Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair, House Committee on Health Care)]: Hi and welcome to House Healthcare, February 10, and we are hearing from some stakeholders, Governor's recommended budgets. We heard from the agencies last week. And first in, we have Amy Johnson, Vermont Care Partners. Thanks for coming. Thank you, Achin.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Thanks for having me. For the record, Amy Johnson, Vermont Care Partners, Director of Legislative Affairs and Public Policy. So I have quite a few slides, quite a few things to talk about today. So we'll talk about our budget request, and we'll also note some of the cuts that you saw on this committee from BMH to network wide initiatives, as well as agency by agency initiatives. And we'll talk about the pressures that we're facing. So kind of start with our fiscal landscape. So you've seen this before, but just to point out that Vermont Care Partners represents the 16 designated and specialized service agencies. And these are just some high level statistics. The one that I think is really compelling that I just want to remind people of is people served daily, 5,260 people served daily. So if we closed our doors for one day, it'd be 5,260 people that wouldn't be served that day. And so you can see there's almost 4,000,000 services provided, which is 14,000 a day, and we have over 5,000 staff that we represent. And I know we came in here maybe a week or two ago, but I say this every time, but I think it's really important for folks to know, 64% of our services are provided in the home and community, and that's really important. That's a part of the system that we continue to see erode. And so when we think about these more crisis based supports, we think about where are we plugging people into as we erode the Pullman community, there won't be places to plug people into. So just want to point that statistic out. You know us, this is where we are.

[Rep. Leslie Goldman (Member)]: Yeah. I'm sorry. Yeah. In contrast, you say

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: home and community as opposed to what? In office care, residential, those types of support. So home and community, I think a lot of people, they hear mental health organization or disability organization, they think that services are provided one on one with a clinician in an office. And we do have adult and children's outpatient services. Sometimes those happen in the office, other times those do happen in the home, but majority of our supports are provided in people's homes or out in the community, like schools, for example.

[Alyssa Black (Chair, House Committee on Health Care)]: Yeah, that's what I'm thinking about.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Yeah, yeah. Schools. You, sir.

[Amy Johnson (Vermont Care Partners)]: I'll skip over the map, if you need

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: to know where yours is. What

[Rep. Debra Powers (Member)]: percentage do you think are adult children that are in those figures?

[Alyssa Black (Chair, House Committee on Health Care)]: You mean like which of each? I'm assuming they're all adults or children. I would say

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: a majority, I would have to use statistics from developmental disability services. We do have those numbers. I can get those for you. Probably best that I don't pull a number out of the sky. But I would say for our IDD programming, much of that is happening, or majority of that is happening in home and community. Yeah, it's a really high percentage for that population.

[Alyssa Black (Chair, House Committee on Health Care)]: I do have that just not with

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: an app. I'll skip over, unless people need to see where theirs is. So I put a key in here. There's a lot of acronyms just for space, but I just want to point out the consumer price index. This talks about inflation year over year. So you can see starting in fiscal year 'twenty eight, what the inflationary rates were. When you get down to fiscal year 'twenty six, 3% is a placeholder. That information hasn't been released yet. I believe that's coming sometime maybe by Friday. But this shows you kind of what we're being hit with by inflation and then what the increases we've gotten from Dale, from DMH, and from DSU. So Dale and DMH are connected. Usually when we get an increase, that same percent is in DMH and Dale, because this committee and the House Human Services Committee agree on a percentage. I will say, I should probably start with this, many of these increases have come from the legislature, not in the governor's budget, not from the agency of human services. That's not exclusively true for every single year, but a majority of the years, these increases have come from the legislature. DSU, you can see that there were several years where there weren't any increases, but this just shows you kind of where we sit in terms of how far behind we are in terms of what the CPI is versus what we're getting. And so right now you can see the variance with DSU for CPI is 28.62%, and we're behind 12.63% with DMH and Dale. So that's really just showing you that we are way below where we need to be to be able to pay for the services that we're providing. Every year costs more. It's the same thing if you're a builder and you're getting hit with tariffs and inflation. If you're a restaurant, same thing with us, our services are more expensive year over year because of inflation, but the increases that we get aren't often matched with that inflation. What about utilization?

[Rep. Leslie Goldman (Member)]: Say more.

[Alyssa Black (Chair, House Committee on Health Care)]: How has your utilization of services changed over number of people you're serving?

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: I would say that utilization is challenged because as we have inflationary rate increases or inflationary increases, it's really challenging to recruit and retain staff. And so if we don't have enough staff, it's hard to provide all the care. So people might sit on a wait list. And I will say during COVID, obviously numbers dropped. We're kind of inching our way back up. And so we're not as challenged in terms of numbers as we were during COVID staffing has gotten better. And I have some slides on that so you can see, but I would say utilization is challenged in terms of the number of staff that we have to provide the care, but then kind of what ends up happening is programs close. So then your utilization might shift upward because maybe more staff are able to support other programs. You've also closed programs that are important for people in the community. And you've seen that with a variety of agencies that closed programming. Just this year, we've had Howard has closed a couple of their programs, other agencies have too.

[Alyssa Black (Chair, House Committee on Health Care)]: Leslie, did you have a question?

[Rep. Leslie Goldman (Member)]: I do. I was here when we did the 8% increase in '23. I mean, that was a big conversation and you're still way behind. And I guess I'm

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: wondering what the I'm sure

[Rep. Leslie Goldman (Member)]: the right word, but how does this work when you negotiate with the administration and the governor's budget to increase? Or how has that gone? Or maybe you're not in a position to talk about it. I may not

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: want to, but I would say that we do let the administration know what we need, but those conversations in terms of them building their budget is embargoed. So we're not able to know that information. So whether a department is saying to the governor, we really need to increase funding for the DAs and SSAs, that's invisible to us, But we do let them know what we need. Well, that's how

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: it started.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: And I will say, I think this is important, and this isn't me just pandering, but we do have a really strong relationship with our state partners. We work with them regularly on a variety of kind of at large things more globally as a network and also kind of smaller programmatic things. So we're in constant communication with the commissioners and other leadership folks at the agency. So they're very aware of kind of where we're at and what we need, and we do have a strong partnership. But yeah, the conversations that they're having with the governor and his folks, that's invisible to us.

[Rep. Leslie Goldman (Member)]: It's my sixth year of hearing that you were coming to us for support. And I'm just a little confused.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Yeah, that makes sense to me. Yeah, definitely. And we did see that the governor prioritized one of the things he talked about in AHS as well as mental health and substance use care. But we also saw a variety of cuts to mental health programs, which I'll address.

[Rep. Brian Cina (Member)]: Thank you. You're welcome.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Just to show where the money comes from, calling this our revenue mix. So 88% of our funding comes from state funds. So DS waivers, developmental services waiver. Have the percentages there so you can see the breakdown. I think that's important. So our federal match, school revenue, success beyond six, and state grants and contracts. So that's a big chunk where a lot of our funding is coming from state funds Medicaid. And then non state funds, first party is client fees. That's really small. I try to bold the points. You can see it's 0.68%. Often if there's fees to clients, if they can't pay them, we have in each agency, they kind of have a collections group. They look at those and often they're wiped and it becomes uncompensated care that we provide. Third party, you can see non Medicaid, federal grants and contracts, again, very small, and then local and other. So this is just to show you the breakdown of kind of where the funds come from so that Medicaid rate increases, inflationary increases from the state are really important for us because that's the majority of where our revenue comes from to be able to pay staff to provide the services. So Leslie, thank you because you talked the last time I was and you wanted to see a lot of these slides. You kind of did my work for me. So we brought in a lot of information just to, again, show you kind of where we're at fiscally. So this is in aggregate, the agency's days of cash starting back from 2017. You can see obviously in the COVID years where things were, we had a lot of money coming into the system to support it. We also had the 8% increase, which was huge for us. And we really appreciate that. But kind of where we're at now, there'll be a slide that talks about our reform efforts, but there's a lot of reform happening within the system, and we're hoping that those all land in a good place. And right now, it's just creating a lot of kind of upheaval and chaos. And then you kind of layer in lack of inflationary increases, and this is kind of where we're at. So we're under sixty days, and you can see that minimum or vulnerable is below the sixty, ninety days, considered risky, especially for groups that are relying on state or Medicaid funding, which you just saw 88% of our funding comes from that source. So we're kind of high risk right now. All right, so now I'm going to get into When you said we, who's we? We, the agencies. In aggregate, so everybody. That's everybody. That's all 16 agencies. Some are at risk than others? Yes. Some are more at risk than others. Some are Let me look back. And I do have I would say there are a few that are in the healthy range. Nobody's in the robust one hundred eighty plus days. There's not one agency that's in that category. I can break that out more if you want to see how many is in each category. I don't have that right now, but I

[Alyssa Black (Chair, House Committee on Health Care)]: can tell you that. That would be great if you could get a set, please.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: I wrote my notes just in case.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: So, I'm not gonna be able to address all of these. And my recommendation would be to this committee, if you wanna hear more about specific single agency cuts, it would be great to have them in. I know that Howard Center is coming in later today. Several of these are actually Howard, so I know that they're coming in today to talk about the budget. But in the fiscal year 'twenty seven budget, there are cuts that equate to $3,600,000 for across the entire network. So I'm just gonna quickly go line by line. The ARC program is Howard's. We were told that the program has ended. Howard discontinuing that program. It serves quite a few people. They'll come in today and be able to answer questions. I will not be able to answer questions of the ARC program. Nursing at Kirby House, this is Washington County Mental Health. It's one nurse, and I believe they might be able to support that through their CCBHC, which we'll talk about later. Community outreach, Howard will come in and talk about that. TBI waiver sounds like it was only serving one client. And so we haven't been able to dig into that much deeper. Elder care and reach up, I have slides on this. I will answer questions about these two programs. So, what I will say is the three programs I'm gonna highlight for you will be Eldercare, Reach Up, and Youth in Transition. These are three low barrier access programs that are really critical to this system. And I won't go into greater detail about those. Washington County Mental Health, there's CSIP, is an outpatient program for justice involved individuals. So it might make sense to talk to them about that. Safe Haven is Claire Martin. And then again, Howard will come in to be able to talk about first call in their primary care. I just wanted to show you in one place, these are all the cuts, dollars 3,600,000.0 on top of no community based provider inflationary increase for anyone in this fiscal year. And I think that's really challenging because when we hear people come in and talk about this is our budget increase, we're working to keep the lights on, we have to keep the lights on too. We're contracted to provide essential services that are required on behalf of the state. And we also keep our lights on, and if we can't, then we start to close programs. And again, you've started to see that. So the lack of increase on top of these other cuts is really a challenge for us. So just one more layer to add on to that. So these are the various system reform and transformations that are happening right now actively. So CCBHC, I'll talk about in the next slide. So I'm gonna skip over that one. We have our crisis continuum is evolving. So we saw some investment in mental health urgent care. That's really important. The dollar amount won't be able to sustain the centers that exist, but we appreciate that there are funds attributed to that because it is keeping people out of the ED and lowering cost of healthcare. DS payer reform, I don't have to talk about this in this committee. It is huge. It is impacting cash flow for agencies. It is creating some major upheaval in agencies. We're hoping that it lands in a good place, but right now it's impacting cash flow for agencies. Pipping prices bed shift, we haven't heard much about that, but that's a model that DMH and DSU are moving to. And so that has the ability to impact us financially as well. And then I think there's some opportunities with rural health transformation, but federal changes with HR1, with Medicaid has a risk to us. Then tier three and tier four residential through conflict of interest free case management, there has to be some shifts from, I'm gonna get this wrong, debilitated to rehabilitative, and that's causing some shifts in how we have people in residential facilities, which will impact us financially and might have some risks to kind of the highest, some of the highest acuity folks that are in the system. We'd love to come back and talk more about that. But these are all the things that are happening in our system all at once right now. And so agencies are really in a vulnerable place due to them. And we're not saying that any of these are bad, just that they're all happening concurrently. And so agencies are really trying to stay afloat during these changes. CCBHC is not next. I think it's after this one. So what's our ask? Great question. So we're asking for a 3.5% inflationary increase to work towards stability of our system, which again is at risk and feeling unstable right now. So that's about $5,800,000 in general fund. I often like to look over at the joint fiscal who will come up with a number that's much more accurate. So because we only represent 16 of the agencies, we don't have financials from the other two agencies. When DAs and SSAs get an increase, those agencies are also included. So that number won't be completely accurate, but it lives in that world. So how we figured this out, so this is based on MEI, the Medicare Economic Index, and that's how we figured it out. And so I'm gonna try and explain this really simply because our CFOs had to explain it to me simply. So we have some reform efforts that have increases baked into them. So CCBHCs have an increase baked into them, a 2% increase. So we took anything that was a CCBHC service for the two agencies that are currently CCBHCs and the agencies that will be coming online at the start of fiscal year 'twenty seven, we took those out of the equation because they already have a two percent baked in. For any other Medicaid service that does not have an increase baked into it, that's how we use those services to figure out what the increase would be. So that's how we came to this, 5,800,000. So as we see more CCBHCs come online,

[Alyssa Black (Chair, House Committee on Health Care)]: which have a federal enhanced match to them, we are going to need less funding because that will help to its truer cost of care and there's a 2% increase baked into it. So for any agency providing

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: CCBHC see services, which isn't all of the services that they provide, but many, we will need less funding from the state or from the legislature, if that's helpful.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: So you can kind

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: of see the key pressures on the system. We've talked about these before, rising benefits, health care, escalating operational costs, workforce competition. I think we see some entities get federally mandated increases, which is great, very supportive of that. We know that through the Pay Act, state workers also get an increase. That becomes very challenging for us, for our workforce when folks say, I can go there and get a guaranteed increase. And so that parity and the workforce pressures becomes very challenging for us to be able to provide the care because we have staff that will leave. So I'm going to keep going, But

[Alyssa Black (Chair, House Committee on Health Care)]: Oh, yeah. Thank

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: you. So the CCBHCs that have a 2% I don't know what that means. Does that like anticipating 2% increase for that one year? Yeah. So you do a costing report. I would probably lose everybody and myself if I went into the deep dive of the CCBHC, but they provide costing report and like, how much is it going to cost to provide these services? So, are the services you can see in the box. These are the services required by the CCBHC to be a CCBHC, just so you can see what they are. So, to provide this care with the staff that you have for the population that you have, what does it cost to provide that care? And that's how they come up with your rate. And then there's a two percent that's baked into that for the subsequent years. And then there's a whole rebasing that happens, but I won't go too far down the rabbit hole. And there are people that are much smarter than me who should be talking about CCBHCs and how they are funded. Yeah, so we know that, or we assume that for Rutland and Claremont, you can see they're active CCBHC, so they should be getting a 2%. And then for that next cohort that's starting 07/01/2026, which you can see NCSS, Washington County Mental Health, HCRS, Howard Center, and Northeast Kingdom, all coming online July 1. They will also have, not this year, but they will have a 2% built into their costing report. And then we also have three agencies who we are not sure what will happen with those agencies. Our hope is that they will also be able to become CCBHCs, but we're not sure where cohort three will land at this point, which could be challenging. And I will say, when I get a little bit deeper into things, maybe I hope, that what we were told around elder care and reach up was that it couldn't be pulled into the CCBHC array of services. Later, we were told we might be able to, but the issue is Rutland, Claire Martin, and the other five have already done their costing reports. And so they have a rate already set. And so we we don't know whether we can or need to pull them in. The costing reports already happened. So this will be very challenging to try and pull these two services into the CCBHC. Again, we've been told that we can't. So we're kind of in a place where we don't know, and we need to know for staffing, for budget purposes. And so we want to continue with these services and we can't wait until July 1 to find that out because we have to set our budgets.

[Alyssa Black (Chair, House Committee on Health Care)]: Okay, so the state budget begins July 1. When do rate changes go into effect? Are they January 1 or are

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: they July 1? I can ask. There's people probably watching like, we know this.

[Alyssa Black (Chair, House Committee on Health Care)]: And so, you said, so Rutland and Clara Martin have both already started. They started July 1. So they're active. And they're actively receiving that enhanced rates as the CCDHC services. Yes.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: And I would love to, if there's time during the session to have folks come in and talk about CCBHC in the process, I think that would be a great conversation because this is a really great model and it has the ability to be very supportive of the agencies in a way that's different than how it looks now in terms of financial support. So we'd love to be able to show you what, for Claire Martin, same day access, they don't have a wait list, there's a variety of positives and certainly there is some challenges associated with these as well.

[Rep. Brian Cina (Member)]: Go ahead, Debra.

[Rep. Debra Powers (Member)]: Just out of curiosity, as you are developing your budgets, what percentage is taken from the monies that have been donated into the community

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: that are in these special accounts? Percentage? Agencies that have donor, like a donor base, Not all agencies have that. Few do, and the ones that do, it's very small.

[Rep. Debra Powers (Member)]: I know Washington County Mental Health has not very small.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: In terms of the percentage of the overall revenue, that's included in the other, so it's really small percentage. And if you want that number from the agencies, I can absolutely get that from you.

[Rep. Debra Powers (Member)]: I just know the Washington County Mental Health has a lot of money that they're investing in, people have donated over the years.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Yeah, and I would definitely defer to Washington County Mental Health, but I do know that because a lot of what we're running is underfunded and in the red, that's helping to keep programs alive, funding some housing initiatives for IDD, intellectual and developmental disabilities. Washington County has a very robust housing program for folks with disabilities. And so we know some of those things that they brought online, that is not money that's coming from the state. There's grants, there's donor. And so, would say I can get you financial information from those entities. Absolutely. But most agencies don't have that. It's a very small percentage for the ones that do. So this is just showing you our turnover and vacancy data. And at the bottom with the gray, it's showing you the rate increases that we got. So you can see where turnover and vacancy, where after the 8% that starts to come down. And so this is really just demonstrating that when you do put money into people's pockets, it does impact them. Now, we're kind of seeing shift upward in terms of turnover, and there's a lot of reasons for that. And I do point to a lot of the reform efforts that are happening. A lot of people left developmental services, conflict interest free case management. A lot of people left to go to the case management organizations, which were able to pay 20,000 plus more a year So for we lost a lot of people during that transition. And I just want to point this out, this employee investment program, this is helping with tuition, this is helping with student loans. And so, you can see the turnover rate for the overall agencies and for people that apply to be a part of this program. The turnover rate is incredibly small for people that apply for EIP. So they get tuition and loan reimbursement. And so again, money in people's pockets does keep them at the agencies, and that's really important. And when we get these increases, we try and give as much as we can into the staff's pockets. All right, so quickly elder care was cut. It's a very small number. This is a really critical program that has not had an increase since the inception of the program. So it's 300 plus thousand dollars. It funnels through the AAAs and then comes to us. And so you can see one in four Vermont residents are over the age of 60. This is for older Vermonters who are home and have mental health and substance use challenges, and they have limitations to access services in any other ways. So is Vermonters who are high risk, who are older adults, and this is a critical program. And I just wanted to point out in the Age Strong Vermont plan, it has elder care referenced as part of the plan. So for us, seeing that knowing that H Strong Vermont is wanting to focus on elder care and then seeing it completely cut is problematic. And so just by the numbers, these are the agencies that provide the service. They provide it statewide. So some of these agencies provide out of county. There's 5.7 FTEs and they serve an average of 107 older Vermonters monthly. And again, these are older Vermonters who have mental health and substance use challenges often co occurring, who are homebound and cannot access the care in the office.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: Besides just those numbers, can you provide more details as to what services are being offered and is there any impact and results?

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: I have that in a spreadsheet, but

[Heidi Seuss (Executive Director, Open Door Clinic)]: thought it might be too much for that.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Then reach up. So again, reach up is low barrier. This serves highly vulnerable Vermonters who are often hesitant to engage in mental health and substance use treatment. So they come to us. They do not need to fill out, besides consent to treat, do not need to fill out all the paperwork. They do not need to go through an evaluation process to get a diagnosis. We're connected to them through their economic services reach up worker. It's a hot handoff. And then we work with them. And as the relationship builds, we're able to plug them into others' ongoing services. If this program goes away, I feel like we will lose a lot of those folks because they might come to us, but then we'll have to do an evaluation and bill for them right away. And a lot of people are hesitant to do that. You need to build that relationship first. This is a low barrier program for folks that are on the Reach Up program that are struggling. And these have proven to be very supportive programs for folks. When the parent child center lost their Reach Up contract many moons ago, serving 25 and under Reach Up participants, a lot of those folks went into the wind. And that was really unfortunate. So this is a program that we're really wanting to maintain and continue to provide. We can't just pull it in somewhere and provide it in a different way because, again, folks, we need a low barrier access point for folks. We're serving over 500 people annually in this program.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: And then I'm just going to

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: point out youth in transition, another low barrier flexible program for sixteen to twenty two year olds. Often I hear in the state house success beyond six is what about the non Medicaid kids? This is serving kids sixteen to twenty two, regardless of their insurance. These are often kids who have complex needs. We say, SED or social, emotional disabilities, and they have challenges to accessing care. They otherwise would fall through the cracks and this program scoops them up and can provide them with care. So this is another program you can see who serves them. I don't have numbers on this. It was slow going for getting numbers for everything. I will get those to you soon, but this provides helping kids to transition to adulthood successfully, often kids with highly complex needs, including kids that are not on Medicaid. So this is a really critical program. We've seen this before. This is just, we do good work and we can show it. And so, I think this is just important to see all the work that we're doing and that people like the services that we provide and it is making an impact. And y'all know I had to put it.

[Alyssa Black (Chair, House Committee on Health Care)]: I scrolled ahead. You scrolled ahead.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Yeah, just to make sure you see it, Vermont is what we invest in. And that's just so true. And I think this is, again, if we continue to provide what's kind of above the iceberg that's happening right now, we're going to shrink all this stuff that's keeping us upstream, keeping people healthy and well before they have to hit those higher cost services. Those are needed, but they need to be smaller and the other ones need to be bigger.

[Rep. Leslie Goldman (Member)]: Thank

[Rep. Daisy Berbeco (Ranking Member)]: you for everything that your providers do for us. And I'm extremely sad to see so much red in the governor's budget when it came to us this year. Is it just me, or it seems like a lot of those programs that are proposed to be cut are low barrier programs?

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Yeah. When I was working on the slides, I was like, Oh, this is low barrier. And then I started to look through it, I was thinking a lot of these are low barrier access programs. And it makes me worried about we've got a homelessness crisis. So where are those folks going? We've got folks that are currently being served in these low barrier programs. Where will they go? I think we're just going to have a lot of people falling through the cracks and we're going to continue to see the challenges that we're facing, but at a bigger scale. So we're really concerned that there's no investment in community providers at large in the budget, and it's these large cuts, the low barrier programs for mental health as well.

[Alyssa Black (Chair, House Committee on Health Care)]: Go ahead, Debra.

[Rep. Debra Powers (Member)]: Do you have figures on the Reach Up program that show how many people, I'll use the word graduate, graduate from there with a job and their self sustaining?

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: I can get that for you.

[Rep. Debra Powers (Member)]: I'm trying to figure out why the cuts are. I'm just wondering, if the Reach Up program has an exempt, it's showing good results, then it's easy for me to make a decision on that.

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: Yeah, I think, and to representative potent point around some additional data connected to what are we actually providing. What we heard was it's just case management and you can pull that into another funding stream to provide it. So I don't necessarily know that people were thinking that these programs didn't have good outcomes, but maybe they could be pulled into something else. And if they're pulled into something else, they are no longer flow barrier as they exist today. So, I can get you additional numbers on reach up and what that looks like. But my understanding in watching the budget presentation was this was not necessarily cut due to poor outcomes. You would have

[Alyssa Black (Chair, House Committee on Health Care)]: to ask DMH about or AHS about that. But I

[Rep. Leslie Goldman (Member)]: can get that from you.

[Alyssa Black (Chair, House Committee on Health Care)]: Any other questions? Thank you, and thank you for the numbers. I'm assuming you're plugging in person. Can move on. I think we're in. Thank you. Thanks Amy. Great, next we have Bridges to Health. Naomi and Olivia, you both doing at the same time or did you want to go separately?

[Rep. Brian Cina (Member)]: That's no good. Yeah.

[Alyssa Black (Chair, House Committee on Health Care)]: You can set up that other chair there or you can also keep that red chair on the end. Hi, and thank you for coming in. I know you all weren't able to make it in the BAA, but glad you're here for the budget.

[Rep. Brian Cina (Member)]: Thank you.

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: Shall I start? Okay. Good afternoon. My name is Olivia Scherer, for the record. I am the executive director of Vermont's Free and Referral Clinics. And I just want to acknowledge I will be speaking on behalf of Vermont's Free and Referral Clinics and the Free Clinic Network immediately after this. And I'm going to go into a little bit more depth about what the Free Clinic Network is and does. But for the purposes of this presentation, I am here to represent VFRC as the new fiscal sponsor of the Bridges to Health program. We will be assuming this role on 07/01/2026. We've got about four months. I'm here to ask that the committee please consider the fiscal year 'twenty seven budget request of $500,000 to fund part of the Bridges Health program's annual operating This funding, which would act as a critical stabilizing funding source and would bolster this essential program. Registahealth is a uniquely effective health outreach and care coordination program that serves immigrants and migrant workers and their families across the state. These members of our communities are frequently excluded from or otherwise unable to access traditional health and social service programs. At the core of their program is the belief that everyone, regardless of country of origin or the language they speak, deserves access to the health services that they need. This is a value that Vermont's free and referral clinics shares. We understand that these people struggle to get the basic care that many of us take for granted, but they are important members of our communities and workers on who employers on our economy abide. Similar to our work, Bridgesta Health serves patients who, in many cases, would be unable to access care outside of the emergency room. It saves hospitals and clinics time and money by supporting patients who have language and service needs that they're not able to currently meet. But beyond the economic considerations, we support this work because we believe that now more than ever, is a moral imperative to act to preserve these critical services for a population that is increasingly under threat. Thank you for the opportunity to be here, and I ask again that you consider supporting the $500,000 Bridges to Health funding request for fiscal year 'twenty seven. Thank you.

[Alyssa Black (Chair, House Committee on Health Care)]: Tougher and Madamoiselle? Oh,

[Rep. Leslie Goldman (Member)]: Leslie, for clarification, so how much is the funding now? I know you're making this shift, but is there funding at all? Or is it all new money, the $5.20 I think you can probably answer that a

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: little bit better, Naomi, because you have existing grants that are going

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: to be transitioning. So my name's Naomi Wolkamakosling. I lead Bridges to Health. We have one active grant that's focused on maternal health that we would be transitioning to VFRC. We're also working on a fundraising campaign. As soon as we can, I'll be starting to write grants under the FRC, recognizing that we've been working for the past few months on getting everything in order to actually be part of the FRC and haven't been able to write grants during that time. So yes, it would be complemented by other funding sources. Can you give us a little history of your funding? Because it was originally grant funded and then the grants

[Alyssa Black (Chair, House Committee on Health Care)]: How have you traditionally been funded? Yes.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: It's always initially we started this work through an RHB, an Office of Rural Health policy grant from the federal level back in 2010, and since then have pieced together different grants as well as philanthropic donations to the work. There have been two times in the past, there have been one time state allocations that have also supported the work. And so, like I said, it's always been kind of just piecing together different funding sources. And so there hasn't been foundational funding from any one source that's been a through line since we started in 2010.

[Rep. Daisy Berbeco (Ranking Member)]: Daisy? I'm not clear if it's a one time ask or this squishy in the face.

[Alyssa Black (Chair, House Committee on Health Care)]: Yes, go ahead.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: In shoulder, for the record, always would prefer face, and we are aware of the context. I think obviously, we're not accepting one time money, it is supporting staff positions.

[Alyssa Black (Chair, House Committee on Health Care)]: Want to tell us a little bit about, you've got another slide, who you serve, how many I mean, the numbers that you serve have gone up incredibly over the last few years. Yes. Could I

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: do a time check just to understand We what you

[Alyssa Black (Chair, House Committee on Health Care)]: have fifteen minutes.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: Okay. Cross a few things out.

[Alyssa Black (Chair, House Committee on Health Care)]: Well, we can take Dan early too, but

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: Oh, I have a lot to say. We just came from a house ag, and I felt like it was important to talk a little bit about the origin story, if you will, of Bridges to Health, because it really connects to how we do the work today. So in 2010, I was living in Franklin County, and I was doing outreach work with the migrant education program, also a program of UMIM extension. I started to transition into a labor management role. So I was doing cross cultural labor management work with farm owners and farm workers, again in Franklin County and Grand Isle County. As I started doing that work, I started making a note of why farm owners and farm workers were reaching out to me. And at the end of the year, when I analyzed that data, 50% of the contacts were about health. The farm owners had a lot of questions about where to access care. Farm workers wanted help interpreting about work injuries to their employers. And there were just a ton of questions about paperwork, transportation, cost of care. And at the time, I had just come back from being out of state for a long time, and I didn't have any clue. I don't think I was thinking back. I don't think I even had health insurance at that point before I started with UVM. And so I didn't know how to navigate the health care system, but they were reaching out to me because I was a known person to them and I was trusted by the farm owners and the farm workers. And so when I think about the community health worker role today, it's really connected to that trust that we've built over time in the past sixteen years that has allowed us to reach, as you pointed out, this growing number of people. So we started, as I mentioned, in Franklin County, we started doing work with dairy workers across the state over the next few years, and then during COVID expanded to work with seasonal workers, most of whom are from Jamaica. And then more recently, we started using the expertise and knowledge that we had gained over time to work with immigrants and migrants that were coming in in the service industry and in the building trades. There's been a shift in migration patterns into the state in the past few years. And so we saw the numbers of kids, for example, coming with workers, both on farm and off, grow exponentially. And the number of workers here, again, working across all corners of our state. So our program, the Community Health Worker Program, is really working with individuals, with families, with households to understand what are their health needs, what are their priorities, what are their barriers, where are those gaps in information and access so that they can be healthy, productive workers as part of our workforce and have family members that have the most access to care as needed. So we have eight bilingual staff. Each individual community health worker has a region based on the size of the region, the populations that we know about in those regions, and they are really building those relationships over time to be able to navigate some really complex systems that exist both for healthcare and social services. I don't know if it's helpful to talk about numbers of people we serve or some examples of who we serve, but I also want to make sure that we have time for questions. Maybe I'll just point out a few key numbers from last year. So last year, we helped coordinate over 3,000 appointments with families, individuals in the workforce. 59% of those appointments were for children and pregnant individuals. Nineteen percent of those appointments were just for dental care, a lot of them acute dental needs, both in the adult population and the child population. We coordinated vaccine clinics with the Department of Health across 63 farms, and we had four community sites. This reached 11 different counties, and that's something we've been doing every year since 2020. We've collaborated with food access organisations to make sure folks in Northern Vermont have access to food. We help people enroll in WIC and other food service programs, and we spend a lot of time enrolling in and renewing health insurance for children and pregnant women, as well as helping people who are uninsured access financial assistance and sliding fee applications. I want to tell you about just about a few people, and then I'll stop talking and let you ask questions. I feel like it's really helpful to understand some of the stories because of the way that we approach this whole person approach the care from a whole person perspective. We had a worker named Terence who we'd worked with for a long time. His new coworker came in. He ran out of blood pressure medicine. He wasn't sure what to do, Terence said, Call Bridges to help. We tried to get him into a local clinic. They were scheduling out more than four months to be able to establish him as a patient. And so we worked with one of our volunteer providers who could prescribe him with his medications. We helped him get a GoodRx coupon to bring down the cost. And then we made sure he had a blood pressure cuff at home so he could track his progress and make sure the medications were appropriate for the duration of the growing season. I'll tell you just about one more person, and then I'll stop talking. So another individual that we recently worked with, Belen, her husband worked in the service industry. She reached out and she just described excruciating pain. Slowing, wasn't able to eat. We helped kind of prioritise registration application, sliding fee application, got her into the clinic. She called us from the clinic saying, they're telling me this isn't where I'm supposed to be. We called the clinic, they said, Oh, well, dentist had a change in his schedule. He's at our different site. We just couldn't communicate with her. We got her to that site, she got seen, they sent in a prescription, we got her to the pharmacy. There wasn't a prescription for her. We called the clinic again. They said, Hey, we called it into the wrong pharmacy. We waited to get it transferred. We were able to help her finally pick up the prescription and take the time to talk about the importance of continuing that medication until the medication was done. A lot of times, once the pain is gone, someone thinks they don't need to take it anymore. So we talked to her about that and then we were able to help her get that tooth extracted. We really try and look at each case on this individual basis and figure out, again, what are the barriers? Sometimes it's immediate barriers, like in the case of Belen, sometimes it's over time making sure people can manage their blood pressure, for example. I'll maybe leave it at that just because, like I said, I have a lot that I could share, but I know you probably have questions for me.

[Alyssa Black (Chair, House Committee on Health Care)]: This is a purely selfish question. You said you've helped out a lot of people fill out their applications for IHIP. How hard is the form? I actually haven't looked at it in a couple of years.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: The form itself isn't hard. I had to ring No. So the form itself isn't hard, but you do have to submit that application, which is about four pages, with identity documents, with income documents and residency documents. And so oftentimes, even if we're filling out that form with someone, it takes a while to collect that. Sometimes people haven't received mail in their name, so we have to send them a letter and then they take a picture of the letter and then we add that to the application. It can be sometimes complex in that way of having everything you need. Our goal is always to submit in a way that it can get approved right away instead of sending the application in and waiting for a letter to say, Oh, you're missing the income documentation or you're missing residency verification. We do a lot of renewals as well, and that's when there isn't a renewal form at this point. And so we write renewal and we highlight it and we put the UID and we put all the information that makes it again as easy as possible for it to get approved. And if we have trouble, we talk to the office of the health care advocate that helps us because we do still run into some challenges.

[Alyssa Black (Chair, House Committee on Health Care)]: I have a further question about this because it's been raised as a concern. I remember specifically when we did IHIP that no information could be shared on a federal this is a 100% state program, could not share information at all with federal government because we knew what population we were talking about. However, we have a lot of people that you serve who have, particularly children who are born here, who are US citizens and do qualify for traditional Medicaid or other benefits, I'm wondering if you're seeing hesitation on the level, on sort of the guardian or parental level of actually accessing programs that their children do qualify for because they don't want to give information. Are we seeing that begin as a concern or?

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: Yes, we do see that from families that we've worked with. At the beginning, I mentioned the importance of trust, and I think that is a really critical role that our community health workers play. And so some of the individuals and particularly families that we work with are families that we've known for a long time, or they're families that are related to or know a family that we've worked with. And so that often helps as we talk about what programs they're eligible for. But we are seeing more hesitation, more questions, which are always good and that we're happy to answer. Sometimes we're not able to give them a satisfactory answer. Generally, for example, with somebody who's pregnant, if they're filling out or if they're applying for IHIP, there's an option to apply for emergency Medicaid as well at the same time. And so we are seeing more people opting to just apply for INEP and not emergency Medicaid, which would cover the birth, for example. Same thing with food access programs. Maybe not so much with WIC, but with three squares applications. You asked about how difficult the IHIP application is, and some processes just require the provision of a lot more information. And so when there are higher barriers to accessing and more information requested of families, I think regardless of what family it is, it's sometimes hard to be like, I have to provide all of this information. And so that can create some hesitancy.

[Alyssa Black (Chair, House Committee on Health Care)]: I become concerned because we've always had the expectation and we've always ensured people that their information is confidential, and I worry that we are eroding that and losing trust.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: If we look at the numbers, I think about 85 to 90% of IHIP applications are ones that we've helped people apply for. So again, I think even within the service provider community, they have a lot of trust in us. So sometimes if they're not sure if a family is going to feel comfortable filling something out with them, they'll send that referral to us so that we can sit down with the family to talk about, again, based on their unique context, what's available to them and explain what the process is.

[Alyssa Black (Chair, House Committee on Health Care)]: Any other questions? Great, thank you. Yes? Sure, yeah. Usually you come in here and

[Rep. Debra Powers (Member)]: I just want to recognize this moment, but

[Alyssa Black (Chair, House Committee on Health Care)]: know what a miraculous thing that we are where we are here today. We've been, I've been in DC for a number

[Rep. Debra Powers (Member)]: of years working with the family to try and get funding between bridges and I just just want want to do a big shout out thank you to everyone who's worked on making sure there's a home for Bridges. Obviously, part of what I'm being honest. That's kind

[Rep. Leslie Goldman (Member)]: of a dark question, and you may choose not to answer, but what happens if this doesn't get funded?

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: We've thought a lot about that, and we've talked about that as a team, because I think everyone's very concerned about that. I think there are implications for employers and that it's harder to have a healthy, productive workforce if they can't access the care that they need. And we also think there'd be a cost. So beyond the cost to the individuals we serve, right? A cost not only to employers, but to the health care system as a whole, because we provide a lot of guidance in terms of accessing at appropriate levels of care. We support a lot of preventative care for pediatrics, as well as anyone with a chronic health issue. For workers that haven't interacted with the health care system, same thing. We're talking about what's the difference between primary care and urgent care and emergency department. And what is the emergency department for? And at what point would you access that versus trying to go to those other lower tiered access points? And so we would anticipate if we are not funded that there would be an increase in emergency department visits. There'd be a decrease in health insurance enrollments and renewals for sure. There'd be a decrease in how people are accessing. And I think the most significant impact is individuals and families that we work with, but there also would be ripple effects for employers and for the health care system. How do you measure prevention? It's always the question.

[Rep. Debra Powers (Member)]: Thanks

[Alyssa Black (Chair, House Committee on Health Care)]: for asking that question, because I actually did have another question that I'd forgotten about. I think when I first learned about bridges, I think at the time it was almost 50% of our dairy industry workers, farm workers, were immigrant labor. It's gone up since then, and now it has moved into huge amounts of our hospitality industry, construction. I'm wondering, has Bridges gone to these trade organizations, industries, and ask them for funding. Not that you shouldn't come to us, but I think about the industries that are profiting and how our economy is helped by these various industries. Has there been any movement in them funding bridges?

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: It's a great question. I think with the farming community, agricultural community, we know that most farm workers live on farms, and we tend to have a more direct relationship with those employers. We also know that they're really pressed, whether it's a dairy farm or whether it's a farm that produces carrots or apples or other crops. I think it'd be pretty challenging as a farm to look at how to support the program, because we know that agriculture is under other financial pressures. And within the other industries, while we know what industries the people we're working with are engaged in, we don't have direct relationships with employers in the same way. Most of the non farm individuals that we work with don't actually live where they work, with the exception of our resource, I would say, that are maybe relying on seasonal workers. And so we really don't have not like when I say, I don't know, 25 of the people that are connected to construction, that it's two or three construction companies. It's one or two people working for this small business. It might be one person here. It might be 10 people for this other organization. But it's as it's hard to wrap your head around large organizations or companies, because it really is. We are seeing a lot of employers that maybe are really small businesses that aren't relying on large numbers of people. Yes. But they do have trade organizations that they belong to and support. Yeah. And it'd be great if anybody who has if anybody knows who is in charge of those trade organizations, I'd be happy to talk to them for sure.

[Alyssa Black (Chair, House Committee on Health Care)]: Thank you. Thanks for coming in. Glad to be here. So Olivia, you can say.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: Sam, you want to come on in?

[Alyssa Black (Chair, House Committee on Health Care)]: That is joining us via

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: Right, he's right here.

[Alyssa Black (Chair, House Committee on Health Care)]: Oh, yeah. It's one right there. Reading is my desk. And

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: it's just it looks like just join Zoom. Microphone mute.

[Alyssa Black (Chair, House Committee on Health Care)]: Or take over.

[Rep. Brian Cina (Member)]: Okay,

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: share my screen. And I should be able to place slide from start. Okay, do we each need to say our names, or should I just

[Rep. Brian Cina (Member)]: do

[Alyssa Black (Chair, House Committee on Health Care)]: we do it first? Yeah, or Wendy's Start speaking, you should say your name. Every

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: time you say something.

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: That would be silly. Okay, I will get started. Good afternoon, again. Thank you for inviting us here today. My name is Olivia Scharro. I'm the executive director of Vermont's Free and Referral Clinics. I'm here to ask you to consider our organization's fiscal year 'twenty seven request to raise the limit of our grant funding, which is a legislative appropriation, by $925,000 half of which would come from the general fund. Vermont's Free and Referral Clinics is a statewide association. We have eight member free clinics spread throughout the lower twothree of the state. The furthest north is Barrie on one side and Middlebury on the other side. The FRC's mission is to advocate for a more inclusive, equitable, and accessible health care system. And our network's collective history is rooted in reducing barriers to care for people in Vermont. Last fiscal year, our eight members provided health care services to over 9,000 patients. Five of our members provide clinical care, medical, dental, and mental health. All of our members provide a range of health system navigation services, which we call referral services. They support patients in accessing health insurance, including Medicaid and other benefits and social service programs such as SNAP. As the rules governing eligibility become increasingly complex, our role as navigator network is becoming more urgent. Because of our work with benefits assistance, our budget request is included in the larger benefits assisted group requests that some of you may have heard about. That request is to support organizations on the front lines of keeping Vermonters on the benefits that they are eligible for. And so again, our request is part of that larger request. It is not in addition to the benefit assisted group request. Services at our network are free, period, always. There's no sliding fee scales. There's no insurance billed, and that is whether a person has insurance or not, and no payment plans. We can provide free care because of our legislative appropriation, other philanthropy, and support from the communities we serve, and because our clinics leverage the passion and dedication of hundreds of volunteers. Last year, we had 33 paid FTEs and over six fifty volunteers. Three thirty were clinical, and we had 42 medical interpreters. Broadly, our members serve patients who are unable to access care in the mainstream health care system. Barriers to care can look differently to different people and different communities. There are structural and policy reasons that people seek care with us related to housing or immigration status, other eligibility rules, among other factors. However, more and more patients are coming through our doors because they either can't find the provider or they can't afford to access the care that they need. In fiscal year 'twenty five, thirty three percent of our patients were uninsured and twenty eight percent were underinsured. We don't have data for January 2026, but anecdotally, I've been hearing from some clinics that they are seeing patients disenrolling from commercial insurance to the cause. And now I'm going to turn it over to Dana.

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: For the record, Dan Barlow, Executive Director of the People's Health and Wellness Clinic in Berry and also Board Chair of the VFRC Network. For over thirty five years, the People's Health and Wellness Clinic has been a safety net for folks involved with the graft. Vermonters who are living without insurance, Vermonters in poverty, and people who are working hard but still unable to afford the care that they deserve. At my clinic, they find something rare, compassion, dignity, and care without judgment. We do a lot at the People's Health and Wellness Clinic with a very small staff. There are five of us, but really about three and a half full time jobs among the five of us. This is amplified by 30 volunteer doctors, nurses, dentists, administrative assistants who provide most of the care at the clinic. We provide preventative primary care, dental hygiene, including extractions, care coordination and assistance with food and security, housing, transportation and health insurance navigation. Last year, we served six sixty eight unduplicated patients, that was two twenty three new to the clinic for the first time, and in total seven forty medical visits and four fifty seven dental visits. Our patients came from 60 towns around Belmont, 25% of them earn less than $14,000 a year, a majority of them live below 20% of the federal poverty level. One in four of our patients tell us that they have delayed care due to lack of access and forty five percent of our patients work full or part time. Our current capacity right now with staffing means we see patients on Tuesday, Wednesdays and Thursday, So both dental and primary care. This amounts to about 24 medical visits a week and 12 dental visits each week. The challenge we have is that, as Olivia said, when we see more patients, we don't get more funding because we can't bill Medicaid and we can't bill private insurance. So we're constrained right now by our budget and our staffing. Increasing our budget line item as requested would allow me to convert part time clinical and case management positions to full time and hire a full time front desk office manager to handle the increased flow of patients. We project this would mean 18 more medical visits each week and eight more dental visits each week, meaning hundreds of more Vermonters receiving preventative care annually. And now I will stop for

[Rep. Debra Powers (Member)]: a second and turn over to my colleague, Heidi Suess. Hello, I'm Heidi Suess.

[Heidi Seuss (Executive Director, Open Door Clinic)]: I'm the executive director of the Open Door Clinic in Middlebury. And to put a human face to our work, I'd like to start with a short little story written by one of our nurses, Michelle Mayo. We always have a schedule for clinic, a piece of paper that details exactly who is coming, when and why, just like you'd expect in the medical office. Somehow, this piece of paper rarely reflects the evening as we're looking back on it the next day. Last night, one patient who was scheduled to see a doctor brought their mom and two sisters to clinic as well, all of whom needed seasonal vaccinations and reassurance from a clinician about a recent bout of flu. Another patient brought their coworker who had been suffering from diarrhea for several weeks and needed to be triaged. An established patient who did not have an appointment walked in to have his blood pressure checked because he had been feeling a little off lately and just wanted to make sure he was Okay. Meanwhile, the volunteer who manages the front desk is finding toys for a toddler who had come along with her dad to his appointment. Our clinic trailer is a humble space. There are a few bells and whistles, but every Tuesday night it warms up and gets an infusion of just the right amount of chaos. We are happy that people feel safe, bringing their friends and family with them and that they are looking out for one another's well-being. So with this slide up, like Peoples, we provide a wide variety of services: acute and chronic care, dental care, referrals to specialists when needed, help with health insurance, and a robust outreach program that's growing to a year round endeavor. We are local leaders in language access. Last year, we arranged interpreters for five sixty seven persons across nearly 2,500 appointments. Addressing the social determinants of health, we have a little Mercado, or free store, where we provide curated staple foods for our patients and warm clothing for the winters. I would be remiss if I didn't mention our volunteers who really comprise the backbone of our organization. Last year, 143 volunteers supported our patients through medical care, interpretation and administrative work. We couldn't do the work we do and have the reach we do without our volunteers. Next slide, please. While we see any individual who qualifies for our services, many people know us for our work with migrant workers, who last year comprised 53% of our total patient population. We've been seeing patients in the field for over fourteen years, but the acquisition of our Exam Dan pictured here that we're very proud of has been a game changer for us. We've always provided vaccines, health screening, and health education in the field, but now we can consistently provide visits with a medical provider in a safe, warm, dry, confidential space. We are meeting people where they are and directly addressing some of their barriers to care, including but not limited to work schedules, transportation, language access, all the while supporting our local farmers by providing health care at their work sites. Final slide, please. So why are we here today asking for an increase to our legislative allocation during a session when there are so many hard choices to be made? As safety net organizations, our ability to provide unencumbered grassroots care allows us to serve people who really have nowhere else to go. As we have grown and evolved over the past thirty plus years, we are seeing far more chronic illness among our patients and patients with complex multifaceted health care needs that require more of our resources, more care coordination, and more case management. Given the recent destabilization of bridges, as Naomi, I believe, discussed, the community health worker position in Addison County was eliminated. And after much internal discussion, we have committed to taking that That's position a new position for us, a new program, and more fiscal responsibility. We also hope to bring our medical assistant to twenty or twenty five hours this summer to better support our vastly overlooking nurses. And still, we could use more staffing, bringing my position to full time and adding more hours to our growing dental program. Our current legislative allocation covers 29% of the ODC budget, leaving nearly $600,000 for me to fundraise, write grants, and find. A tall order indeed, and one that rests disproportionately on the shoulders of our coalition and free clinic model in the absence of statewide infrastructure to address the growing fissures and cracks in the system. An increase in funding would help to reduce our significant burden and sustain our programs that keep people healthy and well and from falling through the cracks. We are a stable, safe, respectful and respected coalition and organization within our communities. And we're an integral mayor and part of the health care delivery system, not only in Addison County, but throughout Vermont. Thank you. We urge you to consider this request.

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: Again, we are asking that the legislature raise the limit of our funding by $925,000 Half of this would come from the state's general fund. Half is federal Medicaid dollars. Our current appropriation is just under $1,600,000 Using our fiscal year 'twenty five patient numbers, if our request is granted, this would amount to two seventy two dollars per patient per year. And again, half of that is state funding. Funding our work is a good investment. We are there for patients when they have nowhere else to go. It's understood that people who don't have access to primary and preventative care often seek care in the emergency room, which leads to avoidable system wide costs. By providing a low cost setting for patients to get the services they need, we divert patients from the emergency room and save the system money. For last year, we estimate $5,000,000 in avoided emergency room costs. This came from providing care to people who are uninsured or who lack a primary care provider or who have a couple specific conditions, such as wounds or dental pain and infection. Another way of saying this is that for every $1.58 invested by the legislature, we save the health care system $5 For decades, we've operated with the various industry string budgets. We've been level funded since fiscal year 'twenty three. We've been stretching and making it work, but it is simply not sustainable long term, given what is happening in the health care system. We anticipate rising demand for services as federal policy changes go into effect and as more Vermonters either disenroll completely or switch to poorer commercial plans due to the loss of enhanced subsidies. We are already seeing more Vermonters coming to us for navigation services. This request does not represent new programs. It is primarily for personnel costs, as you heard from both Dan and Heidi, bringing existing part time staff to full time, being able to operate clinic hours more, and in some cases, bringing on more staff to make up for losses with community partners. This will allow us to scale up as much as we can to continue to meet the clinical needs of the communities we serve. It will also allow us to support more Vermonters than ever with issues with health insurance navigation and other benefits and help people navigate Vermont's fracturing system. Now more than ever, investing in affordable settings and programs that ease the burden on emergency rooms and reduce costs overall is crucial. Thank you.

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: And I'd like to just close with a brief patient story from the People's Health and Wellness Clinic. Our patients don't come with easy stories all the time. They often have lives that are shaped by addiction, trauma, poverty. A recent moment I think really illustrates the role of free clinics. We had a man who was behind our building one morning, he was shouting obscenities, he was in distress, he found his way into our waiting room and locked himself in our bathroom. And my staff and volunteers were concerned this is a red flag for possible drug use. We have to monitor bathroom usage. But when we knocked, we found out that he was walking around in wet boots and socks in winter, in the cold, and he was trying to bandage his feet with toilet paper in the bathroom. So my team sprung into action, we treated his wounds, dressed his wounds, we found him dry socks and new boots at a nearby thrift store. One of my volunteers went to the church across the street and got a hot meal for him. This took hours, this took teamwork, it took a small village to do this. But by the end of the day, this man who started his day screaming in pain behind my clinic, walked out with medical care, new boots and warm food in his stomach. And that's what we do at the free clinics every day. We don't turn people away, we don't rush them out the door. We don't ask them how they're gonna pay for this. In fact, don't ask for payment at all. We ask, what do you need and how can

[Rep. Debra Powers (Member)]: we help? So thank you very much. Thank you.

[Alyssa Black (Chair, House Committee on Health Care)]: Any questions? Yes, go ahead. Just out

[Amy Johnson (Director of Legislative Affairs & Public Policy, Vermont Care Partners)]: of curiosity, do you guys

[Rep. Leslie Goldman (Member)]: do any kind of, now that a lot of people who have now gone to the cheaper bronze plans, who are still getting subsidized through the federal government, are now using these free services, it just seems to me like there's money being wasted or left on the table. Is there any kind of study, like people who are still paying for a plan that they're not able to use at all?

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: I don't have any data. I will say we see this almost on a weekly basis at my clinic. We would consider them under insured because the deductibles are usually too high.

[Rep. Leslie Goldman (Member)]: Oh, I'm not blaming it.

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: Yeah, absolutely. So we have, and again, as the free clinic, we cannot bill Blue Cross Blue Shield or MVP or whoever has that plan just as we can't bill Medicaid for our Medicaid patients. I know in my clinic about 30% of them are Medicaid. I would say maybe 10% to 15% are the high deductible private plans.

[Heidi Seuss (Executive Director, Open Door Clinic)]: And we have a different situation in patient base, so nearly everyone. I think only two percent of our patients are underinsured and the rest are completely uninsured.

[Rep. Daisy Berbeco (Ranking Member)]: Can you talk a bit about your request is split fiftyfifty general fund CMS and 30% of your population that you serve as Medicaid eligible. Can you just talk about why the fifty-fifty split?

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: Yes. It's not based on the insurance status of patients. It's based on the reason that it is fifty-fifty is because of how the services that are delivered at the clinics are categorized. So their Medicaid administrative services Medicaid administrative services get this 50% match. And historically, fifteen years ago, 90% of the patients who were coming to the free clinics were completely uninsured, and it was still the same fifty-fifty match because of how those services are categorized. We've seen over time, and we've talked about it in a few different ways, and certainly in the last few years, just more and more patients who have insurance who are underinsured or who have a perfectly fine commercial plan or have Medicaid and aren't able to get into a provider to be seen. So at some point, I think in the last five years, flipped. And more or less equal to the number of people who are uninsured versus underinsured. But yeah, it's based on how the services that we deliver are categorized.

[Alyssa Black (Chair, House Committee on Health Care)]: Okay. Toucher.

[Rep. Debra Powers (Member)]: You mentioned that they can't get insurance provided, why not?

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: It depends on the community that they're in, and it depends on the type of insurance they We see a lot of issues, for example, with dental, communities where there is maybe only one dental provider who accepts Medicaid, or maybe there aren't any that are in that location, or it just takes a long time to get established with care. I have state insurance because of my partner. And when we moved to Barrie in 2022, it took nine months to get set up with primary care there. So that's not because I was uninsured. It's not because I had Medicaid. There's this dual there's restricted access to primary care, and then particularly for people who have Medicaid or who are uninsured, it's just hard to

[Rep. Brian Cina (Member)]: find a provider who can see them.

[Rep. Debra Powers (Member)]: Is it because they don't accept Medicaid, they won't bring Medicare, the Medicaid patients into their practice?

[Heidi Seuss (Executive Director, Open Door Clinic)]: Relative to primary care, not necessarily, it's just that there is such a backlog of people waiting to be seen by a limited number of providers. So in Addison County, I think some of the practices are six to nine months out if we even had someone who wanted to transition that way.

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: Representative McFaun, think it's an important point. The original vision of the free clinics would be that someone would be coming to us, they would not have health insurance. You'd get them in to see doctor, stabilize them, sign them up for health insurance, find them a primary care doctor and then hopefully never see them again. That last part of the pipe is broken. We cannot find them a primary care doctor. As Olivia said, sometimes it's up to a year and they have emergent healthcare needs right now. Well, we can get them within two weeks. They're not gonna be waiting a year with us. And then we build that level of trust with them. Some of these patients are challenging, both in their medical conditions, but also behavioral issues. And the free clinics can build up that trust with those patients. And that's why they keep on coming back to us year after year. And we keep on trying to find them primary care providers outside of the free clinics, because they might see a different doctor each time they come to my clinic, it's a different volunteer. So it's really challenging. And as I said, we have a few 100 patients each year now who are using the People's Health and Wellness Clinic as a primary care office.

[Rep. Francis McFaun (Vice Chair)]: And how about this new group of doctors that I guess they call themselves independent? I see that popping up now. It's really that group of doctors and being able to get people in there.

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: I'm not sure what group of doctors that is.

[Rep. Brian Cina (Member)]: Well,

[Rep. Francis McFaun (Vice Chair)]: this area. He doctor was that was at practice that I did not listen in.

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: Okay, okay. We work very closely with all the other providers in the area and Central Vermont Medical Center and almost on a weekly basis, CBMC will send us a list of providers they knew who were accepting patients. Often that is an active list for a day or two and beyond, and then it's no longer, yeah, yeah.

[Alyssa Black (Chair, House Committee on Health Care)]: Go ahead.

[Rep. Brian Cina (Member)]: Thank you so much for the work that you're doing and all your volunteers and all your professional folks. It's amazing. And the ask that you come with us today is the best health care ask that I can possibly think of. Last year, lot of money was saved to the system just on reducing some drug prices in the hospital. You're asking for a very, very, very, very tiny portion of that savings from last year. And I think we are really hoping or focusing on making access to primary health care accessible, available and enhanced. And I don't know if you have any thoughts on how we can incentivize or stand up a more robust health care system so that you can refer that person out that came to you in the first place, but then they're set. And I also know part of the population you serve, we wouldn't qualify for any kind of health insurance in this environment. So I don't know, just do you have any thoughts on how to

[Heidi Seuss (Executive Director, Open Door Clinic)]: improve our It primary may be a little simplistic or superficial, but I think having embedded case managers and dedicated social workers in primary care practices would be immensely tough. Immensely. Because I think a lot of the patients that we see and people in general have so many different kinds of needs. And I think we can all appreciate that navigating our system, our broken systems, we have so many of them, is really difficult. And so we do something called accompaniment, and we help people a lot to get through there. And we feel that it's critical to their success. And so I think that's something, and paying for it, valuing it and paying for it would be helpful.

[Alyssa Black (Chair, House Committee on Health Care)]: Thank you. Thank you so much. Thank you. Thank Great. We are going move on to, and I believe we're on live, the Howard Center. Hi, Sandy. How are you?

[Beth Holden (Chief Client Services Officer, Howard Center)]: The host has disabled Beth's

[Alyssa Black (Chair, House Committee on Health Care)]: video. We can hear you now. Can hear Beth. We can see Sandy. Now we can see Beth. But Sandy, you don't have it Sasha's on our end or

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: Is that working yet?

[Alyssa Black (Chair, House Committee on Health Care)]: Oh, there we go. Just because I got a boss. So, thank both for coming in. It just occurred to me that we haven't really had you in at all this year and our time is limited. So we're just kind of we want to keep it contained to the asks regarding what was in the governor's budget or not in the governor's budget, I should say, and get information about that from you.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: Okay, great. We did submit a written testimony and we've got about nine slides that we're hoping to go through at a pretty high level. Some of it's context and then specific on what's proposed in the budget, and then recommending that we hold for questions until the end if that works for the committee to see where That you wanna dig

[Alyssa Black (Chair, House Committee on Health Care)]: works great. Thank you.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: Alright. And I'm gonna do some gym gymnastics here and try to share a screen. I think I've done it. Right. So chair, vice chair and members of the committee, we appreciate the opportunity to testify today. My name is Sandy McGuire, CEO of Howard Center, and I'm joined by Beth Holden, our Chief Client Services Officer. Howard Center is a designated agency providing mental health, substance use and developmental disability services to more than 19,000 Vermonters annually. These are children, adults, families, and elders, many at moments of real vulnerability. These individuals rely on us for consistent support to stay stable, housed, care for family members, and live in their communities. I want to briefly frame why the proposed potential cuts matter so much at

[Olivia Scherer (Executive Director, Vermont’s Free & Referral Clinics)]: this

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: moment. First, the budget includes no inflationary increases, even as workforce and operating costs continue to rise, which leaves community providers providing state services expected to absorb the pressures. Second, providers are implementing major system reforms, including DS payment reform and transition to the CCBHC model. So it's a particularly complex moment given the scope and pace of ongoing reforms. It's not entirely clear which of the proposed changes or cuts represent permanent funding reductions and which services may ultimately reappear in other funding streams, including CCBHC. Compounding that, we're not typically involved proactively in annual budget development or consulted about anticipated service needs, which means clarity about what will be funded and at what level often comes very late. So typically, we're planning reactively, responding reactively, and have prolonged uncertainty for individuals and families, many of whom are left wondering whether services they rely on will continue and what states that services they can count on moving forward. So it's an unusual way in many years, and we have many questions as I know you all do as well. And so just to touch base briefly on context of developmental services, want to be clear, we absolutely support the goals of DS system reform. Our concern remains implementation and unintended consequences. For individuals and families and providers, we've spent months without clear answers, not knowing what services would continue, what would change, or how to plan daily life around supports they rely on. It was several months after the implementation of the reform when we received approximately seven fifty individual budgets for those in Howard Center's care. So a little bit flying blind for several months providing services without knowing what had been approved or authorized and the same for families unsure about what would continue. And so, also recognizing the timing of payments for services and reconciliation, which I believe you all are well versed in. We really want to acknowledge and thank the house for the critical work on the BAA, which appears headed in a constructive direction in the Senate and knowing the work's not final, but appreciate the attention given to stabilizing the system. And as reform continues both with DS and in mental health with CCBHC, it's important that implementation doesn't unintentionally destabilize services or create prolonged uncertainty for individuals and their families. And so we'll start addressing one program area that is in developmental services. I'll pass that to Beth.

[Beth Holden (Chief Client Services Officer, Howard Center)]: Good afternoon all. Thanks for inviting us today. I appreciate it. I'm going to start with ARCH Services. ARCH stands for ARCH is a fully operational program. It's accessing resources for children is what it stands for. It is fully operational. It's serving children and youth with complex developmental and mental health and medical needs. Arch is the only place where these children can receive truly integrated developmental disability, mental health and physical health services in one coordinated program. Both Dale and DMH have listed Arch as ending. That's the word that was used even though families are actively relying on these services being provided today. While many arch services have been requested under new CCBHC funding, it remains unclear whether all services will be funded or remain intact at the same level. For families, the loss or fragmentation of this program would mean navigating multiple systems instead of receiving coordinated care, increasing risk of crisis and service gaps for children when some of the most complex needs.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: And I think just to highlight, as Beth mentioned, both Dale and DMH testimony stated this program ended, which is a question for us as this service is very much up and running and funded through both departments currently. And as we think a little bit about the mental health context, we absolutely are excited about and support the goals of the CCBHC model. We recognize its potential and at the same time, we don't have clarity yet about which existing services will be picked up under CCBHC, how programs will transition or what funding levels will be. In practice, providers often can't finalize our plans for the coming fiscal year until the end of the legislative session, which limits our ability to plan for staff and maintain that continuity of care, which people are depending on as they're struggling. And so we do want to identify that the state has highlighted that we have requested in CCBHC funding. We won't know if that's in there until April or not. So if we just go back for a minute, you'll see on all of the program slides this grid on the right hand side, you can see what the state has proposed as a cut. We're unclear in some situations how much of that is Howard Center or not. For Arch, we're very clear that is a Howard Center only program, and that is all directed to us. And then the next column is whether or not it's been requested for CCBHC funding. And so much of it has for us when we think about the mental health services, but not all because it also includes DS services. And again, we won't know until April what is included in CCBHC or not. So just wanting to highlight that particular piece of context when we think about what is in the proposed budget.

[Beth Holden (Chief Client Services Officer, Howard Center)]: Next, I will move to our crisis and diversion services, also known as outreach services. Programs like Community Outreach and First Call operate upstream of emergency departments and law enforcement. Their value is not just in volume, but in what they prevent. When these services are reduced, people don't stop needing help. They show up later in crisis, in emergency departments, or through law enforcement when options are fewer and outcomes are worse. Next, I will move to youth, elder and family services. The same is true for services supporting transition age youth, elders and families. These programs are relatively small, but highly targeted. They stabilize people at critical moments of transition and vulnerability and prevent deeper system involvement. Cuts here increase long term costs and undermine outcomes. I also want to highlight youth in transition, serves young people with significant emotional and behavioral needs at a critical point between youth and adult systems. It's important to note that thirty two percent of youth served through Youth in Transition identify as BIPOC compared to about thirteen percent of Chittenden County overall and approximately 23% of Chittenden County middle and high school students. So our percentage is a bit higher. That means instability or cuts to this program would disproportionately affect these youth widening existing healthcare disparities at a moment when consistent support can make a long term difference.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Moving

[Beth Holden (Chief Client Services Officer, Howard Center)]: to adult mental health residential services. I also want to flag the compounding risks to adult mental health residential services. Changes in payment eligibility, unresolved room and board funding, and lease restrictions place existing residential capacity at risk. Without resolution, individuals with high acuity needs face displacement, homelessness, or loss of residential services. It's not just disruptive, it can undo months or even years of progress and push people back into crisis.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: We're going to move very quickly through these closing slides. You all have these to take a look at, but it does feel that the proposed budget is a bit misaligned with the state's priorities for mental health, substance use, and developmental disabilities, and certainly has real consequences for the people we serve. Again, that comes with a question mark about what some of these reform efforts will or won't include as we move forward, which we won't know until a couple of months before the new fiscal year. And so certainly, as we think about the ask of the legislature and your committee, it really is about ensuring that the services can currently delivered remain funded in these new models. The focus on inflationary adjustments, stabilization during reform, protecting housing and essential programs, the support of the BAA language to ensure that we're able to keep our doors open. And we will end there recognizing time and wanting to have some time for questions and or flag where additional follow-up might be helpful either today or that we can submit to you outside of this. I'm happy to take the slides down or leave them up if they're helpful.

[Alyssa Black (Chair, House Committee on Health Care)]: You can take the slides down.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: I can.

[Alyssa Black (Chair, House Committee on Health Care)]: Does anyone have any questions? Yes, go ahead, Leslie.

[Rep. Leslie Goldman (Member)]: Yeah, thank you. Thank you for your presentation. I always think of it, and I'm obviously not incorrect, of the Howard Center being Chittenden focused, but I'm seeing on your slides that it's 60 locations throughout Vermont. So, can you help me understand that?

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: Absolutely. We are primarily Chittenden County. We are designated for mental health and developmental services in Chittenden County, and we're a preferred provider of substance abuse services. Outside of those required services that we provide as a designated agency in the county, we also provide some state programs that are outside of our designation. So certainly for substance use work, which we do outside of Chittenden County, but also I think about our Park Street program down in Rutland. That is a statewide program that is outside of benefiting only Chittenden County residents or those who show up for care and operates outside of Chittenden County. So those are just a couple of examples.

[Rep. Leslie Goldman (Member)]: Do you have any programs in Windham County?

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: We do not have any programs specifically in Windham County. Interestingly, when we look at where folks are coming from that we serve, and I was looking at a map the other day, I have to double check, I think it was for our urgent care. I was actually quite surprised at people from all over the state who are coming in and accessing services. So those individuals are likely an ongoing client of another designated agency, but they can certainly access services, particularly crisis services anywhere in the state and welcome to access our services in or outside of Chittenden County as well.

[Alyssa Black (Chair, House Committee on Health Care)]: Thank you. I saw Lori had a question. Okay. Can you explain to us, and maybe like fiscal day of the arch? It just seems to be a transfer that they're just transferring from DMH to Dale. One's up, one's down.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: Yeah, we're not clear exactly what that is. We saw that as well, one up, one down, both with language. Program ended as though it was past tense. The program is very much up and running and we're not aware that it will be ended. And so again, we're not clear if this is part of developmental services payment reform and CCBHC, that those are moving throughout AHS, but that the program will still be funded or if in fact the program is no longer funded. It's pretty unique and heavily relied on serving children with IDD, autism and mental health diagnosis, very integrated programming, and about 300, over 300 individuals and families counting on these and over 150 on the wait list. So high impact program and we're seeking clarity, but we don't have it yet what exactly the program ended language means.

[Alyssa Black (Chair, House Committee on Health Care)]: Well, we'll try to get clarity. Can see that we never have Dale in our room, but we do have DMH. Maybe you could get some clarity for us on that and get back to us. Okay, Thank you. Daisy, did you have a question?

[Rep. Daisy Berbeco (Ranking Member)]: I do have a question. Did I hear you say that you're not yet certain what's being rolled into your CCBHC PPS, basically, so you're not sure what services you will be paid for under that fee. Is that true? It

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: is not completely finalized. There's been a lot of conversations that have guided our submission, our request, which has gone in. There continues to be conversations. I think there was a full day meeting yesterday, but we are not anticipating getting back until April, the final answer on what is included and at what level of funding.

[Rep. Daisy Berbeco (Ranking Member)]: But they're trying to budget without even knowing what services they're going to contract you to provide.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: I'm hopeful that they have a sense of that, but we're not completely clear on what that's going to look like.

[Rep. Daisy Berbeco (Ranking Member)]: That sounds really challenging.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: Yeah, I think there's a lot of core services that feel much more clear and there are some others and particularly as they relate into what was highlighted on the state's budget, some of those things, and we flagged them in our grids, were included in our submission, but whether or not they get excluded in what's funded, we don't know. And others weren't included in that submission, not understanding or perhaps that they're not eligible services. So particularly when we think about elder care and reach up. And so again, wanting to be transparent with you all, with the state and with others, what is included in that submission, what's not. And again, it's unclear to us what will ultimately be in the CCBHC funding.

[Rep. Daisy Berbeco (Ranking Member)]: Right, because that's federal, so it has to be approved by CMS. Nothing that they won't approve is going to be paid for. Everything else that you're providing that's currently under Medicaid, there's no reassurance right now from DMH that those are going to continue.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: Correct. I think particularly some of these program elements that were flagged in the state's budget testimony have become questions of ours as far as what that means. These might very well be in there and we just don't know yet. That would be a great outcome, but we're not clear at this time.

[Alyssa Black (Chair, House Committee on Health Care)]: Okay. Thank you. Thank you Thank so you all.

[Sandra “Sandy” McGuire (Chief Executive Officer, Howard Center)]: We appreciate it.

[Alyssa Black (Chair, House Committee on Health Care)]: Thanks, Beth. Thanks, Debbie.

[Beth Holden (Chief Client Services Officer, Howard Center)]: Bye bye. Thank you.

[Alyssa Black (Chair, House Committee on Health Care)]: I am very cognizant that we haven't taken a break at all, but I would like to you know, two more left. I just feel like you're all adults. If you need a break, go take a break. Let's go on to Eric.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I only have 130 slides. Good afternoon, Madam Chair, members of the House Healthcare Committee. Thank you so much for the opportunity to come and talk a little bit about our home health ask for this budget cycle. So for those of you that haven't met, for the record, my name is Eric Covey. I'm the Interim Executive Director for VNAs of Vermont. I've been interim since October. As you may know, my predecessor, Joe Mazzalton, is now working for the state as the state Medicaid Director. So that's why I've stepped into this role. Hopefully you like me as much as you like Jill. We'll see. Big shoes to fill.

[Alyssa Black (Chair, House Committee on Health Care)]: You knew Jill's position name. A couple of weeks ago, Jill came in here and didn't know that the name was.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Did I say other duties as a sign? Is that correct? I'm going to start off by just leading out with what our ask for the budget is. And we're asking for a modest 3.5% increase to Medicaid home health. And I'm going to go through a little bit about what that means. But some of the rationale behind that 3.5% is that that represents what the average market basket CMS has projected for the April 2026. And of course market basket is their kind of healthcare inflationary increase calculation. So that equals about 328,500 gross. So with FMAP, that's about 135 general fund dollars, I think. You may have remembered some previous conversation with my predecessor about some of the home health rates, specifically some of the pediatric palliative care and high-tech nursing rates being really internally inconsistent with other rates like, for instance, it pays the same to have an LNA and an RN on the

[Rep. Debra Powers (Member)]: same

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: visit. And approximately the same as what it costs to send a home health aide in for a regular skilled nursing visit. Obviously, we know the license is one of the biggest drivers for staff costs. So that internal inconsistency presents some significant fiscal challenges to providing some very, very important and critical services for the individuals who need them. To address that internal inconsistency would be a really big ask, be a little over a few million dollars based on some of the modeling that we've seen. And we are very understanding that in the current fiscal environment that is not a reasonable or legitimate ask, but just wanted to set the stage that that's not something we're coming prepared to ask. And what we're asking for is a flat 3.5% across the revenue codes for home health. We've worked with Veeva on a rate model that compares Medicaid payments, which are the fee for service per visit rates to the episodic Medicare schedule. And that 3.5% for most Medicaid rates, not the ones that have that internal inconsistency, But it brings most of them to a benchmark of just about 70% of what the Medicare payment is. I just wanted to last year, I am so appreciative this committee had one of its highest priorities, an increase for skilled home health. So thank you so much for your support last year. That didn't end up making it in to the budget that went over to the Senate and didn't end up making it across the finish line. So I'm hoping we can count on your support this year to continue to move that down the road.

[Alyssa Black (Chair, House Committee on Health Care)]: Can you actually clear up something for me personally? Because I had thought it was in the budget. And then I think there were some people who thought it was in the budget, but what was in the budget was home health or home care services. Did that receive an increase?

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Yeah. Sometimes there's some confusion. So, my modus provide this, the licensed home health care in the home. That's things like nurse, PT, OT, doing wound care, physical therapy, etcetera. But they also provide under the choices for care at home program, the long term care services that are things like homemaker services, assistance with activities of daily living, nutrition, personal care, things that help people kind of age with dignity in place. And those services under the choices for care program were in the Dale budget. So we got with in house human services. And I think sometimes there can be what I found is that a lot of times when people hear the term home health, what they think of is whatever their personal experience with a home health agency has been. Is it themselves or their family member getting post acute care after a knee surgery? Was it hospice during the passing of a relative? Was it a family member who needed some supports to be able to remain in place? So it can be really different depending on what their personal experience is. And so I think that was part of what happened in some of the confusion. And those, the choices for care at home rates did receive a very substantial increase last year because there had been a DIVA rate study. So there was an increase to bring up rates to 100% plus inflation of the rate study.

[Alyssa Black (Chair, House Committee on Health Care)]: I think we certainly understand that there is a difference between I think it was a surprise that I will just say that I personally will advocate much stronger this year to ensure that everyone understands that there's a difference between the two. Thank you.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Thank you so much and thank you for clarifying.

[Rep. Brian Cina (Member)]: It's It's so important.

[Alyssa Black (Chair, House Committee on Health Care)]: BMAs rise to our priorities.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I appreciate that. I also did try to make it easy this year. We're a part of a long term care crisis coalition that HHS will be advocating for those long term care and ask there is a 3.5% inflationary increase. So if I'm asking for 3.5 in here, just need to keep saying 3.5, 3.5 across the board. And hopefully that's helpful. To back up, touched on something that's really perfect and I always try to talk about when I talk about the home health agencies that VMAs of Vermont represents. We represent eight home health agencies across Vermont. There were nine as you recall, we did have the closure of an agency in Franklin and the agency that covers the Rutland and Bennington areas were able to assume their service territory and continue to provide services without interruption. Don't There is another agency by ADA that's statewide. They're not a member of the Invasive Vermont, but we do communicate with them a lot as well on issues that impact health care. As a component of the broad range of services that the home health agencies they represent provide, as I talked about, they do that skilled licensed home health care. The biggest payer in that is Medicare. But they also do health screenings and vaccinations. And there's a maternal child health, family health set of services that a number of my members provide as well. We're hitting that kind of early development, early life spectrum, the long term care that we just covered, and then also the hospice and palliative care end of life. So it really is across the spectrum of services across the care continuum and also age ranges. We play a really vital role in the health system. The last data I have access to is that home health agencies were responsible for fourteen percent of discharges from the hospital. That's in comparison really close to the nursing home rates, about eighteen percent in that same data set. And in doing so, we work to reduce pressure on hospitals and long term care facilities. Oftentimes home is the lowest cost setting that someone can receive care. And we find often the same that people prefer to receive their care in. All of us generally want to be at home if we can. But with our partners across the care continuum, we recognize it's really important what we often see as somebody goes through their care journey and as somebody ages, they touch a number of different components of that care continuum. At some point, they will have a level of need that will be too great for care to be provided in the home, Or they might not have some of the other supports that enable them to be able to remain at home. So it's really important that we have capacity in our facilities so that people can get the appropriate level of care that they need and it's available and the beds are available. We also tend to serve a very vulnerable population, frail, older and disabled people with lots of chronic conditions, a higher rate than the average Medicare beneficiary. The data I've seen the average Medicare beneficiary in Vermont, about eight percent of them have more than three chronic conditions. But over eighty six percent of Vermont home health Medicare beneficiaries or Vermont Medicare beneficiaries who receive home health care have three or more chronic conditions. And that's just to say that the care that my member agencies provide is really complex and it's really important for the people who depend on their care. This, I think you're probably used to hearing in this committee of us every year coming with cuts from the feds. And I know that you're hearing that from a lot of different places. There's a lot of federal fallout that you're dealing with. In the home healthcare world, the feds cut about $1,800,000 of reimbursed permanent rate adjustment to the Vermont home health care landscape. So I'm not asking you to fill that hole, obviously, 1.8. But our ask for the 3.5% would certainly be a band aid on the wound. And it's coming from a backdrop of a history of pretty significant Medicare cuts. Over the last four years, almost 10% has been cut to the permanent rate. And what that includes this year is something that CMS has been threatening of a temporary adjustment to implement a clawback of prior rates that they believe were erroneously paid. They believe that they were paid starting in 2020 from the change to the current payment model, PDGM. We have some significant disagreement on that claim that they've made overpayments and so does our national association, the Alliance for Care at Home. There are a number of things that went into what they were looking at in that claim, including behavioral adjustments from what they've seen in the data of patients and providers since implementation of PDGM in 2020. I don't know if you all recall, but something else happened in 2020 that's had a huge impact on healthcare and

[Rep. Brian Cina (Member)]: that's

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: COVID. But that 3% temporary adjustment also marks the implementation of what we can likely expect to continue in following years because CMS has estimated that they have found over $4,000,000,000 in overpayments. And the 3% temporary adjustment they used as a cut to claw some of that back this year is about 10% of that $4,000,000,000 So it's potentially feasible we could continue to see a 3% temporary cut. I mean, the percent will differ, but about that same amount in the ten year recoup plan.

[Alyssa Black (Chair, House Committee on Health Care)]: Leslie, I just want to make sure

[Rep. Leslie Goldman (Member)]: I understand. So there's these adjustments of the federal because of

[Rep. Daisy Berbeco (Ranking Member)]: fraud? Is that right? Think that

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: they're alleging

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: Let's call it overpayment.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: When we changed to the payment model, their payment rates were higher than the cost of care that they were looking to cover.

[Rep. Leslie Goldman (Member)]: And that was nationwide?

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: That's their claim, yeah.

[Rep. Leslie Goldman (Member)]: So what we did in Vermont, maybe not that or everybody did it no matter what?

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I think that there and I wouldn't be the expert on that. And I'm happy to get some more information from my national alliance. I think there is just a fundamental disagreement in the data that they use to calculate whether or not the payments they made were overpayments. What I can say is that as of the last data I received from my members, all but one of my members were operating under red. They had operating losses for the 2024 fiscal year. I don't have 2025 fiscal year data yet.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: So could you of let

[Rep. Leslie Goldman (Member)]: us know about cash on hand of your members, cash on hand, that kind of financial data that we've seen for hospitals? Can we see it for your organizations?

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I'm not sure that I can ask. I can figure out because there's some data I, as an association, can or can't have access to. I don't know if I can have their cash on hand numbers. Would imagine I can. But I can try to figure out a way to follow-up.

[Rep. Leslie Goldman (Member)]: I mean, trying to understand in different sectors the impact of all this. There seems to be some common metrics and trying to understand that.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Yeah, I think it's slightly different depending on agency. Because although there's a lot that my member agencies share, their service environments are really different. The structure of their agencies are really different to meet the specific needs of their communities. Serving Chittenden County is a lot different than certainly Addison County.

[Rep. Leslie Goldman (Member)]: But thirty days cash on hand is thirty days cash on

[Rep. Debra Powers (Member)]: hand.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Yeah, certainly. So I can work to see what I can figure out there.

[Rep. Brian Cina (Member)]: When

[Rep. Debra Powers (Member)]: you say cash on hand, can you explain what you mean by

[Alyssa Black (Chair, House Committee on Health Care)]: I said it. I brought it up.

[Rep. Debra Powers (Member)]: Oh, you did all right? Actually said but that's okay. It's a

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: good point. When I think of cash on hand, I were to collect that to my members, it would be at current costs, how many days can you operate before you go under? Well, have your back. Burning down reserves.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: I understand

[Rep. Debra Powers (Member)]: that. I'm talking about cash on hand. These agencies have money that they've collected over the years, millions. Is that included in the cash on hand?

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I'd be very surprised if any of my members have collected millions and millions in reserves. I

[Rep. Debra Powers (Member)]: know there's a lot of money there, minutes.

[Rep. Leslie Goldman (Member)]: Central Vermont what?

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I couldn't speak for that. I don't know that's information from my member agencies. I just wondering if that part of

[Rep. Debra Powers (Member)]: their diesel crude would say it's cash on hand.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I think it would be. I think that cash on hand, but I'm not exactly sure what you're referring to. And I'd be pretty surprised if there is, let's say, reserves to be able to cover operational expenses that are that high.

[Alyssa Black (Chair, House Committee on Health Care)]: Vicky? Think if I recall, all the VMAs at Vaeda are non profits.

[Dan Barlow (Executive Director, People’s Health & Wellness Clinic; Board Chair, VFRC)]: Yes.

[Alyssa Black (Chair, House Committee on Health Care)]: So their financial information would be public. 990s. Well,

[Rep. Leslie Goldman (Member)]: I think it's an important point, if I may. Sure. Because we found out about reserves at other institutions that we then said, Okay, now time to use some of your reserves. So that's a question I think that may apply here. I think

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: thing. Specific numbers aside, and I can certainly follow-up and get to the committee information that you might need. From a philosophical standpoint, even if we're dipping into reserves with rates not receiving at least some sort of inflationary increase to try to keep pace with the cost of care, We're just digging a deeper and deeper hole in the future. And what I can say is if another, if the home health agency system collapses, so many aspects of our care continuum are dependent on that 14% of hospital discharges that my members take. And the cost is higher when people aren't able to go home and have to receive care in more expensive settings. So I would say regardless of some of those numbers, it is critically important we continue to ensure a strong and robust system of care at home.

[Rep. Leslie Goldman (Member)]: No, I think of that.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Some of the other pressures they're facing include workforce shortages. And as a result, and I think there are a lot of industries that have workforce crises. In the home health agency, that's often manifested too with an increased dependence on traveling nurses. Traveling nurses are more costly. And then you also are building that kind of organizational resiliency of future leaders, retained staff. The mileage rate continues to go up. That's another fiscal pressure. Wages, salaries and benefits all go up with cost of living increases that need to be made. And historically those Medicaid rates have been off pace of in the past, there have been Medicaid rates that are below the cost of care. The Medicare margins, because the payment was a little better could sustain perhaps a higher the ability to take a loss on more services. And that reality just doesn't exist anymore. So returning back 3.5%, we think it's pretty modest. Dollars 328,000 gross is what we're hoping we can get into the budget this year. I'm happy to answer any questions you may have.

[Alyssa Black (Chair, House Committee on Health Care)]: Anyone have any questions? I have one, but I certainly will defer to anyone else first. I just wondered if you're all I know it's only February, but I know that one of the complaints with the VNAs used to be the low reimbursements from Medicare Advantage. And one of the advantages of not having Medicare Advantage really anymore is that people go back to traditional. Are you seeing in the people that you're serving, are you seeing a higher percent have traditional Medicare as opposed to the Advantage? And do you think that that will make any difference?

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: I haven't seen updated data yet. I'm sure we will. If it's not available now, it will be soon. And I do think overall from a fiscal standpoint that might have a positive impact. It really is dependent there are Medicare Advantage plans that did pay better rates than others. But I think overall it would probably be a net positive to the kind of agency budgets. Now that is obviously not touching on people's access to the coverage that they want to need. I couldn't speak to that. But once I have any data that shows that I'll certainly share that with you. Great.

[Alyssa Black (Chair, House Committee on Health Care)]: Well, thank you.

[Eric Covey (Interim Executive Director, VNAs of Vermont)]: Thank you so much. And feel free to reach out anytime if you have any questions. Then also, we have MMR in the building too, so if you can't find it there, feel free to grab them. Really appreciate your time, thank you so much.

[Alyssa Black (Chair, House Committee on Health Care)]: Okay, last one, we can end a little earlier. Season is better than sticking around. It's powering through. Hi Amy, thank you for coming in at short notice.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: Sure, I hope you don't regret it.

[Rep. Leslie Goldman (Member)]: I hope you don't regret it. It'll do my very best.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: I'm almost into the Zoom, I'll be right there. I'm not going to share my screen yet, but I was able to make one slide for you, since this morning. Hopefully, when the time comes, that will work. I did submit a handout, which has some of the detail also. I'm not going to read the handout. It's just there for you to outline our request. Is it okay to Yes, start. So for the record, Amy Schollenberger. I'm actually representing several of my clients and also a coalition that has formed, which I will explain. And I'm pretty excited to bring this request to you, and I really appreciate fitting me in today. Thanks for making the time. So the request, just to be clear, is we're asking you to support an appropriation of 4,950,000.00 in FY27 to support benefit assisters and community service providers to help people who will still be eligible for SNAP, Three Squares Vermont and Medicaid to stay connected to those benefit programs and to be able to continue receiving their federal benefits that they are eligible for. And also possibly enrolling people who are eligible and don't know it. This proposal is very specific to making sure there are resources and capacity for those two federal programs, but I want to be clear that all of the organisations involved in this proposal, which you can see on the second page of the handout shows all the logos are there for everybody who has a request included in here, they all serve different populations, and so they will also be checking to see if people are eligible for LIHEAP or WIC, depending on who they're talking to and what's the situation with the person, they're not going to say, Oh, I can only talk to you about SNAP and Medicaid. But the reason we're focusing on SNAP and Medicaid is because those are the two programs that all of these organizations will commit to, that everybody will say, We're helping with SNAP and Medicaid, and then the other benefit programs will depend on the population that they're serving. So we didn't want to list them all out and then have an expectation that everybody's going to screen for WIC, even if they're serving older Vermonters, so just to be clear about that. And you'll notice the number is different than the original handout that I shared with some of you, And I want to clarify that when we were meeting with some of the Human Services Committee members, they raised a question about the recovery center's request being in here. So we followed up with the Recovery Partners of Vermont, and they decided that it was more appropriate for them just to have their request go through the normal channels and to not be part of the benefit assisters' request. And so that reflects the difference in the original proposal and this number, which is $800,000 So some of the recovery centers will do this now and will continue to do it. They didn't feel like they could stand up every recovery center doing this in the timeframe that's imagined in this request when they were asked that specific question. So that's just a nice clarification that happened as a result of discussion in committee down the hall.

[Alyssa Black (Chair, House Committee on Health Care)]: We don't deal a lot in that realm. When we're talking about recovery centers, what are we talking about? I always think of it in terms of hubs and spokes. You might

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: know them as the turning points. Okay. They're the places where you can go to an AA meeting or just go in and get some support from a peer. And Meg, first on my team, represents them directly, I'm sure she can, I believe Recovery Day is tomorrow? So we'll hear all about it tomorrow. So what I'd like to do now, if it's okay with you all, I just kind of want to tell you a little bit of how did this happen, and why are we bringing this proposal to you, and how did we build the request. So it started last spring. So last spring, myself and my team at Action Circles were starting to see what was going on with the federal impacts, and we realized there was going to be a lot coming down, that our clients were going to need to take into account when they were coming to you this year for proposals or requests. Last spring, first we built an assessment tool for our clients to use to talk about how they were connected to the federal government, what money they got through the state budget, what money they got directly from the feds, what could be impacted, what they we asked them to check-in with their national partners. And so we got a sense of what was the scope of just our client base for impacts, and it was vast. And it was alarming. And so then we built a framework for our clients to use over the summer. We have a normal process we go through every summer and fall with our clients to sort of figure out what's the next step in your policy goals, what's the next step in your budget goals. A lot of them are working on three to five year plans with us, and we knew that that needed to be assessed within the context of the federal impacts that are happening. So we built this framework for our clients to walk, to work through, that really asked them to take into context what was happening for the people they serve, and also what was happening in their organization as they were losing federal money or having different rules be imposed on their programs. And what happened organically is a few of our clients came up with the proposal independently for benefit assistance. And many other things happened. That was one of the things that happened. And so we started talking as a staff about this proposal. And then we started noticing other organizations who weren't our clients talking about this proposal. We saw some op eds, for instance. We had some email seeing some email updates that were subscribed to. And so in the fall, I went and testified about it briefly at the joint fiscal committee to just raise it as a thing that probably was coming. And then we started hearing from more people, Hey, we are thinking about this too. One of our clients is Hunger Free Vermont, and they, as you know, are completely committed to having people who are eligible to be on SNAP, to stay on SNAP, to get their SNAP benefits. And so they said to me, We would like you to build a coalition. We'll support a little backbone. And so another organization, United Ways of Vermont, has a Working Bridges program, which you may be familiar with. They connect with employers to support workers to get assistance with different benefit programs. And so Working Bridges, Hunger Free Vermont, and Action Circles worked together. We created a survey. We sent it to every organization we could think of. We sent it to Common Good Vermont. They sent it out. We just asked, Hey, are you thinking about doing this? Would you commit to both SNAP and Medicaid? Would you come to a meeting? And we got a pretty big group of organizations who expressed interest and wanted to be part of this proposal. We started having meetings. And then together, that coalition talked through, and it's a wide range of groups. I don't know how familiar I'm know not as familiar with your committee, so I don't know who are the regulars in here. But some of these organisations are quite small and don't have a lot of resources or serve a very specific population. And some of them are much larger and have a lot of capacity. And it was really nice to see them supporting each other in figuring out what would you need to make this happen. So we built another tool. I don't take credit for this tool. United Way has actually really helped. We have a giant spreadsheet. Every organization got a tab. Everybody talked through what are the different categories of budget that you should be thinking about, and then everybody sort of filled in their numbers. And this is the slide I'm not going to share the spreadsheet, I just want to share one piece of it. Me see if I can do

[Alyssa Black (Chair, House Committee on Health Care)]: that. Embarrassing myself.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: So this just shows from the spreadsheet the breakdown of the expenses that everyone sort of plugged into the proposal. So as you see, it's mostly people. The whole point of this is that these community service providers are the trusted place that people go to get help. They're already coming in the door at these places. These are the people that can say, I get it. It's a confusing letter. Do you want me to walk you through it? Well, let's see, we need to get your pay stubs. Let's figure out how to make that happen. I don't know what your all's lived experience is, I can speak for myself, I've been through this. This is a nightmare. Even if you are a very organised person, it's a nightmare to have to provide pay stubs every month for a benefit programme, especially if you're working multiple jobs. When my child was young, I was on SNAP, I didn't live in Vermont, and I had to report my work every month. And I had anywhere between four and seven jobs in any given month. And I got paid on different days every month. I didn't have a regular pay schedule, and that was all by mail back in that day, right? And if you did it wrong, you got kicked off, right? And so it's really stressful, And it's really nice to have someone who will say, I get it, it's stressful. We can do it. Let's do it together. So the vast majority of this money is supporting staff people, and each organisation is doing it differently. Depending on the organisation and how they work with people, some of them are adding a staff person. Some of them are adding capacity to the staff people they already have. Like, maybe they have part time staff people and they're going

[Rep. Debra Powers (Member)]: to bump up their hours.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: Some of them, it's a combination. And then the rest of this is, they're going to all have to get trained, they might need to buy laptops for some of their staff people who don't currently have them, or an iPad or something. Some of them are going to the people to help them get their services, like you heard Naomi earlier talking about for just the help going out to people. They're not in this proposal, but same idea. And then, just the expense of having people working as well as supplies and other. The other thing that's in supplies and other is the Remote Language Justice Project is not getting the benefit assistance, but they're in this proposal to do translation, to make videos, or to help folks with handouts or something like that. So that's in that big chunk as well. So this just shows you the big breakdown, and am happy to provide more detail to you. I just didn't have time to do it between finding out this morning and being here this afternoon. Does anybody want me to heat this up? Otherwise, I'll

[Alyssa Black (Chair, House Committee on Health Care)]: No, it's good

[Rep. Debra Powers (Member)]: to hear. A we

[Alyssa Black (Chair, House Committee on Health Care)]: sense it's a lot of organizations We have a sense of how many actual

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: individuals I do have that in this charge, and that's what I just didn't have time to add it all up. There's a lot going on today. I apologize. These various organizations must serve some of the exact same populations. There is some overlap. We did talk about that in the coalition, like, what if there is overlap? And the coalition came to the conclusion that that's not necessarily a bad thing. There's not a lot of overlap, honestly, in the populations. Some, you know, like, obviously the caps cover a lot of the ground and a lot of people, and they might overlap with some of these other providers. Same for Planned Parenthood. But the idea is that most people have the place they feel the most comfortable going, or the place that they're already going on a regular basis. If they're a person getting services. And they might have a case manager in one of these places, or they might have a social worker or somebody they're used to dealing with. And we really wanted to make sure that the proposal allowed for people to go to that trusted place. Also, maybe for people who don't have, maybe SNAP or Medicaid is the only program they're on, they're not visiting a food shelf on the regular basis or whatever. So some of these other providers are more like a catchall. They can go to this place, or maybe they call 211 and say, I'm totally lost on my snap. I don't know what to do. And they're going say, Okay, well, where do you live? Here's their closest provider. You can go there and get benefit assistance. So we don't want a lot of overlap, but we did want some to make sure that no one would just be left out in the cold with no help.

[Rep. Leslie Goldman (Member)]: Yes, go ahead. So I'm just noticing, I'm seeing for the first time, of course, maybe having a headliner too deep, but you write in here what we would collect on the number of staff who are certified benefit assisters through DIVA. And I'm just wondering about DIVA's role in this and the overlap there. So are we paying DIVA staff through their budgets? How's that all intersect?

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: So I'm not an expert on the inner workings of DIVA, and I would encourage you to ask them directly. But I did meet with them at the beginning of this to just, first of all, make sure the training would be available to people and that there would be an ability for people to get certified as insisters and do this work properly. And what I know from that is that they do have a program. You could become a benefit assistor if you want to. It's basically a one day training, and then you take a test. And they also have additional resources. My understanding is they have a monthly work group that meets that anyone can come to and ask questions if they're bumping up against some weird technical confusion. Can also, they have you can call and ask for help. And they also have a library of resources for the benefit of sisters so that they can sort of access different documents if needed. On the SNAP side, Hunger Free Vermont is the trainer for the SNAP outreach folks, and they have some funding in this request to make sure they have the capacity to continue to offer that training to all comers as well, and they would help on the SNAP side for the training.

[Rep. Leslie Goldman (Member)]: Are there other states that have this function like this?

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: I don't know. The federal rule changes are relatively new. So I suspect that, you know, just as it was a pretty organic thing that happened here, I'm sure it's happening in other states, I just don't know.

[Rep. Leslie Goldman (Member)]: So, probably unifying organization yet?

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: No, I haven't heard of any national group recommending this or anything. Oh, sorry. I'm not supposed to.

[Rep. Brian Cina (Member)]: Would an organization that said that not on this list, if they knew about this, would they be able to connect and get them? Well,

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: that's kind of up to you. So this funding request is for these organizations. Like I said, we did try to get the word out pretty widely. And certainly, this is not like a closed coalition or anything, but I think if more organizations came in, then we would need to ask you to consider more funding to support more organizations. And one of the things we've talked about a lot in the coalition is, obviously, this will be a multi year request, assuming there's not dramatic fundamental change at the federal level, making it easier for people to get their benefits. And so as we work to stand this up, there might be other organizations that come in a year or two, or we might come back and say, Hey, we learned this thing, and it would be better if we did it this way. We're not pretending like We have every answer to how this is going to roll out. And we fully expect that come next January, we'll be coming back to tell you how it's going so far and potentially saying, We learned this thing. Or maybe this organization found nobody needs it, or whatever. I think that won't be the case. But we would definitely be assessing that. The reason we listed out the parameters of what everybody has agreed to report on, and again, obviously this is your decision as well, if you think these aren't the right things, Because these organizations aren't necessarily connected in any other way. And so we're really hoping that if you approve this funding, and I have been talking to folks downstairs about this, that these organizations would be able to get the funding in the normal way they get it. So not putting an additional burden on DEVA, for instance, to write all these new grants. The easiest example for me is the parent child centers have an integrated grant. It could be added to their integrated grant. There's a process for that already. It's well established. And these reporting metrics could then just be added to their grant proposal or their grant agreement, sorry. And the same for all the other groups. But that way, you get a consistent set of data across all of the organizations, which I think is not necessarily how it often goes.

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: The question may be for people that know more, isn't Diva also asking for more funding for this very thing?

[Alyssa Black (Chair, House Committee on Health Care)]: Diva is asking for 12 new positions, I believe. And that would just be for the Medicaid piece. Don't know what

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: DCF to, Dale? I mean, to CCF, yeah, it's in economic services.

[Alyssa Black (Chair, House Committee on Health Care)]: And I wonder if we

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: have highly qualified, folks. Does that make less people necessary, like it's easier to process it because you have a,

[Rep. Brian Cina (Member)]: I don't know, it's just a

[Naomi Wolcott-MacCausland (Program Lead, Bridges to Health)]: question I have, a good methodology. Great question.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: Yeah, so I can't answer for DIVA or DCF, but my understanding from listening to the testimony is the increase, most of the increased capacity they are asking for is because they are expecting to process a lot more paperwork. It's not necessarily to outreach or to help people file the paperwork. It's just to deal with it when it comes at them. And so I would want you to ask them directly, but my understanding is this would be a different thing than what they are asking for.

[Alyssa Black (Chair, House Committee on Health Care)]: Yes. That's for them to process all the paperwork that these people would be assisting the person getting all the paperwork so that they can send it to new people to process all the paperwork.

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: Yeah. And also, again, I'm no expert. I've been learning a lot in the past three months about both SNAP and Medicaid. But my understanding is once you're a certified Assessor, you can actually help to process the paperwork. You can upload it into the system.

[Alyssa Black (Chair, House Committee on Health Care)]: That an Assister or a Navigator?

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: I think it's both. I think my understanding of the difference between a Navigator and an Assister is a Navigator has a very specific contract with Diva and Diva pays them. And actually, when I met with Diva, they said, please don't use the word navigator because the assistor is a different thing. But it's a similar job. It's just, dealt with differently in the department.

[Alyssa Black (Chair, House Committee on Health Care)]: Thanks, Amy. Thanks for coming in. So on short notice, so we'll have conversations with, Human Services. Have you been in to see them testified yet,

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: but I've met with most of them, and, Chair Wood has been asking many witnesses who are in the chair if she knows they're involved in this about So there has been some sort of ad hoc testimony happening. I looked through the list and

[Alyssa Black (Chair, House Committee on Health Care)]: I'm picking out human services, healthcare services. We'll get together. And they deal with SNAP and we're really concerned about the Medicaid. Medicaid. And just so

[Amy Shollenberger (Policy Advocate, Action Circles; representing a Benefits Assisters coalition)]: you know, House Addison has actually also taken testimony on this because of their food resiliency piece, they're interested in the SNAP side of it as well. Alright, thank you. Yes, thank you.

[Alyssa Black (Chair, House Committee on Health Care)]: Thanks everyone. We can go off of live and

[Rep. Debra Powers (Member)]: we'll

[Alyssa Black (Chair, House Committee on Health Care)]: be back tomorrow morning.