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[Rep. Theresa Wood (Chair)]: Okay. Welcome back. Welcome back, committee members. It's nice to see everyone. And in the second year of the biennium, we get right going. So we're doing that on the first day of the session. We are digging right into H-five 45. And to start us off, we're going to have Legis Council Katie McLinn give us a walk through of the bill. And it is on our website. And I would ask that you look at draft 1.1, which has some modifications that Katie has done since the initial introduction of the bill just this morning. So welcome, Katie. It's nice to
[Katie McLinn, Office of Legislative Counsel]: see It's you nice to see everybody. Happy New Year. And just before we start,
[Rep. Theresa Wood (Chair)]: as I sort of forewarn people, we're going to do introductions around the table. And my name is Theresa Wood. I serve Bolton, Buells Gore, Huntington and Waterbury.
[Rep. Anne B. Donahue (Ranking Member)]: Anne Donahue from Warfield, also at the Wynn.
[Rep. Daniel Noyes (Clerk)]: Good afternoon, Noyes. I live in Wilkett, and I represent Wilkett, Hyde Park, Johnson, and Belvedere.
[Rep. Eric Maguire]: Hi. Good afternoon, Eric Maguire, representing Rutland City.
[Rep. Brenda Steady]: In the Steady, West Milton no. East Milton, Westford. Forget where I am.
[Rep. Doug Bishop]: Doug Bishop representing Colchester's Chittenden Twenty District.
[Rep. Zon Eastes]: My name is Zon Eastes. I live in Yoplin and I also serve right now.
[Rep. Esme Cole]: I'm Professor May Cole, I represent Hartford.
[Rep. Theresa Wood (Chair)]: I represent
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: Essex and Essex Junction.
[Rep. Brenda Steady]: We're in Morris, committee assistance, and then
[Rep. Theresa Wood (Chair)]: we go right around the room. Sure.
[Rep. Brenda Steady]: I'm Mary of Palmetto, I'm the Immunization Program for the Joint Death.
[Dr. Rick Hildebrandt (Commissioner of Health)]: I'm Yvonne Applin, I'm working as a lobbyist for more strategies.
[Rep. Brenda Steady]: My name's Ren Tetra, I'm a UVM student and I'm working underrepresented Rollins.
[Rep. Theresa Wood (Chair)]: Thank you all for being here this afternoon. Appreciate it. And just for people who haven't been in a committee room before, only the people at the table are recognized for discussion or comments or questions. If you have something that you want to say or whatever, catch me on a break, or you can also send a note to Laurie, our committee assistant. So welcome. And we were just doing introductions, so you walked in just at the right time before we get started, if you want to introduce yourselves.
[Rep. Doug Bishop]: Great,
[Rep. Theresa Wood (Chair)]: nice to see you.
[Katie McLinn, Office of Legislative Counsel]: Let's go, Katie. Okay. Katie McLynn, Office of Legislative Counsel. I will pull up draft 1.1. And you might be wondering why are we working off an amendment and not as the bill is introduced. When these bills were when this bill was released yesterday online, got some frantic emails from the health department and DFR about two sections that had been dropped. Sure enough, you should always. So I put together an amendment quickly. So the first half of the bill is exactly what is in the bill is introduced. Second half of the bill has two sections that should have been picked up on the first pass. So that's what we are looking at. As you know, this bill deals with recommendations for immunization schedules. Right now, if we I'm just gonna scroll to this definition. Right now, we have a definition of immunizations, and you'll see that it means vaccines and the application of vaccines as recommended by the practice guidelines for children and adults established by the Advisory Committee on Immunization Practices to the CDC. And really, the heart of this bill is changing that amendment. So instead, the term would be recommended immunization, and that would mean immunizations and the application of the immunization as recommended by the practice guidelines for children and adults established by the Commissioner, our Commissioner of Health, pursuant to section eleven thirty a of this title. That's new a new section that's being created in this bill. So eleven thirty a will set forth a process by which the commissioner would consult with experts on immunizations to develop a list of of the vaccine schedule. So how this definition is used, we'll take a look at it. But it's used not only to set the schedule for immunizations in the state, but also it governs what vaccines are reimbursed and how that process is paid for by insurers. So we've already covered the definition. I'll keep moving. In subsection b, we have language that establishes program that's administered by the Department of Health that has two goals. The first is universal access to immunizations for the recommended immunizations for everyone who's domiciled in the state. And these would also be at no charge to the individual. The second goal is reducing the cost at which the state may purchase recommended immunizations. We have language that the department shall purchase, provide for the distribution of and monitor the use of recommended immunizations as provided for in this subsection, The cost of the recommended immunizations and an administrative surcharge shall be reimbursed by health insurers as provided for in the following subsection. So you're seeing that the underlying structure is the same, but the terminology recommended immunization is what's being changed here. So just to be clear, Katie, it's already a requirement for health insurers to pay for immunizations. Yes. And this just changes how the list of vaccinations that are covered is produced. Okay. Yeah. Just quickly, Donahue. Yes. Go ahead.
[Rep. Eric Maguire]: So there's no cost sharing going on. The insurance company is 100% required to pay for all vaccinations?
[Katie McLinn, Office of Legislative Counsel]: It would be the sort of the status quo. So right now they're covering it for vaccines as defined in current law. And so they would be required to cover recommended immunizations as defined in this bill. So then the cost would be the same. We're just sort of shifting how that list of what's being covered would change.
[Rep. Eric Maguire]: So again, no cost sharing. It's 100% on the insurer to pay for the vaccine. Yes.
[Katie McLinn, Office of Legislative Counsel]: In subdivision two, again, we're keeping the existing language. The section requires the health department to solicit, facilitate, supervise participation of the health care community insurers to accomplish the goals of the program. Subdivision three, again, underlying language has to do with data collection and review. Subsection c, currently, in current law, the state is required to purchase from CDC. This proposed language has the health department determining which immunizations to purchase under the program and allows purchase from vendors other than the CDC. So they still could purchase from the CDC, but this allows purchase from another vendor. In Subdivision D, we have language that distribution of immunizations to healthcare professionals and facilities for the administration to patients. Again, this is maintaining existing law. We're just changing the terminology. In Subdivision H, we have that health insurer shall remit to the department the cost of recommended immunizations as that cost is established by the commissioner based on the recommendations of the Immunization Funding Advisory Committee, so existing committee. And what we're changing there is the terminology vaccine to recommended immunizations and how that list was developed. In subdivision f, this is language about a surcharge from insurers to a special fund to administer the program. No changes there. In Subdivision G, this is the Immunization Funding Advisory Committee that was referenced to subsections ago. This language establishes this group and the purpose of the group is to provide the Commissioner of Health with an annual per member per month cost for recommended immunizations for the pediatric population. Same thing for the adult population and a recommendation for the amount of the yearly immunization assessment. And then we have a list of who is on this committee. There are no changes to that committee. So I might just Unless we want to pause.
[Rep. Theresa Wood (Chair)]: Can I pause just for a I'm sorry? I need to go back to E, paragraph e. So it says health insurance remit to the department the cost of the immunizations as that cost is established by the commissioner. I'm not can you explain what that means? It sounds like the insurers submit what it's costing them to pay for these vaccines, and then the commissioner establishes it based on that? I'm not sure what that means.
[Katie McLinn, Office of Legislative Counsel]: I believe, and I'm sure the department will correct me if I get this wrong, that there is a surcharge to the insurers for every immunization that's administered to somebody within their covered population. And that that surcharge is omitted to the health department to go into a special fund to pay for this program. And if I have gotten that wrong, I would absolutely welcome a correction.
[Rep. Brenda Steady]: Excuse
[Rep. Anne B. Donahue (Ranking Member)]: me. That's okay.
[Rep. Theresa Wood (Chair)]: Okay, we'll ask that same question.
[Rep. Brenda Steady]: So
[Katie McLinn, Office of Legislative Counsel]: we were in subsection G. This was the advisory committee. The membership is the same. In Subdivision 2, we have language about how that committee chair is selected. That's unchanged. In Subdivision 3, we have language that on January 1 of each year, the committee shall provide to the commissioner the annual fiscal assessment of the per member per month cost for the pediatric recommended immunizations. Same thing for the adult population. So, again, we're just changing that terminology. Subsection h. If purchases if purchase requirements do not further the goal of ensuring universal access to recommended immunizations for all, the Commissioner may, following consultation with the Immunization Funding Advisory Committee, discontinue the program with six months advance notice to all health care professionals and insurers with covered lives in Vermont. So again, that concept stays the same. We're changing the terminology. And we have language to adopt rules, unchanged. What is new is Section two, recommended immunizations. So if you remember, when we were looking at the new definition, it cross references another section. This is the other section that it's cross referencing. So that definition says that the commissioner can determine what the recommended immunizations pursuant to this section. So this sort of gives the guardrails about how those immunizations are selected. So first, in subsection A, we have recommendation the types of recommendations that the commissioner can make. So the commissioner shall periodically issue recommendations regarding which immunizations children and adults should receive, the recommended age at which each immunization should be given, the number of immunization doses that should be administered, the amount of time between doses of an immunization, and any other recommendations regarding immunizations necessary to ensure the maintenance of public health and disease prevention in the state. And then we turn to subsection b, prior to issuing the recommendations the commissioner shall. First, consult with the Vermont Immunization Advisory Council. We'll look at that council in a bit. Second, consider recommendations for immunizations issued by CDC's Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and any other organizations the commissioner may deem necessary. So that is what is informing the commissioner's decision. In subsection C, a health care professional who prescribes, dispenses or administers an immunization in accordance with the recommendations issued pursuant to subsection a of the section shall be immune from civil and administrative liability for immunization caused adverse events unless the health care professional's actions regarding prescribed dispensing or administering an immunization constituted gross negligence, recklessness or intentional misconduct. This language is pulled from your statute on opioid antagonist that has sort of similar immunity language for the administration of an opioid antagonist. Subsection D, the Commissioner may issue a standing order authorizing health care professionals, including pharmacists, to prescribe, dispense or administer recommended immunizations or any combination thereof to the extent that prescribing, dispensing or administering recommended immunizations is within the scope of the health care professional's scope of practice. Again, some of this language is pulled from opioid antagonist, where there's also language and statute giving the commissioner standing authority to issue a prescription in that case for the opioid antagonist. So that's sort of where some of this language was modeled on. Subsection E, we have a definition of healthcare professional and recommended immunization. They have the same meanings as in this section we just looked at, eleven thirty, section one of the bill. It's stupid. And then in section three, we have the Vermont Immunization Advisory Council. As you'll see, this is existing language. So this advisory council already exists. And I'll just go over the purpose so we're all familiar with what it does. The purpose is providing education policy, medical epidemiological expertise and advice to the department with regard to the safety of immunizations and immunization schedules. And then we have some changes to the membership of this group. So in subdivision b three, currently, it's the state epidemiologist. The addition is or designee. Adding to this council, the Department of Health's immunization program manager designee. Subdivision five, a practicing pediatrician. This just adds in that that person is licensed in Vermont. Subdivision six, two individuals who are professors, researchers or physicians licensed in the state or any combination of these individuals with expertise in infectious disease and human immunizations appointed by the governor. Subdivision seven, a family or internal medicine physician licensed pursuant to this to licensed under Vermont appointed by the governor. So another new addition to the membership. And then subdivisions eight and nine are existing members, and we're just renumbering that list to account for the new members of the council. In terms of the duties of the council, the council is now providing advice about what is a recommended a recommended immunization under 11:30. So that duty has been added to the list of duties in this section. In terms of assistance, the council currently has the administrative, technical and legal assistance of the Department. The proposal here is to just have the Council having administrative assistance from the Department, not technical or legal assistance. In subdivision E, we have language about the meetings. The council shall convene at the call of the commissioner, but no less than once each year. So that time frame, but no less than once each year, the proposal would be to eliminate that language. And that brings us sort of to the end of the bill is introduced, if you're following along on that document. This next section has to do with insurance coverage. So in section four, we have language that covers group health plans generally.
[Rep. Theresa Wood (Chair)]: Page? Is that a
[Katie McLinn, Office of Legislative Counsel]: I'm on draft point So it says different page.
[Rep. Theresa Wood (Chair)]: So page nine of 1.1. So if you
[Katie McLinn, Office of Legislative Counsel]: look at draft 1.1, page nine, north of top of that page. So again, this section covers group health plans generally. Protections for covered individuals and subdivision four, no cost sharing for preventative services. And then we have language that a group insurance policy shall not impose any co payment, coinsurance or deductible requirements for, and it now says recommended immunizations as defined in 11/30 instead of the language referring back to the ACIP, the Advisory Committee on Immunization Practices. You'll see nearly identical language in section five. This section has to do with health insurance plans that are offered to the individual non group plans in the small group market. So this would be mostly Vermont Health Connect. And then we have the same language. A health benefit plan shall not impose a co payment, coinsurance or deductible requirement for recommended immunizations as defined in 18 BSA eleven thirty instead of referencing the Advisory Committee on Immunization Practices.
[Rep. Theresa Wood (Chair)]: Effective date, 07/01/1926. Thank you, Katie. Okay, so now we will take any questions on the content that Katie may be able to ask. I I see representative Donahue. It was there okay. Representative Donahue.
[Rep. Anne B. Donahue (Ranking Member)]: Just a bit of a technical correction, but I know we've had back and forth in terms of language about when appointing somebody by title implies and legally means you can have a designee versus being explicit, it can only be this person versus. And in the second group, second advisory group, say or designee for some, but in the first one, A and B is a specific person and it doesn't say or designee, it doesn't say one way or the other. So just Right.
[Katie McLinn, Office of Legislative Counsel]: Thank you.
[Rep. Zon Eastes]: Representative, just I have a couple of questions. I just wondered if page two, go there, section c. Me just make sure I'm around the question of lowest available cost. There's an option for purchasing immunizations from CDC or another vendor at the lowest available cost. I'm thinking about the notion that there might come some sort of condition from the federal government about how, whether or not they could be purchased, immunizations could be purchased from CDC. Mean, we can't anticipate, but I just want to get any thought that's put into that.
[Rep. Theresa Wood (Chair)]: Why don't we leave that question for the department when we come up?
[Rep. Zon Eastes]: Then another question I have about page six is just who would be considered for considering or creating the list of immunizations? And I just would be interested to know if there's a consideration for potential. I imagine many states across the nation are doing the same thing at this moment. So maybe this is a question for later, but wondering about confirming with other states if that could be it.
[Rep. Theresa Wood (Chair)]: We will ask the department that. Okay. Any other questions? Representative Estes, was that it?
[Rep. Zon Eastes]: No. I can make. Yeah.
[Rep. Brenda Steady]: Oh, okay. Representative Steady? On page nine, number 11, the council convened at the call of the commissioner, but no less than one year. So it could be five years. I mean, there's no no expectations of having a meeting.
[Katie McLinn, Office of Legislative Counsel]: The proposal leaves it open ended.
[Rep. Brenda Steady]: Okay.
[Rep. Theresa Wood (Chair)]: Are there any payment provisions for the council members and other parts of the statute that are covered in
[Katie McLinn, Office of Legislative Counsel]: the ellipsis? Don't think so. I think I don't Well, let me see. We don't have ellipses here, so I would guess not for this particular group.
[Rep. Theresa Wood (Chair)]: Okay, we can double check with the department. And then I'm not seeing anything here. And I just want to make sure that I'm not misinterpreting it. There isn't anything in this section of law that is talking about the requirement for any particular individual to have a vaccine.
[Katie McLinn, Office of Legislative Counsel]: Correct. This is recommended. There are other sections in the chapter that deal with the school attendance and etcetera, but this does not cover
[Rep. Theresa Wood (Chair)]: Not at those for not dealing with those in this bill.
[Rep. Anne B. Donahue (Ranking Member)]: Okay. I'll just recommend it.
[Rep. Theresa Wood (Chair)]: Any other questions for Katie? Thank you so much, Katie. Appreciate it. Thank you for getting those extra sections. Okay, now we're going hear from Doctor. Gildebrandt. First, we're going to this is your first time in our committee. So welcome as the new Vermont Department of Health Commissioner. Pleased to have you here. Good to be here. We appreciate you taking on this task for the state of Vermont. It's not always easy, but I think Doctor. Levine would say that it had been rewarding at some level as well. So thank you so much for being here, and we will have the floor to you.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Okay, if it's okay, I was hoping to spend the first bit just telling you a little bit about myself.
[Rep. Theresa Wood (Chair)]: That would be awesome. Can just ask one question? Do you
[Katie McLinn, Office of Legislative Counsel]: have prepared testimony? We have some slides we'd like to share,
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: and I was trying to log in onto Zoom. Jessica? Yep.
[Rep. Theresa Wood (Chair)]: Okay. And if you could please send them so they can be posted. Thank you. Thank you. That would be great.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Yeah. So as you had mentioned, my name is Rick Hildebrandt, commissioner for health, and I'm almost I'm completing my third month, so still sort of new in the job. I came to this sort of role in a somewhat unusual way, I suppose. But when I started practicing in Vermont thirteen years ago as a hospitalist and inpatient doctor, there was a couple of things that became immediately apparent to me. One was that I could not solve the problems of my patients at the bedside. It's just the problems were too big and they extended beyond the walls of the hospital. And the second one was that there was a lot of decisions that were made that were not informed by clinicians. And it wasn't that people, administrators and other folks, didn't want clinicians at the table. They just a lot of clinicians didn't raise their hand when people were asking for that. So I started inviting myself to a lot of meetings, which found me on a leadership track and a series of promotions throughout the hospital and ended up in leadership and executive leadership. But in terms of helping my patients, really early on, I started reaching out with my community because I knew that working with the primary care community, working with community partners was going to be important. Initially, focused with the group on things like very tangible hospital things, readmission rates and ED visits and things like that, because we had patients who would continue to cycle through the hospital. We worked through a group that ultimately became something called the Rutland Community Collaborative. Did a lot of great work, had some great improvements in readmission rates, and that grew over time and included things like the VNA and the skilled nursing facilities and other health care partners. It grew to sort of everyone in, including the department about, in the community, which was really great. But still, it really wasn't making a huge difference. We still had the same challenges, and a lot of it boiled down to social drivers of health. We had the same issues would cause people to seek care because they didn't have access to healthy food or to transportation or to health care or to financial resources was a big one. And that had me reach out to other spheres that were not really within the hospital boards and commissions around the state. I joined the local board of the designated agency in Rutland. I joined the board of Vital. At that point, I was the chief medical information officer, which is this unique job in medicine. It's the intersection between providers and the EMR, which is challenging at times. But I had an interest in technology and data, so that sort of felt natural to me. I joined the board of sorry, the board of licensing for the for the state and served as their chair for four years, which was great, great work, and I enjoyed that a lot. And I had said to myself or I was a COVID czar during COVID as many of us got involved in that. I had said to myself for a little while if if and when Mark decides to step down that I would consider throwing my hat in the ring. And a lot of people sort of pushed me towards that as well, and I did. And after six or eight months of interviewing, I found myself in this position. State doesn't often have things move very fast. But, you know, since being here, it's been it's been amazing to see the work that the health department does. The people that work there are passionate and intelligent, and I've been blown away. I don't know what I was expecting exactly, but it was not this. I mean, they are really fantastic people that work there, that care a whole heck of a lot. And I've been learning a lot. I've been learning a lot about the department, about the work that they do, and I still got a lot to learn, which is good. But it's really been great and very encouraging for me. Do we have a slide that's we don't, Jessica? That's okay.
[Rep. Theresa Wood (Chair)]: Doctor. Hildebrandt, I didn't know how we we have down, Meredith and Jessica, it's up to you about how you wanna organize that. You're welcome. I'm not sure if there's we usually have some folding chairs over there that you can bring up or if they are just you I'm saying if you want to refer to them at the sidelines, that's okay as well.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Meredith will be joining at a little bit later on. Was gonna go through a couple of points. She's really the subject matter expert on immunizations and really the person who you can get a lot of the answers that you want from like the one that came up earlier. So I will entirely defer to her on that. But in a few minutes, we'll have her join us. So we did have a slide deck and I apologize that it's not up for you, but the next slide was just showing our mission, our vision and our values for the health department, which is important for us to reconfirm our commitment to Vermonters at this time. Another thing I didn't mention, one of the reasons I also was really driven to this position is just the attack on science and public health around the nation. It was a real calling to me, and the mission and the vision really spoke to me as well at the Department of Health and drew me to seek this position. Our framework that we use in public health so public health is kind of a hard change and defined for a lot of folks because they don't necessarily know always what it means. And if public health is doing its job and nothing bad is happening, that's the goal. So we use this framework of detect, connect, prevent, and respond. So I'll give an example, a very tangible example around pertussis. We had a number of cases of pertussis that we had detected in a region of the state that's called whooping cough, which is an illness we do vaccinate against. It's pretty terrible. I can tell you from personal experience, I had it myself when I was in high school before they did booster shots for
[Rep. Theresa Wood (Chair)]: We all have to get back into practice. There
[Dr. Rick Hildebrandt (Commissioner of Health)]: we are. Anyway, whooping pop is terrible, but there was a school in Washington County that had a number of cases. We respond we responded by providing the school community with resources on how to protect their themselves and their families. And then we alerted the area health care providers to help them prevent the spread. So it's sort of the detect, connect, prevent, respond approach that can be helpful. It goes beyond just infectious diseases. There's so many different things, and there's so many places that the health department's involved that I learned when I started here. But we regularly are connecting with health care providers and partners around maternal health outcomes, or when it's really cold or really hot,
[Rep. Todd Nielsen]: there are places where other people can
[Dr. Rick Hildebrandt (Commissioner of Health)]: go for a shelter, helping to manage healthy behaviors, quitting smoking, managing pain and other health problems, so, so much more that the health department does every day. As I had mentioned a little earlier, there's been a lot of turmoil in the national media and in our federal government. And in talking with my partners around the country, not every health department exited the pandemic unscathed. I mean, there's a lot of places that lost a lot of trust in public health. We did not Vermont. And I credit the health department and doctor Levine to that. It's a very trusted institution. And it's my job and it's our job to preserve that trust, because there's an attack on it right now. And I feel that very central to my job is to ensure that we remain the trusted source that people can go to to get accurate information, because we're going to see more and more information that we question the validity of. And we want people to know that you can always turn to us to get scientifically based information about health care.
[Rep. Theresa Wood (Chair)]: Your PowerPoint is up now.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Great. Okay. Just in time for some pretty pictures. We have great staff that work in our local communities, and they're great at connecting with their partners and making those connections. So here's a couple of our local groups. So we have on the left here is the community garden that was up in the Northeast Kingdom. And the right hand side is the local wonder feed children's museum in Rutland. And in the middle is a dental clinic that was set up by the St. Albans office because dental access has been such a challenge. I've heard that in many of the district offices that dental can be a real problem. Anyway, that's another way we can connect with folks and help preserve that trust in public health. So immunizations, sort of the reason we're here today. There's been a lot of false claims or falsehoods and uncertainty about immunizations. This is very, very meaningful as yesterday, just yesterday, there was a large press release by HHS on immunizations. And we've been working hard to ensure that Vermonters continue to have access to the right information and to vaccines. We're very concerned about what this could look like in the future. As it stands, there's no significant changes in the cost to Vermonters. So despite the changes in recommendations, they were very clear that, hey, we still have the ability to purchase these at the right cost and can distribute it to Vermonters. I'm not confident that's always going to be the case. I'm very fearful this is setting the stage for, okay, next year, now we're not going to provide coverage for any of the unrecommended vaccine. So we've been working with a large group of stakeholders to plan for this and prepare for this to ensure that we don't have any gaps. Gaps. If Vermonters need and want access to vaccines, we can provide. That includes loads of departments, including children and families, FEMA, the Department of Financial Regulation, and OPR, and the agency of education as well. So that's sort of the reason we're here today. We've tried to bring a lot of those changes to you all to bring to a bill and see if we can get this change so that we can preserve access to vaccines no matter what changes on the federal level. Meredith will join me now as she is really here to discuss some of the pieces of this bill and answer any questions that you'll have. But I'm also open to any questions that you have.
[Rep. Theresa Wood (Chair)]: It seems like we have a while we're getting a chair for Meredith, maybe next door, Maguire has a question.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Yeah. Sure.
[Rep. Doug Bishop]: What what are some
[Rep. Eric Maguire]: of the barriers and challenges that you've witnessed or seen up there on the field level in regards to the monitors having access to vaccines?
[Rep. Daniel Noyes (Clerk)]: Yeah, so
[Dr. Rick Hildebrandt (Commissioner of Health)]: access hasn't again, we've not seen challenges in purchasing or acquiring the vaccines or distribution right now. And those those are the two things that I'm worried about, both acquisition and distribution. Mhmm. Gotcha. Through the CDC, when we buy it from them, get it at group purchasing rate, they and distribute it directly to the primary care practices. So if we were to get a group purchasing rate, they don't distribute it, then that would fall to us, and that's the increased cost and resources that are required. We haven't had that issue yet, but we are worried that that may come. So currently, there's not been a challenge of distribution. There has been a lot of confusion. That's been the biggest thing I've had to battle is all the uncertainty and confusion that people have. Thankfully, we've got a lot of partners in this space that have helped direct people toward the right resources, which is their primary care physician, their pediatricians, their school nurses, their pharmacists, the trusted health care professionals, wants to answer the questions. But it's really been about information right now. I am fearful of what will come. There's also been some there was the sort of changes that came with the COVID recommendations months ago, which differs from what we felt was appropriate. And we had to meet the best I can come up with, we duct taped together a solution that really is not durable. And we need authority to really make recommendations that are in contrast to what Aesop is saying. Just to follow-up quickly, because you did touch on it, on the other thing in regards to the costing and did mention there was that concern.
[Rep. Eric Maguire]: And that's actually a concern that I have, and I know many people would with the rising healthcare costs and things like that. There was a potential with
[Dr. Rick Hildebrandt (Commissioner of Health)]: the insurer picking up 100% of it. How can we be assured that the premiums on people's insurance wouldn't go up? Yeah. So the science on this or the data on this is actually a little bit down. The reason we use vaccines is to prevent expensive and deadly illnesses. Flu is a great example. Flu shots reduce the incidence of ED visits at hospitalizations and ICUs, which can cost tens, if not hundreds of thousands of dollars for a shot that costs $10 to acquire, $15 to acquire. And when we approached Blue Cross Blue Shield about this bill and the changes, they didn't even bat an eye if we had to go to a different source. Mean, they are all in on, hey. This makes fine not only is it the right thing to do for people, it also makes financial sense to do this because it avoids huge costs if we don't do these vaccinations. So I agree. The financing of healthcare is super important. The data on vaccines is a slam dunk, though. It uses cost saving, not a cost generator.
[Rep. Eric Maguire]: And do you believe that currently at this time you have the infrastructure and capacity to where this could be rolled out smoothly and there wouldn't be many hitches or No.
[Dr. Rick Hildebrandt (Commissioner of Health)]: I mean, we are working on that diligently. So having a backup to an institution or a system we've had for decades is not something that we've been working to develop. So we don't have it today.
[Rep. Brenda Steady]: Thank you. Yes. Sam Donahue? Yeah.
[Rep. Anne B. Donahue (Ranking Member)]: So obviously, I mean, whole area of science is not an absolute permanent, unchanging knowledge And so I'm
[Rep. Theresa Wood (Chair)]: just wondering,
[Rep. Anne B. Donahue (Ranking Member)]: you're sort of, we're asserting that the CDC has gone in a wrong direction.
[Rep. Todd Nielsen]: How
[Rep. Anne B. Donahue (Ranking Member)]: do we identify direction and that they don't as the federal agency? Right, and that's at
[Dr. Rick Hildebrandt (Commissioner of Health)]: the crux of this. How do you get the right information? Which is why what we want to do is rely on a wide range of sources. We want to have a committee that has people who actually know this stuff and live it every pediatricians who see it every day, infectious disease doctors, the American Academy of Pediatrics and and Family Physicians who have been giving vaccine recommendations for decades, and they do legwork. Right? And they bring it to a committee or to me and say, here's what we think it makes the most sense based on this. Okay? But it's you're right. It may change. And and a good example of that is RSV. We didn't have an RSV vaccine five years ago. AAP has recommended that as a general vaccine because it's been so impactful in reducing hospitalizations and ED visits that they now recommend that as a routine vaccination that we didn't have five years ago because there's new evidence that says, hey, this is something we should be doing.
[Rep. Anne B. Donahue (Ranking Member)]: I guess my question is more to as a state and what we have access to as state resources, how can we assume that we are able to better identify that than the federal CDC?
[Dr. Rick Hildebrandt (Commissioner of Health)]: Yeah, and I don't know if better identify that is what I would say. It's more that we're going to rely on institutions and resources that have been in existence for decades. I don't know where or why CDC, I don't know where they came up with this schedule, I really don't. That's concerning to me. If I make a recommendation, I'm gonna point to, hey, here's where it's coming from. It's coming from these individuals with this resource, which is not gonna be just Vermonters. It's gonna be national experts or worldwide experts in infectious diseases.
[Rep. Theresa Wood (Chair)]: Thanks. Go ahead, Representative Bishop. Can you send the PowerPoint, please, to Laurie? I don't know she can share it.
[Rep. Doug Bishop]: Follow-up, I believe, the line of questioning from Representative Donahue. There's organizations and others that are listed as far as who would be consulted, whose opinions would be trusted, if you will. What I don't see on here, not that I know a lot about it is, I recall some reference, I think with respect to some COVID vaccine recommendations of like a
[Rep. Zon Eastes]: Northeast or New England contact.
[Rep. Doug Bishop]: Is that an organization that could be playing a role in this?
[Dr. Rick Hildebrandt (Commissioner of Health)]: So it's not an organization, it's part of the challenge, to be completely honest. The Northeast Public Health Collaborative is a slightly more formal arrangement than what it has been for ten years, which is all the state health officers in the Northeast talking with each other because public health doesn't obey state borders. So the epidemiologists in Maine and New Hampshire are gonna talk with our state epidemiologists when they have an issue. That group is in regular contact. So they sort of formalized it a little bit, but it doesn't have a structure yet. It doesn't have a charter. It doesn't have anything. Just get there working on that right now. But it's a great group to talk about these issues. So in full transparency, I heard about this press release thirty minutes before it was released because the New York Public Health Collaborative, one of the folks there emailed me and said, this is coming out in thirty minutes. And when people are making press releases and stuff, they're sharing it with each other so that people know, hey, here's what we are doing, which is really helpful, especially for me being new in this seat. I can hear from folks around the region who have been doing this for much longer and see what they're doing. Now our states are all different. We have different nuances in every state, but it's a really good resource. They're not something we should be naming because they're not a thing yet. That could change in time, but right now they're not.
[Rep. Doug Bishop]: Would I be understanding you correctly is they may not have a process that vet recommendations in the same way that the American Academy of Pediatrics, the American Academy of Dental Physicians, etcetera?
[Dr. Rick Hildebrandt (Commissioner of Health)]: Yet. And they very well may in the comments. Okay. Thank you.
[Rep. Theresa Wood (Chair)]: We have Representative Noyes and
[Rep. Daniel Noyes (Clerk)]: then Representative Nielsen. Thank you. I know that a lot of older Vermonters access to getting vaccines when there's real limitations to transportation. I was wondering if you could expand on any thoughts you may have on whether it's meal sites, senior centers, whatever, just to be able to get these immunizations.
[Dr. Rick Hildebrandt (Commissioner of Health)]: I agree. And I'll tell you, it's not specific just to older Vermonters. Certainly, that's a challenge. It's also health care workers. If you don't make it easy for them, it's hard to get someone vaccinated. If look at the vaccine rates within hospitals, they're not 100%. And the way they get doctors is they have roving teams of nurses that say, hey. It's time for your vaccine, and they give it to you. Okay? We should have that for everyone. Right? Because access is important. When people want vaccines, we should we should be able to provide it. And transportation is a challenge. Mobility is a challenge. I don't have solutions for this, but I completely agree with you that we should make it as easy as possible when folks are saying, hey, I need a vaccine to get it to them in a timely manner. So is this something that the Department of Health is gonna potentially look into? I don't know that. There's some work that we're talking about with paramedicine maybe in there, I don't know. But it's certainly something that's worth looking at.
[Rep. Theresa Wood (Chair)]: Represent Nielsen and then Represent Garofano.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Good afternoon. I am Todd Nielsen.
[Rep. Todd Nielsen]: I was gonna introduce myself directly.
[Rep. Doug Bishop]: Okay. That's okay.
[Rep. Todd Nielsen]: The I'm a little bewildered. Why are we not worried about the hazards of of immunizations and the vaccine, the COVID stuff? And why why would just keep pushing it? Yeah. I feel like it
[Dr. Rick Hildebrandt (Commissioner of Health)]: has to be he ate out.
[Rep. Todd Nielsen]: I'm on the vaccine, I'm one of those people.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Yep. I couldn't do it.
[Rep. Todd Nielsen]: My wife risked getting her job, risked getting fired.
[Dr. Rick Hildebrandt (Commissioner of Health)]: And a little damp. Yeah, so again, what we rely on is what the research shows us. Unfortunately, I did live through COVID and saw so many people die of it. My perspective is different. I saw loved ones expire because they didn't get vaccinated at a much higher rate than those who were. Are there sequelae of vaccines? The ones that have been documented are so minor that for things like flu shots and for hepatitis B that the benefits so far outweigh the risks, it's not even the discussion. With COVID specifically, everyone should make a personal determination. No one's pushing this on anyone. The people who do want access to vaccines should have it. And that's, you know, my my hope is to preserve that. If people have questions, say, What's my personal risk of this? They should talk
[Rep. Todd Nielsen]: to their doctor. One more question. Yeah. I have a problem with this. I have
[Dr. Rick Hildebrandt (Commissioner of Health)]: a problem with the state paying for it.
[Rep. Todd Nielsen]: People shouldn't be paying for themselves. Can't have what
[Dr. Rick Hildebrandt (Commissioner of Health)]: we can afford in this world. To be fair, the state, it's the insurers that are paying for this. So health insurers. That's okay. Thank you, I appreciate it.
[Rep. Theresa Wood (Chair)]: Yeah, absolutely. Representative Garofano.
[Rep. Golrang 'Rey' Garofano (Vice Chair)]: And you may get to this, so if you're going to get to it later. But I'm just wondering if you've thought about and if you have concerns about confusion out in the field between the recommendations from the feds, from the CDC, and what Vermont is kind of standing up to kind of
[Dr. Rick Hildebrandt (Commissioner of Health)]: I do. I have serious concerns. And that's, again, the biggest issue that I've been addressing right now is just the confusion that this has caused, not just in Vermonters, with health care providers, with everyone. Thankfully, we've got partners in the Vermont Medical Society, the Vermont Chapter of the American Academy of Pediatrics who have been vocal. And a couple of news media have reached out to me that I've been trying to help people understand, hey, we haven't changed. Here's our recommendation and have an updated website to reflect that. But I'm very worried about the confusion this is possible.
[Rep. Theresa Wood (Chair)]: Thank you. Okay, Meredith, I think we're going to actually let you have an opportunity to help educate us about some of this stuff. So thank you for being here. I neglected to say, and I think this is the first time that both of you have been here, generally people just say that for the record kind of thing and then state their names so that it used to be we only had audio. But now we have video as well. But for those folks who only listen and can't see, it's helpful for people to say their names when they just sit down and start to testify.
[Meredith Blunton, RN (Vermont Department of Health)]: I'm Meredith Blunton. I'm a registered nurse, and I've been with the health office. This will be my fifteenth year with the state. So a lot of that time has been doing immunization work and I'm really excited to be talking to you all today. So thank you for allowing us to come and chat. Doctor. Holtebrant talked a lot about the issues and how it would affect us in being able to supply vaccines to the primary care providers across Vermont. And we really wanted to look at all of the statutes across the different areas. And we found language for, DFR, which is Department of Financial Regulations. There's language in the health department statute. And then there's also language in the OKR statute. But the OKR statute, is separate. We are working really hard closely with them to align our language with what they're submitting. So we'll be in alignment. So
[Rep. Theresa Wood (Chair)]: I just want to ask a question about that. So OPR submitting separate language in a separate bill to address any issues that might come up through their board and certification licensing stuff? Yeah. Okay. It's H545. This is H545. Oh,
[Meredith Blunton, RN (Vermont Department of Health)]: We don't have have a a for theirs? Okay, sorry.
[Rep. Theresa Wood (Chair)]: Okay, it's just helpful to know that there's another symbol Sorry that's going
[Meredith Blunton, RN (Vermont Department of Health)]: about that. So Doctor. Hildebrandt talked about a few examples of potential impacts of changing federal guidance. And I'm going to start with COVID vaccines. So this fall, the ACIP, so that's the advisory committee who makes all of the recommendations for, vaccines schedules, who should get the vaccine, and what age ranges should get the vaccine, they made changes to who the vaccine was recommended to. So they said 65 and older and anybody with high risk medical conditions.
[Rep. Todd Nielsen]: And
[Meredith Blunton, RN (Vermont Department of Health)]: to, I don't remember your name, I'm
[Rep. Theresa Wood (Chair)]: sorry. Representative Nielsen.
[Meredith Blunton, RN (Vermont Department of Health)]: Thank you. So to representative Nielsen's point, we're not asking for mandates, we're asking for access for people who want to be protected. And we issued our own guidance. And that looked like changes to our protocols. We had to update our standing orders. We had to talk about access with providers and who they're able to vaccinate. We talked really closely with VMS about providers being covered if they follow the AAP or AAFP schedules instead of ACIP schedules. Yeah, that's what gonna talk about. AAP is American Academy of Pediatrics. AAFP is American Academy of Family Practitioners.
[Dr. Rick Hildebrandt (Commissioner of Health)]: It's the Professional Society for Pediatrics and Family Medicine. Yes. You. Of all the professional societies that exist, they give a lot of recommendations on routine vaccination schedules that are really great to reference correctly, and they're easy.
[Meredith Blunton, RN (Vermont Department of Health)]: Yep. So I'm going to go through in a couple of slides how we actually procure vaccines, just so you all have an awareness of how our program works. But I wanted to just say that we were really worried that CDC would pull some of these vaccines from their list of, provided vaccines, and we would not have access to them for primary care providers. And thankfully, that did not happen. And that was one of the really big potential risks that we were concerned with COVID vaccine as well. On the next example, we're talking about hepatitis B birth dose. So the Advisory Committee for Immunization Practices met in December, and they revoked a universal recommendation for the birth dose of hepatitis B vaccine. That recommendation has been in place since 1991. And we've actually seen cases of hepatitis B reduced by ninety nine percent in infants and teenagers in The US in the last thirty plus years. The birth dose now, according to ACIP and CDC, is only recommended for babies who are born to, mothers who are positive for hepatitis B. There are a couple of nuances in there. And then VDH again issued our own guidance, to pediatricians and Brooklyn hospitals, and said that we want you to continue to routinely offer the vaccine at birth to every infant. So as Doctor. Hildebrandt talked about, we had kind of a bombshell of news yesterday that HHS released a completely revamped childhood immunization schedule. They reduced coverage from 17 diseases down to 11. And this followed our presidential directive to align The US recommendations with peer nations. And HHS and CDC have announced changes to the actual schedule. And we have some printouts if you haven't seen it yet. So I do want to say, they moved a lot of vaccines to shared clinical decision making, which means you should have a conversation with your provider before you get a vaccine. I think as a pediatrician, I'm sure you're going to hear next that they have conversations all the time with their patients and families. So I am a little bit baffled as to why some of these vaccines were moved into that category as well. And my fear is that they're going to start pulling vaccines out of that list completely. I do want to talk really briefly about our immunization program and how we work. And I know that we got a few questions about that before. So the immunization program within the health department supplies primary care providers with all routinely recommended vaccines for children from birth through 18 and then for adults age 19 through 64. We don't currently offer vaccines through our program for 65 and older because Medicare doesn't pay into our program. We are working. So we use federal and insurer funds to, pay for vaccines within our program and to pay for the operational costs of running our program. Currently, we purchased all of our vaccines through the CDC. So if CDC is no longer allowing us to purchase certain vaccines, part of the language change that we're asking for is to be able to go to a different source to get those vaccines. And then our language right now aligns completely with ACIP. And as you've heard both Doctor. Helfand and myself talk about, we want the ability to align with professional medical organizations. I really hope that we get back to CDC and CIP at some point. So somebody asked earlier how the vaccine cost is calculated. So we use a history of vaccine utilization. So how many vaccines were given during the past year, past five years. We look at the projected uptake based on vaccine recommendations and the population for those age ranges that the vaccine is recommended for. And then we use an outside agency to help calculate those per member per month fees. And the per member per month fee also includes operational costs to help us run our program.
[Rep. Theresa Wood (Chair)]: Is now an okay time to stop for questions? I think there were couple of questions.
[Rep. Daniel Noyes (Clerk)]: Just quickly, back when you were talking about the hepatitis B, only offering it to people who potentially would expose their newborns to that, can we test everybody?
[Meredith Blunton, RN (Vermont Department of Health)]: They're supposed to test everybody, but not everybody gets prenatal care. And they test during the first trimester. So if that mother is exposed to hepatitis B after she was tested and is now carrying hepatitis B before birth, that baby is now exposed. That's not the only way that a baby can get hepatitis B, though. So it lives on surfaces. If they have a household contact that's positive and doesn't know that they're positive, they can pick up hepatitis B that way. In daycare settings, they can pick up hepatitis B. Do you have anything to add?
[Dr. Rick Hildebrandt (Commissioner of Health)]: So what they're saying is back what we did back in the early days. Yep. It's the exact same policy. Okay? And we had tens of thousands of people that were contracting hepatitis B every year despite testing moms. Okay? And they're talking about going back to that, which is harrowing. Because when a kid gets exposed to hepatitis B, unlike an adult, they don't clear the illness, and a high percentage of them end up with chronic hep B and chronic liver disease. So gastroenterologists around the nation are sort of up in arms about this because you're talking about exposing people to a condition that's entirely preventable and leading to significant morbidity and cost of liver disease, which is just scary. And we know what's gonna happen. Go back to 1990, that's what it was like.
[Meredith Blunton, RN (Vermont Department of Health)]: Thank you. Go ahead, you. Anne, can you talk a little
[Rep. Golrang 'Rey' Garofano (Vice Chair)]: bit about, you mentioned in the press release from the CDC, there's something about peer nations. So just kind of curious, what does that mean? Looked at your press release, there was no link- Denmark.
[Dr. Rick Hildebrandt (Commissioner of Health)]: They randomly picked Denmark for some unclear One country. No idea why. Okay.
[Meredith Blunton, RN (Vermont Department of Health)]: Thank you. A country with universal medicine, a country with very homogenous population, a country who almost one hundred percent of pregnant people are tested before delivery.
[Dr. Rick Hildebrandt (Commissioner of Health)]: It's just a backlink.
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: I just want to clarify that it's
[Rep. Golrang 'Rey' Garofano (Vice Chair)]: not Pure Nations, it's Pure countries.
[Dr. Rick Hildebrandt (Commissioner of Health)]: It Denver. If you look at the recommended vaccine, It's like one difference. Maricela, that's the only difference.
[Rep. Theresa Wood (Chair)]: Okay, thank you. Continue, thank you.
[Meredith Blunton, RN (Vermont Department of Health)]: Any questions about funding or how our program actually works before I move past? I actually do because I'm not sure that
[Rep. Theresa Wood (Chair)]: I'm totally clear about it. The insurers pay for the vaccine. I'm going to back up. So the department gets access to vaccines. The physicians, nurses, healthcare professionals provide the vaccine. The insurers pay for it. And then what's the per member per month thing that you were talking about that helps to fund this program? So is that part of what is paid to the insurance company or part of what the insurance company covers? I'm a little unclear about that piece. Thanks for asking. So the insurance companies pay us, the health department, a per member per month fee.
[Meredith Blunton, RN (Vermont Department of Health)]: And that is calculated with how many people are in that age range that vaccine is recommended for, what the vaccine uptake looked like in the last year or the last five years. And that per member per month fee goes into a fund and allows us as the health department to purchase vaccines and then provide them to primary care providers across Vermont.
[Rep. Theresa Wood (Chair)]: They're essentially helping to fund the vaccines that they then purchase from you or they don't purchase from you, but they cover the cost of. Exactly. Okay. So there's,
[Meredith Blunton, RN (Vermont Department of Health)]: for children, about half of our vaccines are paid for through the Vaccines for Children program, which is a federal program. And it's Medicaid, Medicaid eligible, American Indian, Alaskan Native, and uninsured children. And then the other 50% of children are paid for through private insurers who have insured kids in Vermont. And then adults, Medicaid pays into our program and all private insurers who insure people that live in Vermont pay into our program. Okay.
[Rep. Theresa Wood (Chair)]: So it's not just private insurers, it's public as well.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Medicaid is Medicaid and Vermont and a lot of other states are looking to us to see if they can do a similar thing in their state because it has been so successful.
[Rep. Theresa Wood (Chair)]: Okay. Great. We have representative Bishop and representative.
[Rep. Todd Nielsen]: Just just
[Rep. Doug Bishop]: to make sure I'm thinking about this correctly, would my assumption be correct that it's built out this way because it saves huge costs on administratively trying to charge per vaccine when it's something that is very high uptake on the use of the vaccines? If we're otherwise charging reimbursement?
[Dr. Rick Hildebrandt (Commissioner of Health)]: My understanding is it's more about universal access. Anybody who wants a vaccine for any reason, whether they have a charge or not through this fund, gets the vaccine, period, end of story. It's just universal access.
[Meredith Blunton, RN (Vermont Department of Health)]: We have heard from other states, and I'll let the pediatrician in the room talk about this. But it is a barrier for some smaller practices to have to purchase vaccines, have them sit in the refrigerator, wait for a patient to come in, then billed for that vaccine and wait for reimbursement. And if they have a loss, it could be thousands and thousands of dollars. Some larger practices have hundreds of thousands of dollars of vaccine in their refrigerator. So with our program, we build in a little bit of waste knowing that we're going to see some vaccines expire. We're going to see some waste due to malfunction of machines. The insurers know all of that, and it's part of our calculation. But then the primary care provider is not that money. Thank you.
[Rep. Theresa Wood (Chair)]: Did anybody else have a question? Oh, I'm sorry. No worries. I'm sorry.
[Rep. Daniel Noyes (Clerk)]: Real quick, in this bill, allows, if the CDC decides not to carry particular vaccines, it gives the department the ability to purchase outside. These could be through private for profit companies that we would be buying for, possibly funded through private equity and more based on profit than getting
[Dr. Rick Hildebrandt (Commissioner of Health)]: Not private equity, it's more about we need another group purchaser. That's what it really is. So if our group purchaser is not CDC, and it absolutely could be a for profit company, but we need another group purchaser that we can buy from that can get it at a discounted rate and distribute it. If it's not going to be a public source, it's going to be private source.
[Rep. Theresa Wood (Chair)]: So that could be potentially where the collaborative that representative Bishop was talking about, the Northeastern states might come together to do a group purchasing. Correct. Okay. Did you have a question, Representative Kind
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: of, yeah. Just wondering, especially as we go into private companies and things like that, sometimes low risk costs means a loss of quality. And I noticed the language directs us to always go with the lowest cost. I'm just wondering if you had accounted for that. I know now we can trust that they're all quality and will do what they are meant to do. I'm just wondering if you had thought all about that.
[Dr. Rick Hildebrandt (Commissioner of Health)]: Thankfully, when we give recommendations for vaccines, we do spell out the specific vaccine. So what it's saying is, hey, we're going to recommend this specific Moderna vaccine.
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: And then it's the supplier she
[Dr. Rick Hildebrandt (Commissioner of Health)]: Who's going to buy it for shipment? So we're not going to just say, oh, you flew Vaxx, and then here's this crummy one that doesn't do that to you.
[Rep. Theresa Wood (Chair)]: You. Why don't you continue, Meredith? Committee members, the PowerPoint is on the website now. For other people who know that,
[Meredith Blunton, RN (Vermont Department of Health)]: you have to refresh your site. So just a couple more slides, the need for statutory changes. So we really want to be clear and transparent. We want to provide authority to the Commissioner of Health to issue recommendations for immunization for children and adults considering science based recommendations and using those professional medical organizations. We will consult with the Vermont Immunization Advisory Council, which was talked about in the language. And we want to expand the membership to that advisory council to include experts. We just talked about the ability for flexibility of purchase. So if CDC does start pulling vaccines from their list of available, immunizations for us to purchase, we do have the option to go somewhere else and, procure those vaccines for primary care providers. And then the language change will also ensure that private insurers continue to cover immunizations. And then lastly, on that slide, address potential barriers faced by health care providers. So Doctor. Hildebrand actually signed a standing order for COVID vaccine to allow practitioners to still give the vaccine to anybody who wanted to be protected and then to help provide immunity from, liability for licensed health care providers if they're following those professional medical organizations. So this slide really just talks about the specifics. So I think we had already added back in the changes for our DFR. I did want to just ask about Section one. So individuals domiciled in the state. We give vaccines to primary care providers all over Vermont, and we do have some residents of New Hampshire who seek and some residents of New York and Massachusetts who seek primary care in Vermont. I don't want the primary care providers to have to screen for eligibility in that way. We've never done that. So I just want to be careful with that language and maybe just go back to what we originally had because that allowed us to offer anybody seeking primary care in Vermont.
[Rep. Theresa Wood (Chair)]: Just to be clear, you're recommending eliminating the phrase individuals domiciled in the state. And
[Meredith Blunton, RN (Vermont Department of Health)]: to that point, a lot of Vermonters also seek care at Dartmouth and other neighboring hospitals, and they're able to be vaccinated there as well. Section three, practicing was added in and it wasn't added in. I think it said practicing pediatrician. It wasn't added in for the family practice provider. So I know that we have some really wonderful recently retired physicians who we would love to have on our panel. And I don't know if practicing means that they would no longer be allowed on the panel. And then it had said effective date for July 1, I believe. And with the recent, at least yesterday's, change, I'm asking to have that be considered as soon as the bill passes. Which I think is what
[Rep. Theresa Wood (Chair)]: it does say now. Okay, perfect. So I have a couple of questions that I think are for you folks. And I also want to let folks know that we do have a representative from the Department of Financial Regulation on Zoom as well. So we asked him to if you have any questions around DFR committee members. So getting to the when you were talking about the practicing, I was also thinking about the licensure. Why would we limit it to physicians licensed in Vermont? Let's say we were maybe fortunate enough to have some national expert who happened to reside in Vermont, but might not be licensed in Vermont. I'm just wondering why we'd limit it. Beyond the Advisory Council, To be on the Immunization Advisory Council.
[Dr. Rick Hildebrandt (Commissioner of Health)]: I'd like to have a national expert. Or someone who we know forever and then just moves to another state and wants to stay on the
[Rep. Theresa Wood (Chair)]: And wants to stay on the Yeah, yeah. So I would ask you to take a look at that language and then maybe give us some tweaks to that language or work with Katie on that or suggested tweaks to that language. The other question I have is on page eight, lines ten and eleven. Okay, this is the council again. Provide any other advice and expertise requested by the commissioner, including advice regarding immunization recommendations issued by the commissioner. I think that we need to find a better way to say what I think you're saying here. Is it that you are saying that you want this counsel to give the commissioner advice about immunization recommendations that the commissioner will then make to the public. Okay? I I don't think this is the best way to do that, but I wanted to make sure that I understood the intent.
[Dr. Rick Hildebrandt (Commissioner of Health)]: That's the intent.
[Rep. Theresa Wood (Chair)]: Okay. So maybe we can work with Legis Council wording on that. Katie, I think this maybe is a question for you. The expansion of the immunity. I'm just flagging that because we'll have to refer to another committee because we can recommend it. This is not really our jurisdiction, but just so you know. And then I am just wondering about what the feasibility of combining the so we deal with this all in one bill, the OPR changes. I think procedurally, would be best if we could deal with this all in one bill. So I would appreciate any reaching out that you all can do about that. And I certainly will reach out as well. And Are there any definition of healthcare professional, that includes pharmacists, correct?
[Katie McLinn, Office of Legislative Counsel]: I believe so. Have to work
[Rep. Theresa Wood (Chair)]: for a day until 11:30. Okay. Those are all the questions I have. Yeah, Representative Bishop.
[Rep. Doug Bishop]: A question on language. You had referenced the individuals domiciled in the state and as we revert back, reverting back, if I'm looking at this correctly, we'll go back to Vermonters, so that wouldn't necessarily address situations you raised. We look for other language, I guess, people who receive care in Vermont or something along those lines, just to understand the direction you want to go in. A non language question. There was a change recommended in this bill with respect to the frequency, I think, of the council meeting, the advisory council, and it had previously said at least once annually, I think, that's been taken out. Can you share the thinking on that part?
[Dr. Rick Hildebrandt (Commissioner of Health)]: I don't know that I have the background, but I can look into that.
[Rep. Theresa Wood (Chair)]: To the lay people sitting around the table, it would seem like, why do we have a council that or if they're not going to I can see that as needed, but it seems like once a year doesn't So you would, take a look at that. It would have people question, What's the purpose of this? Okay. Any other questions for these witnesses or anything else that the witnesses want to share?
[Rep. Todd Nielsen]: Other than thanks
[Dr. Rick Hildebrandt (Commissioner of Health)]: so much for having us. I appreciate it. It's great to
[Rep. Theresa Wood (Chair)]: Well, we really appreciate you bringing this forward
[Katie McLinn, Office of Legislative Counsel]: at this.
[Rep. Theresa Wood (Chair)]: Obviously, we're current times. One of the things I think that you said, Meredith, is that, well, hopefully we can refer back to the CDC. And I think what you might see as a suggestion from us to think about a sunset date for this so that these changes are reviewed again after a certain period of time. And that's something that we'll talk about when we get to markup.
[Rep. Brenda Steady]: I do have the scheduled, but I'm just going to pass it around. Don't think I made enough copies, but at least you can see it. Thank
[Rep. Theresa Wood (Chair)]: you so much, both of you and Jessica, being here. Appreciate it. Okay, next we're going to hear from providers. Stephanie, you're up. Is this Tracy over here? Sure.
[Rep. Todd Nielsen]: Welcome.
[Rep. Brenda Steady]: You for having us.
[Rep. Theresa Wood (Chair)]: Tracy, don't think you were in the room when we all introduced ourselves, but welcome to House Human Services. Thank you. Happy to
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: help you. I'm so nervous.
[Rep. Theresa Wood (Chair)]: Okay. We promise to take it easy You on
[Rep. Brenda Steady]: don't take it easy on me. Just sit from you.
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: I think I'm going to go first and give a little background, and then Doctor. Tyson will take over the clinical aspects. I'm Stephanie Winters. I don't think I've testified on this committee this biennium, so I don't know a lot of you, so I'm happy to be here. I am the Deputy Director of the Vermont Medical Society. I just celebrated my twenty eighth year yesterday, and I also serve as the Executive Director for the American Academy of Pediatrics Vermont Chapter and the Vermont Academy of Family Physicians. There is a bunch of other organizations, but for today, those are the ones I'm representing. So I'm happy to be here. We are really happy about this bill, thankful to the bill sponsors and the health department for bringing it forward. We started to recognize this need actually early last session and thinking about what we needed to do as a state to provide the most protection for our Vermonter. So thank you for doing this. We strongly support H545. We believe it will allow Vermont to uphold evidence based medicine recommendations regarding vaccines and ensure that we have really to the minute responsiveness if we need to. As you talked about a little bit, this bill aligns with trusted national bodies, such as the American Academy of Pediatrics nationally, American Academy of Family Physicians, who rely more the AAP does the childhood vaccine schedule, which they just released not long ago. And then the AAFP does the whole thing, but relies on AAP for the childhood and then does adult vaccines. So they have been doing that for, I don't even know how long, decades at least. So this is not new. They have national experts, they have researchers and clinicians looking at what these vaccines should be. So relying on that is also not new. That's what the Advisory Committee on Immunization Practices used to rely on. They used to sit on that board and talk through what vaccines should be on the list. So this is not new. And also, the bill still includes ACIP, so the Advisory Committee on Immunization Practices. So we can still rely on that if evidence comes back to that committee. And so what I will just say is that on behalf of practitioners, so the Vermont Medical Society represents physicians and physician assistants, and then AAP Vermont Chapter and family physicians represents family physicians, pediatricians, and nurse practitioners. And we all really feel strongly that this bill will provide clarity and consistency for health care professionals and patients. We talked about the confusion in our state as far as how people are feeling. And we have heard, and it's been reported, that there's increasing confusion, both among healthcare professionals and patients about recommendations, coverage, where you can get vaccines. And it's only going to increase given the announcement yesterday, which I think is the intended purpose. And we really think that this will help, this bill will help. It also protects healthcare professionals acting in good faith. So this is the, practitioners are increasingly facing legal uncertainty as immunization recommendations evolve, and H545 will provide essential civil and administrative liability protections for licensed healthcare professionals who act in accordance with official recommendations from our state health commissioner. And Doctor. Tyson can talk more about this, but we really feel like this bill will also strengthen the medical home and care coordination. So there's a section about expanding access to immunizations through standing orders and team based care models. The bill continues to enable pharmacists because pharmacists can already, which I'm sure some of you know, provide immunizations. So we feel like that is appropriate in their current scope and it will preserve the medical home as the central point for care coordination. On the cost, I will just say that this preserves universal no cost access. So this is not changing anything about how vaccines are paid, the cost share for patients. It preserves that so that insurance companies cover them at 100%, there is no cost share. The health department supplies the vaccine, which is also a reduction in administrative burden for practices. And so nothing about that changes. It just solidifies that they will follow the recommendations put forth by the Commissioner of Health. I think it supports a stable vaccine supply. So I think we did see some access issues when they changed recommendations around the COVID vaccine, which is why the commissioner did a standing order. So there is the potential for access issues given changes in vaccine recommendations. And so this would support stabilizing that and reducing administrative burden. The universal vaccine purchasing program has really been critical for the success of delivery in clinical practices. And by allowing VDH to purchase vaccines from another vendor, it will increase flexibility and supply stability. And finally, it will ensure that clinical expertise remains central to immunization policy. As we saw yesterday, not all policies are made by experts or clinicians, and that is really detrimental to our population. And so H545 would strengthen the role of the Vermont Immunization Advisory Council. I will say that I do have historical knowledge and it has not been utilized to its potential. So I'm actually excited about utilizing our Vermont expertise. We have pediatric infectious disease physicians who we have relied on through all of the pandemic to really tell us what's happening. What does the science mean? Because they have brains that work in ways that are mysterious to me as a non clinician, but it's really amazing. We have the Vermont Vaccine Testing Center. We have expertise right here that can serve on that committee. And why shouldn't we utilize that as well as the national organizations and ACIP and the CDC. So I think it's really important to have that clinical voice. And we believe that immunization policy must be informed by those who deliver care. So that's really important because they see what happens on the ground and in real life. So in conclusion, yay, we really support this. We really think that this will protect our population. It provides clarity, protects health professionals who provide immunizations, strengthens prevention and patient access, and it really maintains Vermont's commitment to evidence based clinician informed public health policy. So thank you. And I will take any questions, but also Doctor. Tyson is practicing pediatrician and can answer a lot of your clinical questions as well.
[Rep. Theresa Wood (Chair)]: Thank you. Any questions for Stephanie before we move on to our physician? Okay, great. Do you have written Yes, I testimony to do. So just a reminder for people in the room, please send that in advance to our committee assistant. We'll just have to be issuing that reminder frequently. I have a feeling. Thank you very much, Doctor. Tyson. Thank you for being here.
[Rep. Todd Nielsen]: Appreciate it.
[Dr. Tracy Tyson (Pediatrician)]: Thanks for having me. I do better just off the cuff, so I'm gonna put this away. And so much of what has been said of the nitty gritty has been said by people before me. So I'll try to get down to what's most important that you want for me. I'm Tracy Tyson. I'm a board certified general pediatrician for over twenty years. I run a private practice in St. Albans, Vermont. I've been in Vermont for five years. So some of the things I will talk to you about are things I've seen in other states prior to coming here and what actually brought me to Vermont to practice primary care. I am also the president-elect of the Vermont Chapter of the American Academy of Pediatrics. And I recently have delved into education for social media online. So I have a really good idea of what our families are concerned about and what pediatricians are concerned about and why all of this language matters. So the National American Academy of Pediatrics absolutely supports the states having their own vaccine schedules that are backed by the medical societies, their own researchers, their own things to give more clarity to providers who are actually providing vaccinations. So this is not just supported by the state AAP, but it is also supported nationally. Sue Presley is a pediatrician who was just the past president of the American Academy of Pediatrics. And I actually spoke with her this morning. She was extremely excited that this was happening, and it needs to be happening everywhere. They see Vermont as a trailblazer in protecting the relationship between public health, its providers, and its patients. And I hope that that's something that can continue because we really are known nationally for how we support public health and vaccine safety in the state. What we are seeing on the ground is a lot of confusion. We're seeing families not getting what we call true informed consent, which is getting evidence based medicine presented to them in a way that they can understand trust. And it's gone, it's lost. And they're scared, and they're confused, and they're making decisions without all of the information. And it's being disgruntled. I'll give you a few examples. One was we had a family who the nurse came in, offered a normal intervention that happens at birth, the hepatitis B vaccination. The family said, No, thank you. They did not get the dose. There was a little bit of a lapse because of concern about how much information can be given and what are the recommendations. The family came into the office to see me. And when I explained why the dose would be given, why we do this, why we recommend it, both parents burst into tears. And they said, we don't feel we have all the information to make these decisions and these choices. We felt it was a choice. So if it's a choice, it must not be needed. So language around public health really does matter. It may seem as if it's giving more autonomy to families, but what it's giving is confusion, and that is going to lead to lapses in care. And we're seeing that with every vaccination. We're seeing families coming in and saying, I don't know who to trust. Who am I supposed to talk to? Where am I supposed to get my information? We also have families coming in saying, I only want what's mandated. I only want what's required for my child to go to school. So those words are words that our families are using, and they don't mean the same thing that they used to. We don't even know how to explain to them what is mandated, what is universal, what is recommended, what is routine. I can give you the science as to what this vaccination is given for. How does it work? What are the side effects? What would happen if you didn't do it? How has it changed the face of pediatric practice? But to give them that language, I no longer have it. So we have pediatricians, family practice providers, APRNs who are concerned with which schedule do they follow? Do they follow the evidence by their medical institutions and all of the scientific evidence that we read? We all read hundreds of hours a month on these vaccinations to like, who should they be given to? We lean on these to. I used to get excited every year with the ACIP meeting, because I thought, Oh, great, they're going to do a lot of this heavy weight for me. And I can listen to this committee, and we can make recommendations, and I can feel confident. But this was the first time in the history of this committee that the American Academy of Pediatrics was not invited. And they were not asked to be on the panel. They could give public comment, but that was it. But it's not the first time that the American Academy of Pediatrics has recommended a different schedule than the CDC. That has happened before when the science didn't align. So it's not an unprecedented thing, but the actual providers of evidence based medicine to say, this is our childhood vaccination schedule that is supported by science. But evidence based medicine has to have science that is appropriate and rigorously studied, as well as experts who are providing the care and the experience of those providing the care. And that's not what we have right now from our current CDC. We have in the past, and we have that language with the vaccine schedule that we already had. We do also have a lot of fear in our community from parents who want access to vaccines. We have a massive amount of calls from families who are want they believe in the science, they want it, they want access to these, and they are really afraid that that is going to be taken away from them. Can they afford to pay for these vaccines out of pocket if something were to happen? What would happen if they come into my waiting room, and there are families in the waiting room who are unvaccinated, and their child has a leukemia and is undergoing brief? Like, are they going to be protected? What are we going to do to protect children in their community places? We also don't have the infrastructure to handle airborne diseases like varicella in our practices, it requires a negative pressure room, you can't bring them in the office, it is one of the most airborne illnesses that we have. Measles is the most contagious thing on the planet. They can live in a room, I mean, after someone leaves, they can leave the room and you can contract measles by being in the room. We are not ready for this. And as we've seen in other states, it has absolutely collapsed some of their healthcare systems. And so we really are doing our job on our end to try to get the information out to people, to try to get the education, to try to get that informed consent. But we need the language behind it so that we have something to stand on. Like this is the Vermont schedule of immunizations that's backed by science, it's backed by these medical organizations, backed by the federal government if that happens, and that we feel confident. Also need the school nurses need to know which schedule am I supposed to be asking this family about? We need that language. It's so much more important than ever. I'll take you back to why language is also so important. In the early 1990s, when HIV was still a really kind of taboo subject, you had to opt in to getting HIV testing if you were a pregnant person. And lo and behold, it was like a twenty percent where people would say, sure, I'll get that test. Because there's just so much around it, they didn't understand it. Like we assume families have a lot more ability to understand what this testing is for than they do. And we were still seeing 1000s of children getting HIV perinatally transmission from mom. All we had to do was change the language to opt out. This is a test that is automatically done, but you have the right to opt out. It went to ninety nine percent. We have not had a perinatal transmission of HIV. Like we are one of the most successful countries in the world for that. So that's another big reason why what we do, what you do, and rooms like this matters so much to what we actually do in practice. And it's important. The last thing that I'll speak to, because I'm sure you'll have questions for me, is the moral injury that is happening to your medical providers is something that really needs to be considered. I moved here five years ago from the state of Florida during COVID. Because of the moral injury that was happening, the inability to ask families about whether or not there was guns in their home so we could try to protect children from the number one cause of death in them. We were yelled at for wearing masks. We had limited access to vaccinations. We didn't have a lot of support. And it was a moral injury I could no longer sustain. And I thought I can't do my job. That's evidence based. So I need to go to a place where I can. And Vermont met that bill. You support primary care unlike a lot of other states do. It is absolutely astounding. You support pediatricians as primary care providers. It's actually quite astounding how many pediatricians are in these small rural towns because we are experts in medical care for children. And you stand up for public health, you stand up for the exam room, stand up for us having the ability to have that relationship with our families. And it is so greatly appreciated. But we're tired, we're exhausted, we get death threats, we are constantly it's tiring. And right now, when there's a primary care shortage, this is not the best time to be attacking your primary care providers. We need more people like me to move from other states that maybe aren't doing this. We need to be like, hey, we will support you. There is a doctor who messaged me that has been a step aside from the bedside after fifty four years. She was a nurse first and then a physician because her state is not supporting this. She cannot get access to COVID and flu vaccines because they didn't do what the state of Vermont has done to protect those. And in one of the worst flu outbreaks that we've seen in thirty years, she is not able to provide the flu vaccine to her patients. And so she's leaving. There is also some things going on in our state where doctors are being reported to medical boards for recommending routine vaccinations, if it differs with the CDC guidance. And that's coming, and it's going to get more. And we can't ask people to continue to do that. It's a lot to put on us in a time where we are already feeling as if the moral injury. And actually, the last thing I will say is that when I first started practicing, there was fever was a real thing, right? The fever phobia, you have children right now, grandkids, you know, fever phobia is like, oh, it's just a virus, don't worry about it. That was not the case even twenty years ago when I first started practicing. A fever was a big deal. I was excellent at spinal taps. I was excellent at blood draws, external jugular blood draws. I could read a gram stain under. I could do so many more things that I have not had to do in fifteen years. I don't know how to do those things because vaccinations have changed the face of pediatric practice. I don't want to
[Rep. Brenda Steady]: go back and sit in
[Dr. Tracy Tyson (Pediatrician)]: a room and say, Oh my gosh, your kid probably has age flu meningitis. And we could have prevented this had we done what the science told us to do. And I don't know back to that. I don't know that I can go back to a world where I'm a teacher now. I'm a counselor. I'm a mentor. I'm a coach. I'm a trainer. I am not a medical provider that is saving lives every day, because of vaccinations. And I don't want to go back to that. And I think I can speak to every person who treats kids and has kids that they don't want to go back to do that. So I cannot express enough support from this. And really appreciate that it's being looked at. Thank you all for the work that you already do in the state to protect primary care. Thank you, Doctor. We appreciate you being here.
[Rep. Theresa Wood (Chair)]: And know that it's not always easy to arrange schedules because you're practicing physicians. You've got patients to see. So thank you. Questions from committee members. Go ahead, Representative Cole. Thank you, Doctor. Tyson.
[Rep. Esme Cole]: I wonder if you could paint the picture a little bit about that time in recent pasts about when things didn't align with
[Katie McLinn, Office of Legislative Counsel]: the CDC and how long that lasted.
[Dr. Tracy Tyson (Pediatrician)]: Oh, gosh. I'd have to get back to you on very, very specifics. I just learned about it this summer myself when we went to a leadership conference with the American Academy of Pediatrics, where they were all kind of setting us up for the fact that, hey, yes, we have been a part of this Vaccine Advisory Council. We actually helped form it. However, there have been times in the past, and I want to say it had to do with the first time that we brought out the hepatitis B vaccine universally, but I'd have to get back to you specifically. So I will do that for you. Yeah, because I didn't know that either. I thought it was always so intertwined. But there have been times where we've had to break away. So I'll get you those specifics. Thank you for asking.
[Rep. Theresa Wood (Chair)]: The questions for Doctor. Tyson. Thank you so much. You were very eloquent in explaining the impact. I hope you can feel my passion about this. I do feel very passionate about it. We could definitely feel your passion and the impact of practicing. And thank you for making a choice to come to Vermont. Thank for
[Katie McLinn, Office of Legislative Counsel]: having me.
[Stephanie Winters (Vermont Medical Society; AAP VT Chapter; VT Academy of Family Physicians)]: Great place to We are lucky.
[Rep. Brenda Steady]: Okay,
[Rep. Theresa Wood (Chair)]: thank you very much. Appreciate you all.
[Katie McLinn, Office of Legislative Counsel]: It's representative Cole. Okay, I'll get back to you.
[Rep. Theresa Wood (Chair)]: Okay, so let's take a