the self insured,

[Alyssa Black, Chair]: the ones that are regulated at the federal level. Do you want to speak to any more things to have

[Owen Foster, Chair, Green Mountain Care Board]: Yeah, to follow-up on represents Rebecca's question about the provider burden.

[Alyssa Black, Chair]: Oh, yeah.

[Owen Foster, Chair, Green Mountain Care Board]: There are two sections that I would look to on that, and it's on page 21, the prior authorization component, and then I'll also speak to the site neutral billing on page 22. 21, prior authorization change. This narrows the scope. I think the legislature two sessions ago made it that any primary care provider that was ordering something didn't need a prior authorization. This brings that in a little bit where it's only non hospital primary care providers. I think the intent is to get around a potential loophole where hospital based primary care providers can get a request from a specialist. And if you run it through them, now you don't have to get it. So I think this does help with the insurer solvency potentially. It does give them a prior authorization is a tool they use to make sure that there's not unnecessary utilization. We have seen utilization increases across the state at hospitals in the last couple of years. So I do support narrowing this. I don't know sitting here today how big of a problem it is. I haven't seen data suggesting that the hospitals having this as well is a huge, huge problem. I do know that we haven't seen data indicating when you pass this, I believe there was an intent to reduce administrative costs. We haven't seen those administrative savings materialize yet. I don't think there's been the report and we haven't seen it in our budgets. So I would support this change. It is a protection effort to keep healthcare costs down and it's minimal. You can then see how it works with the independent primary care providers, and if you need to expand it again, you easily can. Sorry.

[Lori Houghton, Member]: We're kind of

[Alyssa Black, Chair]: ten years off my life. Moving on.

[Owen Foster, Chair, Green Mountain Care Board]: Site neutral billing on page 22. This is one that we do not support. We support the concept. We believe site neutral billing is an appropriate tool that the state should be going towards. And a lot of the care board's regulatory efforts have been made to equalize the rate of increase for payment for non hospitals and for hospitals. What we saw in previous years were hospitals getting 8%, ten twelve percent increase on commercial price and everyone else getting 0%, 1% or 2%. Through our regulatory efforts, we've really made that much more equal. And I think in last year, the non hospitals were actually maybe a little bit above the hospitals. So we've done a good job through the regulatory structure of doing that. But your problem is the base expense on which we've equalized is really, really high for provider hospital services and really much lower for the non hospitals. So the concept I think is the right concept. We want to make sure we have these non hospital providers that have great quality and access available throughout the state. That is, in my view, one of the fundamental problems with our health system is care has been concentrated in hospitals. I've spoken about that a number of times here. The reason that I do not think that this provision is necessary is because it overlaps with some of the work done in Senate last year, Senate S-one 126, forgetting the act number that that was going to be

[Dr. Hildebrandt, Commissioner, Vermont Department of Health]: Act sixty eight?

[Owen Foster, Chair, Green Mountain Care Board]: Sixty eight, yes. And so because we're already working on that, it's subject to rulemaking. This is an effort that we're already working towards. And second, I think it's a little bit awkward to put DFR in this piece. So with Act 68, it's the board's responsibility. We have the rate setting authority. We always have. So having to do it with DFR gets a little bit awkward because they're not also doing the hospital side of it. So I do think it's superfluous, although we do support the concept. The other point I would make here is that insurers can already do this. They negotiate contracts with hospitals and with nonhospitals. And we do get to a point where I think the legislature and the regulator are doing a lot of the work that I actually think the hospitals and the insurance companies should be doing. So I don't know, there's nothing stopping Blue Cross from already saying, hey hospital, you're going down, and we need to increase the payment over here. That can happen. I think it should happen. I will acknowledge that there are market disparities in power that have created difficulties for Blue Cross to be able to do that. I think that has shifted a little bit. I think the governance change actually helps with this too. Because if the Blue Cross board has people with more of the public interest, broader, and governor appointees or legislative appointees, they'll be pushing on this. And I think if you do the same thing on the hospital side, they'll be pushing on this because it's not just the interest of that one organization. So I think these changes together make sense. But I don't support adding this additional duplicative section. Emily, do you have any No. Oh, sorry, one other point I did want to make. I apologize. The first section of this says that the board and DFR shall identify outpatient or ambulatory services that are safe and appropriate to be delivered in low cost, non hospital settings. I don't really know how we'd actually do that. We don't have a staff of clinicians to say this one's safe, this one's not safe. And there's incredible complexity there. An MRI is not an MRI. An MRI for this procedure might need to be done at the academic medical center. MRI for a different procedure can go somewhere else. So for us to do the work to figure that out would be very, very time consuming and costly.

[Alyssa Black, Chair]: Any other questions? A question you can't answer. We've heard a couple of times yesterday that we're waiting for Fed rules to be able to do this or that. So you know what I'm thinking about. Common something, it is. Do you have thoughts about that? I mean, we do it anyway and have it prepared in case the rules change or not change? What's the downside of doing or not? And you may not know.

[Emily Brown, Executive Director, Green Mountain Care Board]: Are you talking about the association health plan?

[Alyssa Black, Chair]: Yeah, but it came up other places too, but that was the common something plus. I can find it.

[Emily Brown, Executive Director, Green Mountain Care Board]: I'm thinking, yeah. I'm not sure what the cost

[Alyssa Black, Chair]: It's definitely around the association health plan.

[Lori Houghton, Member]: Oh, you're in commonality test.

[Emily Brown, Executive Director, Green Mountain Care Board]: Commonality test, yes. So history here is that during the first Trump administration, they changed the association health plan where they tried to open up the market. There was then a court decision that what they had done at that time was not legal. So that federal rule was then put on hold. The next administration, I believe, went back to and reverted to the prior AHP rules. And I believe it's now the intent of the second Trump administration to, again, try to expand that test that you're referring to, the commonality of interest test. That is a federal, I understand it's a federal test that needs to be complied with to create an AHP. I am not aware of where in the process that is. I'm just not tracking that. Yeah, my question is more about, does it make sense to enact legislation based on a potential federal rule someday maybe?

[Alyssa Black, Chair]: There's probably no answer

[Emily Brown, Executive Director, Green Mountain Care Board]: to I don't know how

[Alyssa Black, Chair]: to proceed with this uncertainty, I guess, thinking about that. Thank you. Sorry, Deb, put you on the spot. Thank you. Thank you. Thank you so much.