Vermont Legislature SmartTranscripts:

[Rep. Theresa Wood (Chair)]: Okay, welcome back folks. Thank you for being here and being here promptly this afternoon. Before we delve into the budget for the health department, we are going to be hearing a couple of bits of additional testimony from our amendment that we'll be voting on shortly on H545. So I'm going to, if you don't mind, Representative Elan, do we have a Doctor. Tyson who has other commitments? Know you have other commitments too, but I think Doctor. Tyson will be relatively Oh, she's not on. Okay. Representative Lamoille, there you go. Yeah, that was fast.

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: And I was hoping not to have to say anything after the doctor said stuff. I am not a doctor. I am Martin Malone, representative from South Burlington.

[Rep. Theresa Wood (Chair)]: Aren't you a doctor of the law?

[Rep. Esme Cole]: No. Is very

[Rep. Brenda Steady]: serious. Very serious.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: I am the juris doctor.

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: I never think of myself as that. So I'm chair of the House Judiciary Committee. So I'm testifying about the amendment even though I we haven't taken testimony directly on that amendment. We essentially did last Thursday. So we had a witness in the morning who raised the issue of informed consent and that that that should be a requirement before there is the immunity. So we had additional testimony in the afternoon about informed consent and what it involved and whether this was something we should have. And the bottom line is that we were satisfied that we didn't have to do anything additional with informed consent to pass or to agree with the immunity language. And maybe you've heard this already because I'm going to kind of rehash some of the testimony that we received.

[Rep. Theresa Wood (Chair)]: What did hear from the Legis Council this morning is a review of the current provisions of state law around consent. We looked

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: at that.

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: Okay. Well, great. I won't won't get into

[Rep. Doug Bishop]: the actual language. But essentially,

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: what we heard and what we decided that we were fine without having essentially what this amendment provides is that it's already required in Vermont by statute that if if some if a doctor or provider does not provide informed consent, then they're subject to a medical malpractice suit. And it's not related to our immunity clause. It would be a separate claim. We wouldn't be immunizing, so to speak, the provider if they failed to give informed consent under this other statute. We also learned that there's a federal requirement when it comes to immunizations of what has to be provided as well as far as the explanation of risks and benefits and the like. So between the state statute and the federal requirements, we really felt that that was well covered and that was not necessary for this particular treatment. And the other testimony we heard, we heard from the General Counsel of the Department of Health. We heard from the Executive Director of the Vermont Medical Society. And the idea is that we don't need to have an additional informed consent for additional treatments. It's covered. We don't have to do it for different procedures or treatments. We already have it covered. And it's even more covered again because of that federal requirement. So that's what we relied on to say we were fine with the immunity provision without having additional informed consent.

[Rep. Theresa Wood (Chair)]: Thank you. Thank you very much. So just to summarize the stuff that's the language that is in the proposed amendment, essentially your committee took testimony related to that issue when you were considering the bill as presented and didn't feel a need to have any additional language.

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: Correct. Voted nine ten that we approve this.

[Rep. Theresa Wood (Chair)]: Okay, thank you so much. I appreciate that. Thank you for in and out. Our schedule's been a little topsy-turkey.

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: I was excited to come and talk

[Rep. Eric Maguire]: to you.

[Rep. Theresa Wood (Chair)]: Thank you, Chair Lalanne. Doctor. Tyson, thank you so much for being here this afternoon. Appreciate you interrupting your schedule today, particularly it's around clinic hours and stuff. So definitely appreciate you being here. And I'm going to make a presumption that you're familiar somewhat with the amendment. And what we'd like to hear from you is from a physician's perspective, the impact of the amendment or essentially what current practices and how you think that that is already is, whether that is covered or not.

[Rep. Brenda Steady]: Okay. Yes, thank you so

[Dr. Tyson (Physician witness, Vermont Medical Society)]: much for having me. I'm glad to be here. So what is already happening right now is that every vaccination given in the state, there is a discussion with the family over the risks and benefits. We give out whether in paper, through the portal, the vaccine information sheets. We answer all questions. Families do not sign to decline or to accept the vaccination at this time. There is a discussion of informed consent in the room. Changing this language to having to go over, it's the word all that is concerning because it's so encompassing. It's too broad. It's too vague. Like, what exactly does that mean? And also the idea of changing the way that we do this. You would have to sign if they declined. You would have to sign if they took it, whereas now it's a conversation between the provider who is giving the vaccination, and this even occurs in the pharmacies where this has to go on. So it just changes how we do this and it would be a pretty huge barrier when you're talking about giving, you know, sometimes hundreds of vaccinations within an office. It's also difficult when you're doing nurse visits for something that's already been decided that the parent wants to have, which is a flu vaccination because that is a nurse administering that based on a standard of care. So we do have quite a bit of concern that's going to a huge administrative burden without actually adding any benefit to the parent and could also be confusing.

[Rep. Theresa Wood (Chair)]: You were breaking up a little Oh,

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: I'm sorry.

[Rep. Theresa Wood (Chair)]: That's okay. Let me just see if I understood sort of summarizing that you said that this would add a very large, I think you said huge administrative burden without actually providing any additional benefit for the patient and or their guardian.

[Dr. Tyson (Physician witness, Vermont Medical Society)]: Absolutely. And some other examples where this is not done when it comes to the immunity factors. We already have some examples such as reproductive access in the state and naloxone where, you know, we are providing that kind of different level of immunity based on what might be available in Vermont versus at the federal level. That immunity language is also something that it's not new and it's been done before and doesn't necessarily it doesn't improve that by changing the wording of it.

[Rep. Theresa Wood (Chair)]: Thank you. And just to remind folks, as Ledge Council said, this is the same language that is in this bill that is in the other immunity clauses that the General Assembly has previously already voted on. Are there any questions for Doctor. Tyson? Go ahead, Representative Cole. Thank you, Doctor. Tyson. So my understanding of the intent behind this amendment is that we want

[Rep. Esme Cole]: to encourage the dissemination of information as much as possible and to, you know, when people have concerns, they're able to talk about them, you know, when they're thinking about if there may or may not be risks associated with a certain vaccine. And so that education piece and that very candid conversation between the recipient or the person considering the immunization and their provider. If this bill is not the way to encourage that, and it's more of an administrative barrier and maybe scary because it's more of a conversation about lawsuits. How can we better incentivize those conversations? If there is fear, how can we help support with information about what research shows?

[Dr. Tyson (Physician witness, Vermont Medical Society)]: Great question. We already do that, and it's in the Vermont statutes that every provider who administers vaccination has to provide the risks and benefits and be available to answer questions by the family. And so that is already being done and does not need to be rewritten as far as we're concerned with the Vermont Medical Society and it's done quite well. There's, you know, pretty extensive ways that this is happening and you know, now there's more questions than ever because of a lot of these changes and we're all stepping up to the plate and providing even more information than ever because it's the right thing to do. And good news is it's already in our statute.

[Rep. Brenda Steady]: Thank you. Thank you.

[Rep. Theresa Wood (Chair)]: Are there any other questions for this witness? Park seven Maguire? I don't know if it would

[Rep. Eric Maguire]: be for her, but I I just wanna throw this on out because I don't know if could I ask a question? Do want a doctor? Not yet. Okay. No. It's in regards to the amendment of the bill, but something clarity.

[Rep. Theresa Wood (Chair)]: Doctor. Hildebrand, would you mind taking the witness chair?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: It's okay.

[Rep. Eric Maguire]: He may not be right. Will do my best

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: to answer any questions you've got.

[Rep. Theresa Wood (Chair)]: That's right. We'll we'll add you to the witness list on Just this amendment

[Rep. Eric Maguire]: more clarity. Okay. The bill is more or less we're providing the oversight and authority to you to put together a schedule of recommended vaccinations. At this time, you follow the federal government's recommendations. Does that change possible liability? You get where I'm going for like, okay, it's time we give those consents and everything like that. But is there any possible liability for the state or the provider in regards to, okay, we're changing, you now are the one providing that. Yep. There may be a choice made, oh, we're not going to go with the federal one. Right. I'm trying to worry.

[Rep. Theresa Wood (Chair)]: I'm not, not, I'm going to try to help you out.

[Rep. Eric Maguire]: Yeah.

[Rep. Theresa Wood (Chair)]: Are you asking, is there a difference in liability for the health care professional because we're

[Rep. Eric Maguire]: Now following this

[Rep. Theresa Wood (Chair)]: We're now adding an option for people to follow the state recommendation. Is that your question? Yes.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: And that is the intent behind the immunity clause explicitly. So that if someone were to follow the recommended practices by the opposite commissioner, and they follow them as they're written, that that is not something that you could raise a lawsuit against in the state of Vermont. So that's the purpose of that protection is to say, hey, we're gonna follow evidence based practice. We're gonna listen to the AAP. We're gonna come up with a set of science based recommendations. If you follow this, and even if it differs from the ACIP recommendations from the federal government, that's where you have immunity protection. Okay. That is the purpose of immunity clause.

[Rep. Eric Maguire]: So there's there's no like since now, again, you're taking over the oversight, you're the one making the recommendation, there may come a time that the recommendation passed on to the federal government might say, no, I'm going go in this direction. So what I'm just getting at, that all those protections still remain into place no matter who makes the decision. There I go. The protections for the All the liability, what is already in place, Correct. Still applies to the government who's making

[Rep. Brenda Steady]: the decision.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Correct. The liability protections that are currently in place for providers would remain in place despite it not coming from ASAP coming in from me instead. That's correct.

[Rep. Eric Maguire]: Okay. Thank you. I gotta stop using Tylenol if I will suffice.

[Rep. Theresa Wood (Chair)]: All right, folks. Thank you, Doctor. Hilbrand. We'll have you back in the witness chair momentarily. Okay, folks, we need to take, I'm sorry?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: We need to thank the women.

[Rep. Theresa Wood (Chair)]: Yeah, I didn't know if she was gonna sit around for a minute, but I'm being reminded to thank you, Doctor. Nice. I should at the outset, but I should do it at the end as well. You're welcome to stay on. And we're now going to take a vote. We've had quite a lot of testimony on this amendment today, off and on during the course of many different iterations we've heard from a number of people. And so I would entertain a motion regarding the amendment. What are you moving? I'm moving

[Rep. Golrang “Rey” Garofano (Vice Chair)]: that we oppose the amendment.

[Rep. Anne B. Donahue (Ranking Member)]: Find it unfavorable.

[Rep. Brenda Steady]: Because we're voting, yes. Okay. Don't let me

[Rep. Theresa Wood (Chair)]: Todd. Uh-huh. Okay. So Todd knows when we're voting on this. He can yeah. He can certainly anyway, at this point in time, I just wanna make sure that people understand what a yes vote means. So the motion was to find it unfavorable. A yes vote means you are finding it unfavorable. A no vote means that you are finding it favorable. Is everybody clear about that?

[Rep. Brenda Steady]: Okay, say it again.

[Rep. Theresa Wood (Chair)]: A yes vote means you are finding the motion. You're agreeing with the motion to find it unfavorable. Okay. So you're voting against the amendment if you say yes. I realize that this is a little confusing.

[Rep. Brenda Steady]: I'm all confused. I don't get it. Okay. If I'm for the amendment And

[Rep. Theresa Wood (Chair)]: you will vote no on the motion. Thank you. If that's what you desire to do. I'm not telling you what to do.

[Rep. Brenda Steady]: No. I know. But I just need to Yeah.

[Rep. Theresa Wood (Chair)]: That's why I just wanna be clear. Okay. So there's been a motion. Any further discussion? Yes.

[Rep. Anne B. Donahue (Ranking Member)]: I'd just like to kind of summarize in my mind, because I think we ended up very clear. There's two separate issues. One is the required signature on a I got the information from the doctor. And I think it's been clear now that that informed consent piece for actually any medical, but particularly around vaccines, is already clear that there has to be a discussion and understanding versus just sign something without even needing to understand it. So it actually would offer something weaker. But also, I don't see any reason to, make this set of recommendations handled differently from all of our long term established law on the requirement of informed consent and full information. But the second piece I found more interesting because I think if there was a change we're making that changes the, it was called the assumption of risk about a vaccine, then I think it would make sense to inform somebody about that. And it led me back to looking at the existing federal law, which was really a trade off saying you can't sue for the vaccine because of the public interest in vaccines, but we're giving you this other outlet where you can get reimbursement. And that doesn't change at all. We're not doing anything different in establishing that this same immunity applies, that we're saying because we're passing a state law, we want to create that same immunity. So I don't see something as changing. That risk benefit, the fact that you would have to go based purely on the vaccine, creating an adverse effect, that you would have to go this route that's been established in law federally for a long, long time, that won't change under this. The same route, the same trade off. So there is no new change in the risk presented to a person. And so therefore, I support the motion to find this not friendly. I think on the surface it seems, oh, offer patient rights, but actually it doesn't really enhance any patient rights, because we're not reducing any patient rights in this bill. Thank you, Anne. Okay.

[Rep. Doug Bishop]: I would say that we are taking these steps with our underlying bill because the federal government has, in my view, taken steps that are both bad for public health and because the federal government has taken steps to show confusion about vaccinations, immunizations. And specifically, the clause that requires a position to talk about legal issues, immunity with their patients is fraught with the possibility to engender greater confusion than we currently have and concern. And therefore, I think the public health benefit of immunizations would be harmed. And so I'll be voting yes to find this unfavorable.

[Rep. Theresa Wood (Chair)]: Alright. Thank you. The clerk shall call the roll.

[Rep. Daniel Noyes (Clerk)]: Representative Bishop? Yes. Representative Cole?

[Rep. Esme Cole]: Yes.

[Rep. Daniel Noyes (Clerk)]: Representative Donahue? Yes. Representative Estes? Yes. Representative Garofano? Yes. Representative Maguire? Yes. Representative McGill? Yes. Representative Nelson? Representative Noyes? Yes. Representative Steady? No. Representative Wood?

[Rep. Theresa Wood (Chair)]: Yes.

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: Great. 910. 9111.

[Rep. Theresa Wood (Chair)]: Thank you, Doctor. Tyson, for being and thank all the people who may be not exactly here today, but were here earlier this morning, And those who remained here during taking up this amendment, we appreciate your additional information and clarification that you've provided. So thanks very much. And everybody is welcome to stay because we're now moving to the health department budget. We will welcome Doctor. Hildebrandt to the witness chair. And members, you should find information on the committee's website. So, back, Doctor. Hildebrandt. Been a very brief stay. Okay, so this was just something I had a little fun with Doctor. Levine about, but we've had the same picture. PowerPoints. I can't even tell you how many years. He's five. We need it now.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Just you wait.

[Rep. Brenda Steady]: We love

[Rep. Theresa Wood (Chair)]: you being, carrying on the tradition apparently.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Put a stock bucket on that tree there.

[Rep. Theresa Wood (Chair)]: So Doctor. Hildebrandt, the floor is all yours. Thank you for being here.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Great, thank you so much for having me. So I've got a handful of slides here that we're gonna go through, and then we'll get to some of the meat and potatoes here. So first up, here's our mission and our vision and values. I've shared this with you before. Again, this is here to reconfirm our commitment to Vermonters, that we stand by them even in this changing landscape. The health department organizational structure, again, complex organization, a lot of moving pieces, six sixteen positions in the central office and 12 district offices throughout our state. And I do regularly refer to this just to remind myself of all the ways in which we touch the lives of Vermonters. It ranges quite a bit from very concrete clinical activities, like the chief medical examiner, nursing home visits for new families and laboratory testing, excuse me, to much more community based work, such as chronic disease prevention and health promotion, environmental health, testing of water and soil and air. I have great staff that are experts in all these fields that I rely on heavily to provide information and testimony whenever we need it. And today, I have Megan with me that will be joining us later to help with some of the financial pieces that you may all have questions. Just another slide to say, hey, we do more than this as well. We are responsible for compiling a number of reports, including state health improvement plans, state health assessment, health of Remodel 2030 dashboard, a variety of the ways in which we provide information to the state and things that we love to do. All right, this year is different, and you'll see that I know I'm the first person within AHS to give testimony before you, but AHS had a very different way of doing the budgeting process this year in comparison to years past. I am new, and I walked in sort of halfway through this process. So please understand that I was learning it as it was changing. But we knew it was gonna be a challenging budget year. We knew that we were looking at budget shortfall in the order of $75,000,000,000, and that we have a lot of critical services to Vermonters. And we looked holistically at all of our departments when we were lining up our budget and not just insular within each individual department to say, should we be making cuts? It was an interesting process because you had a lot of things that we all had to learn about these different programs that we hadn't been talking about in the past in corrections or in DCF or in Dale or in B. Everything was new to me, but I was learning about these programs and the importance of that. We made a prioritized list of what we felt was important and that informed a lot of these decisions. And I gotta tell you, none of these are easy because these are all important programs that we all care a lot about. Some of them felt really, really important that we knew we needed to continue when even looking at the list of potential cuts and others were felt to be less impactful for a variety of reasons. You're not gonna see a lot of ups in our budget. We have additions to programming through the Opioid Settlement Advisory Council and through the Rural Health Transformation funds, is we're still unpacking that, but we knew there was gonna be some program development in those spaces, but you're not gonna see ups within the governor's budget. So my understanding is this is a slide that we present every year to give the landscape of where our funding comes from. And this is our recommended fiscal year twenty twenty seven budget, which is just over $221,000,000. It's a 1.2% overall decrease from last year. Federal funding remains the single largest source of funding for us, which sometimes causes me to lose some sleep. General funds account for 11% of our total budget. The general general fund share of the budget plus the state share of global commitment is 22% of the department's budget. Compared to last year, the global commitment budget request is $5,000,000 lower, and the federal receipts are projected to be 1,100,000 lower.

[Rep. Eric Maguire]: Alright.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: So there are three proposed program eliminations. Two of them have a similar vein, and one of them is very different. And we have some sustained funding that I had listed below. So given the knowledge that we were looking at removing $75,000,000 in budgetary allowances in the budget, And when we were comparing the programs, some of these programs such as the Health Professionals Educational Assistant, which is a $4,000,000 program, and the AHEC program support, we like those programs. We like them a lot. But when we're comparing them to other programs like OT services for those with disabilities, it wasn't felt to be as impactful to the Vermonters in the same way. In addition to that, we knew that we were going to be having some ways to look at the way in which we're doing workforce development within AHS. We have an opportunity through some of the rural health transformation funds to reimagine the way in which we provide that assistance to the workforce development and support for health professions. So given those two things together, we are proposing to eliminate those programs. And then the third one that's listed there is discontinue efforts around implementing the unused drug repository. This is a program that had not been implemented. And I'm going go through in a little bit more detail some of these programs and what they do. But we've never been able to implement it because the amount of funds that have been allocated to it really no, we had no bites on an RFP for this because it was going to cost more than that to actually implement this process. So we had tried for quite some time, we never actually implemented it. All right. So again, VSAC, the proposed budget would end health care professional educational assistance programs operated by the University of Vermont statewide Area Health Education Center and by the Vermont Students Assistance Corporation. These programs provide either forgivable loans for students or loan forgiveness for practicing professionals in exchange for commitments and practice in Vermont. And the current funding level for the UVM program is two thirds of the $667,003,500,000 for the program operated by VSAT. So that's the first larger pot of money. The second proposed cut is in APAC, which is a recommended end to the Global Commitment funded grant of $500,000 that provides operating support for the statewide area health education centers. The focus of those centers is promoting careers in health care and local college, high school, and middle school students, not just physicians, but all healthcare professions. And it would also end up a $50,000 annual grant with UVM's AHEC program to recruit UVM medical students and medical residents to work specifically in Vermont. As I said, this year has not been easy. This has not been an easy choice. And frankly, these are programs. I I like both of them. And I wish we didn't have to cut anything. But given that we knew that we had the opportunity to continue to score workforce development in other ways, we are looking at those as. And the last one is the state prescription drug repository program. So this is an interesting program which sought to collect unused prescriptions and repackage them for distribution to patients, which sounds great. The actual cost of doing that is quite high. And frankly, I don't think that you would get this many hundreds of thousands of dollars in recruit meds. If you were to just have money for people to get meds filled, you probably would do better than this. I think it was a great idea. I just, we never were able to operationalize because it was cost prohibitive. So,

[Rep. Theresa Wood (Chair)]: sort of remember this coming through. Is there anything in state statute that needs to be changed about that? Was that mentioned in state statute? Not that I'm aware of, but I will confirm that. Okay. If it is and it's doing it, then we need to take it out.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Absolutely, completely agree. So again, full acknowledgment. This has been a tough budget year. Looking at cutting forgivable loans is a bitter pill for me specifically. I think when I'm looking at the entirety of the budget, though, and what's best serves Vermont, it makes sense in the broader picture, although it's not something that I like proposing, to be completely honest. And again, we like the message to be yes, and here's the way in which we're going to continue to serve the needs of Vermonters. Here's the way in which we're going to operationalize workforce recruitment and retainment in the state of Vermont. And frankly, we hope to have a better system when we're done re envisioning this. We welcome any questions.

[Rep. Theresa Wood (Chair)]: I was gonna say thank you for this pause because I'm seeing little twitches all the way around the table. So Representative Noyes, I think was the first to twitch. That's enormous. And then we'll move to Representative Maguire and whoever represent Garofano. Okay, go ahead.

[Rep. Daniel Noyes (Clerk)]: Thank you so much. And I definitely hear your concern with removing these programs and agree with you. However, yesterday at the older Vermont Stockist, we heard about the number of gerontologists, people going into gerontology is really

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: down- Really low, yeah. Really low.

[Rep. Daniel Noyes (Clerk)]: And I would be interested in any ideas you may have on how we can continue. We have to figure out this because we have this population, as you know, that's aging. And if we can't provide adequate healthcare, it's just gonna add to healthcare costs in our state. If we don't have people that are trained and going into the profession of providing gerontology and services to older I'll

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: tell you, when I first started practicing, I had no interest in being a geriatrician. That's absolutely what I ended up in for many, many years of practice in the hospital, because overwhelming majority of my folks were over the age of 17. That has changed in the last ten years where I'm seeing much more younger people, mostly led to substance use disorder, to be frank. But you're absolutely right. We need to have strong clinicians in many fields, but fields of primary care are vital. And the specialty training that's provided by a geriatric professional is not identical to that of internal medicine. There's a reason people do fellowship training in these programs. It is hard when the reimbursement of a fellowship program is less than that of if you were to graduate from your residency program and start practicing. Mean, that's really the rub. No accident that orthopedic surgery has become one of the most competitive residency programs where that wasn't the case twenty years ago because of the reimbursement associated with it. So I agree with you. I know a lot of this has to do with the way in which we reimburse medical specialties around our state. And I know that there's a lot of people within the state that are very interested in changing that and improving that and having primary care bolstered in many different ways. Getting folks to be interested in that fellowship program is a really challenging problem, but a lot of it does come down to financial incentives. I don't have any solutions, like which I do.

[Rep. Daniel Noyes (Clerk)]: Maybe you and I can work on this for the years to come as our

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Absolutely. It's not going away. You're right. And I think I would offer also, yes, you're right. Fellowship training program is ideal. Okay, if we can't get that, what do we do? How do we make sure that our healthcare professionals do have access to education specific to the care of elderly that are in primary care, internal medicine, or family medicine that are currently in practice. I think that's another important part of Thank you. Representative

[Rep. Brenda Steady]: Maguire, think you're next. Yeah, thank

[Rep. Eric Maguire]: you. Representative Noyes touched on pretty much where I was going. So I just wanna ask one thing. Is what's the is there any effect on anybody that's is there any participants currently participating in this program? And

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Yeah, there will be effects. Let's say that loud, you're right. The funding that we're looking at from the Rural Health Transformation has an exclusion for tuition reimbursement. It's in black and white. So we can't do tuition reimbursement, and that would be a change. What do people Who are in this program, you're right, would definitely be affected by this.

[Rep. Eric Maguire]: Okay, is it immediate cut, that's it? That's gonna make them aware? Unfortunately, we can't move forward with any All more reimbursement and then right, thank you.

[Rep. Theresa Wood (Chair)]: So I just wanna make sure I'm clear. So for people already in the program, you'll discontinue their participation and It wouldn't be funding to continue to support reimbursement. Support, okay. And how many people?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: I don't know the answer to that, but I can find that out.

[Rep. Theresa Wood (Chair)]: Okay. So I guess one of the things that we're going to be asking a bunch of data based questions and understanding, it's just our trying to understand implications of making some of these hard choices and what decision making process that you went through in order to come to these conclusions. So, Okay. And then we have Representative Garofano.

[Rep. Golrang “Rey” Garofano (Vice Chair)]: Great segue to my question. So I was hoping that maybe you can talk about the outcomes of the programs, not just the number of people that were impacted, and you can come back to

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Yeah, we've looked at that. And really, when you're looking at outcomes, I think what you're asking is how many people stay in Vermont to practice in primary care or in other fields. We have looked at that. It's not ever. It's also not as good as we think it could be. There are current clauses within the AHAC program that require a certain number of years of service. I think that could be improved upon to ensure people are more incentivized to stay here in a way that makes sense. So I don't have the exact retention numbers, and it falls off as you go on in years. But again, it's not horrible. It's just I think it could be better if we looked at this program and how we're doing it in the district to look different.

[Rep. Golrang “Rey” Garofano (Vice Chair)]: So based on that, I would encourage us to maybe think about some of those improvements rather than and I understand it's a hard we all know it's a hard budget here. The other question I have, which you touched on, but in your testimony, you said that the rural health grant might have some opportunities for workforce development. But then you also said that it has very explicit exclusions for tuition reimbursement. So I'm just hoping that the department will have a really good understanding of what we're allowed to do, because I know that grant has very specific guidelines for allowable uses, balancing that with making sure that we have something for workforce development as we know how desperately we need, especially primary care. And I know both of these programs slated to be eliminated, really focused on that, the end of the spectrum that we have great, great need for.

[Rep. Theresa Wood (Chair)]: Absolutely. I'm just going to follow-up on that for a minute before we cut down. No, you asked

[Rep. Jubilee McGill]: my question and Ray kind of touched on mine with wanting more information on that. Every

[Rep. Theresa Wood (Chair)]: time we talk about healthcare in Vermont, we talk about the lack of primary care. And I'm just trying to figure out sort of the decision making process when we look at things like this that even could maybe even more focused. So if rather than sort of eliminating them or maybe potentially reducing them and sort of like having a laser focus on for instance. I'm trying to figure out how this comports to everything we see in health care reform and in the transformation grant and everything is in the blueprint is the need for more primary care to reduce the reliance on emergency departments and hospital based care. And I'm just trying to figure out how this relates to that very identified need.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: And again, it's reduced funding for tuition reimbursement. That's not going to increase the amount of primary care physicians that want to come to Vermont. Again, I do think there's an opportunity with the RHDP. It's a different way of looking at it. It's not tuition reimbursement. It's scholarship programs and other ways to incentivize individuals to go into medicine and to stay in practice in Vermont. We can structure that program in a way that does continue to incentivize primary care. To your question, we do got to get all the details about exactly the rules around this, because I know some of them, not all of them. But I completely agree with you that whenever we're looking at specifically physicians, when we're looking at workforce development of physicians, we need to make sure we're addressing the gaps that we have, not just the generic folks. The other piece that I'm frankly very optimistic about is the non physician staff, where we have a real opportunity there that we can really look at LNAs and RNs and all the other health care professionals, med techs, you name it, our state that we're lacking that cause real problems in gaps, whether it's in residential facilities and hospitals, clinics. Because it's not just physicians. Yes, we have the needs for physicians, but we have physicians in many other fields that we can, again, relook at this program with a different lens and say, hey, this is what we need for today.

[Rep. Theresa Wood (Chair)]: I'll hold my next question. So, Oh, no, you do cover mine, we're asking Nancy. Okay, then we have Representative Cole, Representative Steady, Representative Eastes.

[Rep. Esme Cole]: I too was wondering about percentage utilization rates of the money that was budgeted for these programs. Maybe that's for the next

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: time. Utilization of the funds or?

[Rep. Esme Cole]: For the loan forgiveness in particular, how was it completely being deployed when we did have it basically, or were some being but it's not all utilized?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Yeah, and I'll let Megan weigh in on that later, but I believe the answer is yes, they were all utilized. It wasn't a question of utilization. When we look at outcomes related to this, we're not just interested in making stay in Vermont. So that was the main outcome metric is, hey, after we get these tuition reimbursement out, how are people staying in Vermont and for how long? Because obviously life comes up and people move for a variety of reasons and there's hooks in it. But what's the duration people stay in the state? And that was the main outcome I should look at.

[Rep. Esme Cole]: And as a former dental assistant to these two dental issues, I'm curious if you've talked to people in the field in that specific industry about these programs and how they've affected them for

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: the most These programs? Yeah. I have not specifically talked to the dental industry about this. I'm very acutely aware, and I talk about it in every single district office I go to, about the huge gaps we have in dental access and something, frankly, the health department works really closely to try and help with. Again, I do think we have an opportunity to look at more holistically health care in the state and not just look at physician staff, which listen, I'm a physician, and sometimes I'm very myopic about looking at physicians' needs. But that's not my role, and that's not the way we should be looking at. This should be dentists and dental hygienists, because dental hygienists make huge need within our state. Is there opportunity to have funding for that as well?

[Rep. Brenda Steady]: Groups and study. That might be a dumb question, but what's IDT stand for? And then I have another one, I'm just curious. I don't

[Rep. Theresa Wood (Chair)]: know the initials like Departmental transfer. Yes. Well, that

[Rep. Brenda Steady]: they can transfer those imbalances needed. Between departments.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: When there's a memorandum of understanding of a grant that the Department of Children and Family have that we're also part of, they would give us one. I just didn't know.

[Rep. Brenda Steady]: And then my other question is, do you get $1 amount and then your office or department decides where the cuts will be, or does the governor's reclamation actually give these details? So we didn't even look

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: at it as a department. We looked at it as an entire agency and said, hey, we're looking at on the order of this amount of cuts. And we said, hey, here's some programs we could consider in that pile. And the whole agency did that and said, here's the pile. What makes sense to cut versus what makes sense to keep? And that's sort of how the process went. Yeah, I'm just learning. Yeah, me too.

[Rep. Brenda Steady]: So you get $1 amount, and then your agency decides where that money's gonna go.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: It's more about we're looking at reductions in budgets.

[Rep. Eric Maguire]: Okay.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: We're looking at reductions to the order of the tune of this amount of money. And then we look at where are potential programs that we could reduce to get to that funding target. It's not a start from zero and let's build a brand new budget. It's more of a let's start where we're at and where can we reduce.

[Rep. Brenda Steady]: And the reason I asked this because somebody on livestream will say, I can't believe governor Scott got 4,000,000 from educational assistance. So he literally did. He just gave you a dollar bill. That's all I

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: just want. To be fair, though, we looked within the agency, and this was extensively reviewed by the governor and the governor's team.

[Rep. Theresa Wood (Chair)]: Yeah. I I just wanna be clear. This is the governor's budget.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: This is the governor's budget.

[Rep. Brenda Steady]: Yeah. Know. But he signs off after your agency decides.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: We make proposals. We make proposals. I understand. It's really

[Rep. Brenda Steady]: That's good. Yeah. I just wanna get some.

[Rep. Theresa Wood (Chair)]: Yeah. Well, I I just wanted to make sure that everybody was clear that this is the governor's budget. The governor is making Right. Right. As the chief executive He is. As the chief executive officer of the the governor presents the budget to the legislature. That means, yes, he is signing off on everything in the budget.

[Rep. Brenda Steady]: Correct. No, I got a pen. Okay. Okay. Alright, Representative Bishop.

[Rep. Theresa Wood (Chair)]: Was referenced to

[Rep. Doug Bishop]: a $75,000,000 shortfall. Is that at the agency level or is that what the Department of Health was asked to your agency?

[Rep. Eric Maguire]: In the agency of

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: human services, hey, we're looking at around this quarter. Okay.

[Rep. Martin LaLonde (Chair, House Judiciary Committee)]: Thank you.

[Rep. Brenda Steady]: Hi, Representative Donahue, you have a question?

[Rep. Anne B. Donahue (Ranking Member)]: Yeah. Thank you. I I wanted to clarify between the slides and the comments you were just making about doctors and the opportunity to look at non physician. On slide eight, those are the three programs being cut. And one of them is specifically for the dental hygienists and another nursing. And then there's the dentist.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Those are

[Rep. Anne B. Donahue (Ranking Member)]: all the ones being cut.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: You're correct. There's a large pot of money that is more specifically for entities. You're right, though. It is not the funding that we currently have is not just for entities. I I didn't mean to Right. Say that. You're right. It is for variety, but it has some limited sort of buckets in which it's in, and we would like to make that even better.

[Rep. Anne B. Donahue (Ranking Member)]: So do you have a breakdown of each of the existing buckets of, like, what is the hygienist program amount, what is the nursing amount versus some of the VMD buckets? Not today on the spot. I can get that.

[Rep. Theresa Wood (Chair)]: Did anybody else have their hand up before I ask? Okay, So it would also be helpful to make sure that we're understanding all this in addition to what the members have asked for, to understand how long the programs have been in existence. I know that they've been collaborations between the health department and the legislature in the past around these professions. And there are some of them. I know AHEC's been around for a long time. The loan forgiveness program's less time. And so if we could have the length of time, we want to know the number of people who have gone through the program. We want to know the number of people who are going to be impacted now who are currently in the program. So that's that on that. I'm switching thoughts. You are continuing to refer to the Rural Health Transformation Grant. And being on the Healthcare Oversight Committee, I probably have some familiarity with that, certainly non expert. I'm not sure that what we're talking about here, and I know it's not gonna be replicated. I'm not really understanding when you say we hope to have new opportunities. Could you elaborate what you mean by that? Because I didn't really see that in the The grant is a lot focused on purchasing things and providing ventilators for nursing home. It's not so much focused on staffing, although it does try to address workforce. I

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: would definitely encourage you to talk to the folks who are overseeing this program for There greater are four main pieces of work within the Rural Health Transformation bucket. The fourth one is workforce development. So there's a significant amount of funding that is earmarked specifically for educational programs for health care workers and workforce development. You're right, there's a lot of it that's around structural changes, regionalization, IT systems and other things, and then blueprint money. But the fourth pillar, if you will, is around workforce development.

[Rep. Theresa Wood (Chair)]: So that's a five year grant, right? So the things that we're looking at, I guess I'm thinking particularly around AHEC services that have been part of our health care education and workforce development and workforce support for a long time. I'm just wondering, even though there might be a short term opportunity with that grant, it's definitely not something we're building into the base budget and it is only something that's available for five years. So I And guess we'll just be asking more questions, I think. And our budget team, which is Representative Maguire and Representative Eastes for the health department, will certainly be digging into this more and will bring back more information. So are there any other initial questions?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Yep, I move on. Thank you very much, I appreciate it.

[Rep. Theresa Wood (Chair)]: Thank you. And you're welcome to pull up another chair if you can sit there together, doesn't matter, it's all good.

[Rep. Doug Bishop]: The chair right there.

[Megan (VDH Finance Director)]: Records, Megan Hope, financial director for B.

[Rep. Esme Cole]: Megan, are you new to that position?

[Megan (VDH Finance Director)]: I've been in a financial director role for two or three years now, but just last year I kind of started coming in to do our coaching. Ah, okay. Was gonna

[Rep. Theresa Wood (Chair)]: say another person. Somewhat new, but not really. Not really. Okay, well thank you. It's nice to meet you.

[Megan (VDH Finance Director)]: So as Doctor. Hildebrandt mentioned, we have our proposed budget this year. Just a quick overview

[Rep. Theresa Wood (Chair)]: for those

[Megan (VDH Finance Director)]: of you, if you're not familiar, the health department budget has three different appropriations. And this slide kind of gives you some detail about what specifically is in each appropriation. So our administration and support appropriation, public health, and substance use programs. So we'll go through one by one of those. And you're all familiar, the lovely AHS ups and downs, which I think you'll probably just go the first department to come in. I don't know. I was

[Rep. Theresa Wood (Chair)]: just gonna say, you were like the first to appear other than Commissioner Gretchen did a broad overview on Tuesday. Before you kind of get going, I'm just curious. I think that you all received an email from the House Appropriations Committee Chair about the process and the information that the legislature would be expecting this year, which was definitely more than ups and downs.

[Megan (VDH Finance Director)]: We are working on gathering that documentation. We expect have it ready when we go to house appropriations. We weren't quite expecting to be in this early, so we're working on it. We do have some items in an appendix to these slides that you can see. So we've got a piece of it, but we are working on getting productive.

[Rep. Theresa Wood (Chair)]: So we may, in fact, ask you to come back if we have questions as we go through that. It probably won't be as long, but appreciate the fact that you're working on that. Thank you.

[Megan (VDH Finance Director)]: It should be posted when

[Rep. Theresa Wood (Chair)]: we go back. Okay, thank you so much.

[Megan (VDH Finance Director)]: Again, this very first section of the ups and downs in admin and support is personal services. So these are just the net changes to salary and fringe costs from fiscal year twenty twenty six to fiscal year twenty twenty seven.

[Rep. Theresa Wood (Chair)]: Again, I'm sorry for interrupting, but would you like questions at the end? Do you want to stop when you

[Megan (VDH Finance Director)]: If you can think of it while we're on the slide, I'll try and answer then. If not, I can

[Rep. Theresa Wood (Chair)]: do a mix. Okay. So before we move to the next slide then. So it's our understanding that in the budget instructions from the governor that you were asked to accommodate salary fringe changes, all of the sort of contractual obligations within state government within that overall 3%. Is that correct? Okay. And then can you tell us what you are expecting with regard to, and I'm not looking ahead, so maybe you just say this, like vacancy savings. What have you budgeted for vacancy savings? And how does that compare to previous years?

[Megan (VDH Finance Director)]: I will have to get back to you on vacancy savings. I thought I had a note about it, but now I'm not seeing it. I believe our vacancy savings rate was left unchanged from prior years, but I can follow-up. Okay, all right, thanks.

[Rep. Theresa Wood (Chair)]: And then we're seeing, obviously, we were aware last year that there were some reductions in grants that sort of immediately ended for the health department. And so could you explain the impact on both the numbers and the types of staff that you have with regard to any federal reductions that you've experienced?

[Megan (VDH Finance Director)]: So I'll try and piece that out into two things. The reductions in those grant programs that Doctor. Hildebrand talked about are just the They're in the grant's major object of the budget, so there's no impact on staff there. So we're seeing a

[Rep. Theresa Wood (Chair)]: lot of reductions here in federal funds. What's So

[Megan (VDH Finance Director)]: what happened here, this is the net changes of everything over the year. There are 59 positions in our '27 budget compared to 62. Part of that is two positions that were in the admin and support division have moved into public health. So those positions are still at the health department, they're just listed in a different appropriation. And then there was one position in the admin appropriation that was RIFT because of the cancellation of the federal health disparities So two moved and one And

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: those was

[Megan (VDH Finance Director)]: three changes are all summarized in all of these

[Rep. Esme Cole]: ones, Thank you.

[Rep. Theresa Wood (Chair)]: Appreciate that. Anybody else have

[Megan (VDH Finance Director)]: any questions on that slide? Great. This next section shows a change in our internal service fund charge from fiscal year twenty twenty six to 2027 in the operating expenses. The ADS allocated charge amount, that line, what is it, 516,685, Agency of Digital Services, reflects a change in how services are being billed to the Agency of Human Services and then to individual departments. So some charges that were previously included in the AHS allocation to departments are now being billed to departments directly. That, for example, on that line, you'll see it's a million dollar, 1.5 up. The reason for that

[Rep. Theresa Wood (Chair)]: is just a change in how ADS is doing their work. So would we then be expecting when AHS central office comes in a decrease in what we see there?

[Megan (VDH Finance Director)]: Potentially, yes, I believe so. And when we come in for budget adjustment, when we previously came in for budget adjustment, we had that ADS Yes. In theory, this is what we're expecting to have happen in the future, is more costs directly billed to the departments, fewer costs to the agency to then be pushed out to the departments.

[Rep. Theresa Wood (Chair)]: Do you have any idea, maybe I'll check-in with energy and technology. Do you know what the calculate is? Is it based on usage? Is it just based on employees? Is it based on projects that they're doing?

[Megan (VDH Finance Director)]: That is a good question. And I admittedly, I am not in the agency additional services finance office. I'm not sure how exactly is it.

[Rep. Theresa Wood (Chair)]: I know you don't have any choice in it. I'll ask my counterpart in energy and technology. Any

[Rep. Golrang “Rey” Garofano (Vice Chair)]: other questions?

[Megan (VDH Finance Director)]: Next slide is where you'll see some of those programs that I mentioned, the two program staff that moved from the administration appropriation into the public health administration. So the first three lines in this section, the Rural Health System Improvement, Clinical Development and Support, and the Healthcare Quality Assurance, all those labeled net neutral, those are the activities that have moved from the administration appropriation into the public health appropriation. So you'll see a down here and a corresponding up in our public health appropriation. Programs are not going away for those. And then the next two lines reflect the program cuts that Doctor. Hildebrandt mentioned earlier, so the AHAP program support and education loan repayment. Those two are two of the proposed program allocations. And then finally, the last line here, the quality improvement prescribing is again another program that is moving from administration into public health.

[Rep. Theresa Wood (Chair)]: Do you have any idea what proportion of this five fifty to AHEC is? What proportion of that, of their budget that five fifty represents?

[Megan (VDH Finance Director)]: That is a good question, and you could look that for me.

[Rep. Theresa Wood (Chair)]: Okay. Something else, I'm seeing our budget team take feverish notes.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: And

[Rep. Theresa Wood (Chair)]: I guess I'm curious about, and this is maybe for you, Doctor. Golrang Rey. So I see quality, you're retaining quality improvement prescribing, and that's a state funded program. Curious about the decision to retain that over AHEC, for instance. How did that decision process work within the department and agency?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: And admittedly, when I had entered the process, we had gotten far enough that that wasn't on the list of proposals. So at the point that I had entered, there was a list of slated years, potentials, and that wasn't there. So I can't be able to speak to that. Okay.

[Rep. Theresa Wood (Chair)]: I appreciate that. So our team may be looking a little bit further into that because I, when we're weighing things, we need to weigh what we should keep and what we shouldn't. And we'll need to know a little bit more about that. You, Mary.

[Megan (VDH Finance Director)]: Yeah, if there are no more questions, this is the end of our administration appropriation. I'll move on to public health. Again, very similar. You'll see this is within our public health appropriation, the net changes in salaries and fringe. So because of that reorganization, we had There are five ten positions in fiscal year twenty twenty seven compared to the five thirteen that were in 2026. There's the two positions from administration that have come into this. Have 11 new positions that are moving from our substance use appropriation to public health. So these are all additions to the public health administration appropriation. There's one new position and then 17 positions were eliminated. So

[Rep. Theresa Wood (Chair)]: a

[Megan (VDH Finance Director)]: lot of information there, but an overall net reduction of three positions within public health.

[Rep. Theresa Wood (Chair)]: And I'm interested in the 11 from substance use. And

[Megan (VDH Finance Director)]: I can talk about it here, I can talk about it either way. Essentially, we had 11 positions out in each of our district offices about ten years ago. I've been at the health department about ten years. So it's been as long as I've been at the health department. But shortly before that, the positions were located in our public health appropriation within the district offices. They were moved from that into the DSU appropriation. We're now basically changing that again. We're taking those positions that have always been district based and worked with our districts, worked out in the local communities. We're taking them and putting them back into the district office's kind of organizational structure. So if they were within substance use, then we're putting them back into household.

[Rep. Theresa Wood (Chair)]: Were they central office positions? They've always been out in the district.

[Megan (VDH Finance Director)]: So again, it's kind of just an organizational blow.

[Rep. Theresa Wood (Chair)]: I understand what you're saying. I guess my bigger question is, are they going to continue to work on substance use issues?

[Megan (VDH Finance Director)]: Yes, they are continuing. The work they are doing is staying the same. It's really just an organizational reporting structure.

[Rep. Theresa Wood (Chair)]: I'm just gonna say, is it that's who they're gonna report to? Okay.

[Megan (VDH Finance Director)]: All right. Go ahead, Representative Donahue.

[Rep. Anne B. Donahue (Ranking Member)]: So just so I know they might be small subcategories, but do you give us a general overview of the positions that have been eliminated? Yes. The net positions you've got.

[Megan (VDH Finance Director)]: Do you want the up positions, down positions or just the ones Okay, that yes. So we had 13 positions that were related of the eliminations that were for COVID response era grants. So some of our supplemental funds for Epi Lab capacity, public health emergency response, immunization, and STD, sexually transmitted diseases. Two positions, again, were related to that health disparities grant that was terminated. Two positions we had where the federal grant work had ended. So there was a I forget, I'm gonna say the acronym and I forget what it stands for. CARA First Response and Sudden Unexpected Infant Death. And then, so that's the total. Those were

[Rep. Theresa Wood (Chair)]: helpful. Helpful. Thank you.

[Megan (VDH Finance Director)]: Any other questions on this side?

[Rep. Eric Maguire]: Right now

[Megan (VDH Finance Director)]: I'm all discombobulated at grounds. And the last line in this section is, again, as Doctor. Hildebrandt mentioned earlier, that unused drug repository contracts that we're no longer pursuing. The funding has been in our budget. As Doctor. Hilzebrandt mentioned, it wasn't enough to do the work that we wanted it to do. So this is that third and final program. Nature. And then in our operating section, you'll see the change of fee for space. That's increased occupancy costs for our public health laboratory and other state owned office buildings that the health department utilizes. And then the medical and lab supplies line is a You'll see a lot of this from us. Again, we're moving our spending authority this program to the substance use appropriation. This is the statewide NARCAN institution. I'm just gonna ask you.

[Rep. Theresa Wood (Chair)]: Oh, I'm sorry, go ahead.

[Rep. Eric Maguire]: The fee for space charge, the space obviously outside, how much of that space is actually manned and being utilized? There are people there.

[Megan (VDH Finance Director)]: So this and our public health appropriation, it includes all of our district office buildings. Admittedly, I can't speak to the occupancy rate in those district office buildings.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: I can just say my, anecdotally, walking around, they're full. Their employees are there every day. There's some offices that are leased to other folks that are empty, but they're full buildings.

[Megan (VDH Finance Director)]: In addition, our public health laboratory has staff that

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: are there.

[Rep. Golrang “Rey” Garofano (Vice Chair)]: Any other questions? Oh, I'm sorry, I had to step up quickly, but the fee for space charge, you may have said this and I missed it. Is that related to the move to Waterbury? No, that is not.

[Megan (VDH Finance Director)]: This is just a general, we're anticipating a 3% increase in the costs for our space. Is any of

[Rep. Golrang “Rey” Garofano (Vice Chair)]: the costs associated with the return to work, are they reflected in this at all? No, not in the health department.

[Megan (VDH Finance Director)]: And finally, have our public health grants major object. Again, here you'll see some of those programs that we were taking out of administration coming into public health, so that rural system improvement, clinical development support, and then healthcare quality assistance.

[Rep. Theresa Wood (Chair)]: So there is some still education loan repayment. Yes, so that is a federal grant that the Health Department received. So that program is changing. And who is that targeted towards?

[Megan (VDH Finance Director)]: Have to get back to you on that. Okay, thank you. A few more items in our public health grants line. We have our immunization program is asking for about a 7.5% increase in vaccine, or we're budgeting for a 7.5% increase in the cost of vaccines that are used in the Vermont Vaccine Purchasing Program. As you all are probably very well aware, we've heard a lot of testimony on that lately. The program ensures universal access to vaccines for all people in Vermont at no charge to the individual. And the program costs are funded by assessments to health insurers and then deposited into a special fund and used solely for the purpose of administering the program.

[Rep. Theresa Wood (Chair)]: And are the fees that are being charged to those folks, are they keeping up with the cost?

[Megan (VDH Finance Director)]: That is why we are asking for the So they're not? Well, we're anticipating a need for increased costs.

[Rep. Theresa Wood (Chair)]: They're not covered by the special fund. That's why I'm asking, is the special fund funding 100% of the

[Megan (VDH Finance Director)]: Yes, the special fund for the vaccine purchasing program, yes. The special fund is funding 100% of the cost, but we're anticipating higher costs for some vaccines in the coming year, which is why we have

[Rep. Theresa Wood (Chair)]: the increase. Okay. So there's offsetting revenue to this 1.7 in other words?

[Rep. Eric Maguire]: Insurance. Yes.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Okay.

[Megan (VDH Finance Director)]: The next slide, HIVAIDS services. This is another budget neutral change because of program transfers within the health department. The syringe service program, this is what that represents is now being housed out of our substance use appropriation. So you'll see a corresponding bump in substance abuse production.

[Rep. Theresa Wood (Chair)]: Is that appropriation, that's the general fund share. Are there, federal funds in that or some special Ryan White funds or something?

[Megan (VDH Finance Director)]: Yes, it's a different Ryan different

[Rep. Theresa Wood (Chair)]: programmatic effort. It

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: can't be SSPs.

[Rep. Theresa Wood (Chair)]: Yes. I'm sorry, what did you say?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Can't be the string service programs.

[Megan (VDH Finance Director)]: The next two lines, the Maternal and Child Health Program grants, IDT down, and that's, sorry, interdepartmental transfer represents a shift in the preschool development grant that is run by the Department of Children and Families. They've had that grant for a few years now. The health department has been partnering with them and we will continue to, but basically there's just a shift in who's doing what for that brand. So DCF, some activities that the health department was working on, DCF is going to take on in the coming year. The health department still is having some of those helping and working on that brand, but we have just less. We are doing less DCF as well. And then the question? Yes, go ahead, Brooke.

[Rep. Jubilee McGill]: Are the overall grant amounts, this is kind

[Megan (VDH Finance Director)]: of net to neutral, it's

[Rep. Golrang “Rey” Garofano (Vice Chair)]: just being moved, or

[Megan (VDH Finance Director)]: are the overall grant amounts across AHS decreasing at all in this? I would have to defer to DCF on the PDG grant specifically, just because it's not held directly by the health department. I can say the amount that the health department is going to receive and anticipate spending out of that grant next year is smaller. The next item we have is a net neutral to DIVA. The school Medicaid assistance claiming program has been run by the health department. It is going to be moving to the Department of Vermont. So, keep going. Yep. So that was the end of our public health appropriation. And now we are in substance use programs. Like So, a broken record, but we have all of our net salary and fringe changes represented on this slide.

[Rep. Theresa Wood (Chair)]: Are the changes in classification, or not classification, but the positions moving to

[Megan (VDH Finance Director)]: public This represents the 11 positions in the district that were in the public health, the substance use program, sorry, and

[Rep. Theresa Wood (Chair)]: are moving to the public health appropriation. This is probably too deep of information, but I'm going to ask anyway. Since they're doing substance use, their work is related to substance use. And I realize that they're located in district offices. Were they not getting sufficient supervision and support from central office? It seems a little bifurcated to me. I'm just curious.

[Megan (VDH Finance Director)]: And maybe we should ask Kelly, I don't know. My understanding is that it has been a, the work has always been done within the districts. Yes, they are doing substance use prevention work. However, those staff have always really been district focused, district centered. They work within their communities, therefore it made more sense programmatically to house them within the office of local health had they previously worked. And I don't know if you

[Rep. Theresa Wood (Chair)]: We'll ask DSU for some additional information, just because I'm sort of honestly thinking also about in the back of my head, ACT 119 recommendations that have come up around DSU, and I'm just wondering out loud about this.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: This is all prevention work, to be It's not treatment work. It's not the 119 treatment arm of DSU. This is all prevention staff that work in the district offices.

[Rep. Theresa Wood (Chair)]: So do they connect with the local prevention coalitions? Is that okay? In addition,

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: a lot work in schools.

[Rep. Theresa Wood (Chair)]: A lot of work in schools, yeah.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: I've been connected with a number of them. They're very much a fabric of the district office. I can tell you philosophically, they are part of the district office. Yes, they do substance use work, and we have people in our district offices that do work that is also represented at our central office, but they feel like they're, and they

[Rep. Eric Maguire]: are, a part of that community.

[Rep. Theresa Wood (Chair)]: Okay, thank you.

[Megan (VDH Finance Director)]: Any other question on physician changes? The one operating change you will see is again that syringe service, or I'm sorry, the opioid antagonist program moving into substance use programs. Then finally, our grant's major object, the Substance Use Prevention Grant account code, you'll see an increase in the annual appropriation from the Substance Misuse Prevention Fund. The source of funding for this special fund is the 30% cannabis excise tax revenue. And the administration estimates that the amount available in fiscal year twenty twenty seven will be a total of about 9,500,000 Okay.

[Rep. Theresa Wood (Chair)]: Will you explain, will you just say that again? I'm sorry. Trying to follow what's on the page with what your words say and I'm not saying.

[Megan (VDH Finance Director)]: So this substance use prevention line, 602910, we have an overall up in that line and the special fund increase of about 2.5 or yeah, two zero five ish, that represents the increase in substance misuse prevention fund. So the Substance Misuse Prevention Fund is sourced from the cannabis excise tax. Yes, I'm familiar with that. 30% of that is deposited into the substance misuse correction special bond. And say again, what the total would be in this. We anticipate the total revenue in fiscal year twenty twenty seven or total available to be 9,500,000.0. We had a previous appropriation of almost 7,000,000. So this $2,000,000 increase gets us to that full 9,000,000. I

[Rep. Theresa Wood (Chair)]: guess we're going to be looking for how you intend to use those funds. Again, that comes to the Appropriations Committee Chair and Vice Chair's request to understand. We realize that it's set in statute, much and prevention is all good. I think that it will be helpful to hear more about how you intend to use those funds in future testimony. Yes, go ahead, representative.

[Megan (VDH Finance Director)]: Thank you. This is

[Rep. Golrang “Rey” Garofano (Vice Chair)]: just general question about grants and contracts out of Vermont Department of Health? We've heard testimony in other areas. I think some may been associated with the BAA, but just generally that there's delays around getting money out the door. And I know last year we had some issues with opioid settlement funds. So just wondering if you have an update on how that's going, what the improvements are.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Yeah, the feedback I've heard specifically has been in our substance use programs. And that is something that I'm directly involved in proving because it has taken too long. I fully acknowledge that, and it needs to be faster. Frankly, we need to be more nimble with distributing funds in a lot of different ways, But they're working with that division to make sure that we can do that as a definite priority one. Not fixed, and it's not going to be fixed quickly, but I am working very hard with that division to ensure that we can get money up there faster.

[Rep. Golrang “Rey” Garofano (Vice Chair)]: Just to follow-up as well, I just want to kind of put my concerns on the record for the Rural Health Grant, that those are time limited funds that we can't, we would literally have to give back if we can't get that money out the door, and just really encourage you to work with ADS. I think they're really wanting to be collaborating on some of the requirements that slow some of the process down. So I think if you're not already collaborating with them, that might be a good place.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: Yeah, that is, I was hinting at a little bit, yes, I completely agree. We are going to be very diligent in making sure that we have the money obligated and spent in exactly the timeframes of the federal government. We do not want a dollar to go back. So completely agree. We will work with ADS and others to make sure that we can get this.

[Rep. Theresa Wood (Chair)]: I appreciate your attention, your personal attention to the substance use grants. It's honestly been several years now and there are small providers out there. Cash flow is a real issue. And one of the things that we're encouraging is we recognize that there sort of are different operational elements of a grant. And there don't always have to be a separate grant for each function. And to the extent that we can have grants that cover multiple functions and multiple funding sources, that could ease the work on the inside of VDH as well as on the reporting and oversight side of things. But go ahead, representative.

[Rep. Eric Maguire]: Just to touch on that, it's the money getting out the door. Also, what I'm hearing from there, and I've heard it from many providers, the grants haven't even been executed. For the rural health transformation fund? Or for this no, no. DSU. DSU, there are DSU, whether it's for the recovery centers and other providers that

[Rep. Theresa Wood (Chair)]: Okay, settlement funds.

[Rep. Eric Maguire]: Yep, that were supposed to be executed on, say, October 1, haven't even been executed yet. I know it's difficult to get money out the door, but it starts with getting the The grant done. The grant done and executed on the grant. So we hope to see significant improvements in that too. That's correct. We had a recovery center that literally had to go out and take out a loan to make SAP pay.

[Rep. Theresa Wood (Chair)]: Thank you. Representative, you. Just

[Rep. Anne B. Donahue (Ranking Member)]: this is a pretty generic comment, looking at all of these, are helpful or not necessarily all that helpful, the categories, but it's really helpful to see what's up or down. But what is really missing for a broad perspective is what's the full amount in that, You know, I can look at substance use prevention, you know, six zero two nine one o. And I see, okay, there's an add, there's a subtract, that's the total add. But is that out of a $5,000,000 total budget that now 1.4 is added or a 50,000,000 or a 1,000,000? So you more than doubled it. Yes. It's like

[Rep. Theresa Wood (Chair)]: That's that's part of what the appropriations committee is asking.

[Megan (VDH Finance Director)]: That's that's part of It's what the going to be. All right, thank you.

[Rep. Anne B. Donahue (Ranking Member)]: Thank you, I'm so happy. Any

[Megan (VDH Finance Director)]: more questions on substance use prevention? We move on to the substance use intervention. That, again, is the corresponding increase to the down that was in the public health appropriation for our syringe service program. In substance use treatment account code, we have a change in the general funding mix of how we are funding this category. There is an increase in federal funding and a decrease in general fund and global commitment funding. Again, we're just kind of aligning the mix of funding more to how it has been.

[Rep. Theresa Wood (Chair)]: So I'm curious, since we're seeing a decrease in global commitment investments, what's the

[Megan (VDH Finance Director)]: other source of federal funds? There's the substance abuse block grant, is a good portion of that. So did you

[Rep. Theresa Wood (Chair)]: get an increase in that block grant or is that you're just you using

[Megan (VDH Finance Director)]: We're it again for different more better aligning the budget with how our actual spending has been in this particular code. So we haven't necessarily seen the total budget for that line is, or for global commitment is, sorry, I'm getting ahead of myself. The overall budget for that line, that substance use treatment line, is 39,500,000.0. So that kind of gets to your question, what's the total? 85% of that $39,000,000 is global commitment funds. So relatively speaking, 1.4 down is small. Does that help answer your question?

[Rep. Theresa Wood (Chair)]: Oh, no, that answers your question perfectly. Just say we don't often see a reduction in global commitment and an increase in other federal funds, particularly now. So that's all.

[Megan (VDH Finance Director)]: Then our last line is the certified community based integrated health centers. This change is a transfer of funding from the health department to mental health for treatment costs budgeted for providers who are transitioning to that certified community based integrated health center model. The payments to the providers is changing from a fee for service billing model to a per member per month that will be paid for by the mental health department. And that is that Medicaid, you'll see an up in DMH, corresponding increase in their budget. There is not, that is the last budget slide. It's the last change in our appropriations. Any last questions?

[Rep. Theresa Wood (Chair)]: I think we've sort of peppered you with enough questions. Handled very well. So thank you. Thank you. We appreciate that, Megan. So our We have some additional sort of background information to follow. Are you going Do you want to go through that? Or how do you want to go through that?

[Megan (VDH Finance Director)]: Our responses to your question?

[Rep. Theresa Wood (Chair)]: No. I just need

[Megan (VDH Finance Director)]: our slides. Those were I apologize, I stopped sharing my lines. That's okay. Do you want mine? No, it's fine. The first three slides were the AHS ups and downs. The whole picture I noticed the agency hasn't been in yet, so I wanted to give you the full version rather than just chunks of it as it was in our presentation. And then the remaining slides were just some additional information for you all about the health department, each of our programs, divisions, the work that they do. So that's great. It an attempt for us to give you some of

[Rep. Theresa Wood (Chair)]: that supplemental I appreciate that. Thank you so much. And I will keep our Megan straight. I know, I know, Megan Steady. And how do you pronounce your last name? Oak. In joke. Yeah,

[Megan (VDH Finance Director)]: Oak. Great.

[Rep. Theresa Wood (Chair)]: Are there any other questions for the witnesses today? Yes. Go ahead, representative Bishop.

[Rep. Doug Bishop]: Just some clarification on the section b three twelve, the public health maternal and child health program grants, which I think you said was being shifted more towards DCF to DCF to execute. There's no reference to that. Is that because it's outside of Department of Health and in DCF?

[Rep. Jubilee McGill]: Correct. Yeah, I made a note of it to ask DCF.

[Rep. Theresa Wood (Chair)]: I'm sure we'll see a corresponding up in the DCF.

[Rep. Eric Maguire]: I'm hoping

[Rep. Jubilee McGill]: to find out what I'm not

[Rep. Theresa Wood (Chair)]: sure which type. In yours? I think so. PDG. Okay. Other questions? Thank you both for being here, and look forward to additional information. And hopefully it wasn't too rough, you know, your first budget.

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: I appreciate you, but the understanding that I disanswered. Absolutely,

[Rep. Theresa Wood (Chair)]: absolutely. No, we appreciate that and also appreciate your assistance previously with our discussion around H545.

[Rep. Eric Maguire]: Thank you.

[Rep. Theresa Wood (Chair)]: Okay, so the VDH team being our local here team on the House Human Services Committee, I almost call this appropriations. House Human Services Committee team. So you have some stuff to look into. You'll be getting more information, but you've got a little bit of a head start on the rest of the crew. And let us know how we can be helpful. And just to remember that you will be, as a result of this budget presentation, you will be, I'm sure you'll hear from AHEC. I'm sure you'll hear from the medical society. I'm sure you're going to hear from other folks. So it's going be up to you to recommend who we will hear from that are community partners. That's

[Rep. Esme Cole]: great.

[Rep. Theresa Wood (Chair)]: Any other questions on budget?

[Rep. Jubilee McGill]: I have heard feedback from not so much questions, but comments, feedback from community partners that it is they're struggling to make some of their responses and recommendations, because they're still waiting on some of that information from the department. So that was just kind of, they're struggling to fully flesh out the information and what they hope to ask in their meetings with us because they don't quite yet have the information and detail they need. So I figured I would just kind of pass that along to you.

[Rep. Theresa Wood (Chair)]: Well, hopefully they have more information now to see where there are some at least ups and downs.

[Rep. Jubilee McGill]: I think it's that big detailed 1,500 page, big one that has all of the that you really you know, it's long, but that's what they use, and that is not out yet, I think, or some kind of replacement with all that information. I think

[Rep. Golrang “Rey” Garofano (Vice Chair)]: The ice and downs are not available yet. We don't have them for the health department.

[Rep. Theresa Wood (Chair)]: So we

[Rep. Golrang “Rey” Garofano (Vice Chair)]: don't have them for any other departments.

[Rep. Theresa Wood (Chair)]: Honestly, we're ahead of appropriations. So we're getting them in advance of appropriations. And we're doing that because there is an expectation that our committee in particular is going to take a much deeper dive. I mean, we do a deep dive. Don't honestly, I'm not sure how much deeper we can go because we do a pretty deep dive. But we are expected to they're going to be relying very heavily on what we come back with. So we need to fully understand before we make any recommendations to the Appropriations Committee, what the impacts of the changes are, what the impacts of those tuition reimbursement and loan repayment programs are, where we're going to spend the additional prevention money that's come in through the cannabis tax. Are there any reductions? Is there anything proposed for any COLA, which I can probably answer that question already, no, but for any of the community providers? And then don't forget, as it relates to the health department, we will have a separate bill, age six sixty, that will deal with the opioid abatement settlement fund. That will be a separate appropriation. So some of the increases and decreases that our community partners may be thinking about are probably also going to be within the context of us on age six sixty. So, you kind of have two things that are coming in on that. And since we have a couple of minutes, I'm going to sorry, I'm going to do the H-six 60 now. Okay. Because that H-six 60 is a short form bill, we have to have a vote to work on H-six 60. And it's a procedural thing. Do I have that right, Mr. Flirt?

[Dr. Hildebrandt (Commissioner, Vermont Department of Health)]: I believe so.

[Rep. Theresa Wood (Chair)]: Okay. Thank you all. Appreciate it. So H-six 60 is a short form bill that was introduced by Representative Maguire. You may recall, we had a bill last year, particularly, I don't remember the number, but we have the Opioid Abatement Settlement Fund has been around now for three years, I want to say. I think this is going be the fourth year. So that fund was set up to receive the results of the lawsuits that the state's attorney, attorney general State's attorney? No, attorney general. Yeah, I know I always say that the wrong way. The attorney general's office has participated in, so Vermont has participated in, and we receive funds from the various drug manufacturers as a result of settlements that are agreed to in the courts. That money gets deposited there. There's a very specific bill that relates to how that money can be used. And it was in the first couple of years, the money was sort of interspersed all throughout the budget and language was in different places and it was very hard to track. And so last year we made the decision to have a separate bill that only covered the appropriations for the opioid special fund. So it's one of those must do bills. Otherwise, the money is just sitting there, and the advisory committee will have met all summer and fall for nothing. So Eric, do you want to add anything? Eric is our committee's representative on the special fund committee.

[Rep. Eric Maguire]: Nope. You've short it all up.

[Rep. Brenda Steady]: Explain it to me again.

[Rep. Theresa Wood (Chair)]: It's a short form bill. Okay, and does everybody know what a short form bill means? Short form bill means that it's essentially the title and maybe a brief description, maybe one or two sentences.

[Rep. Brenda Steady]: Look it up, but there's nothing there. Exactly. That's the point. That's a short form bill. We'll fill in all the details Oh, we do it.

[Rep. Theresa Wood (Chair)]: We do it. Oh, But because get it. Long form means that we, you know, for age, you know, what is our number bill? 45 that we just went through or 594. Those are long form bills. This is a short form bill, which means we have to have a vote. It's a straw poll. I don't think it's a I don't think it's a you know, it's not a yay nay thing. To take it down off from the wall, that we're taking it off from the wall. And it means that we will work on that bill and we will be filling in the details.

[Rep. Brenda Steady]: I'd be a skinny on it.

[Rep. Theresa Wood (Chair)]: Yeah. That's I can't what see what it means. It doesn't say anything there. That's what our job is to fill in the blanks. Okay.

[Rep. Brenda Steady]: So, it's the first one since I've been here.

[Rep. Theresa Wood (Chair)]: Oh, no, we did it last year too. We did. Okay. So, does everybody understand the question that I'm about to ask you? Okay. So could I see by show of hands those individuals who are favorable to working on age six sixty? Any opposed? Okay, great. So we've done that procedural vote. Okay. So now we are not gonna be meeting after the floor. That's gonna be your time to continue to delve into the budget stuff. We'll probably be on the floor a little bit longer today because our bill will be there to support representative Eastes. We'll be there and the report from the presenter of the amendment will come. And so there'll be a couple of different votes today. So just letting you know that. And then afterwards, you can work on your budget questions and start to think of. So you've got a taste of what I think we'll see. The health department is the easiest one that we have. And you can see how many questions we had at the health department. So when we go to DCF, we'll probably need three days. I don't know. And then we'll have Dale. And I also want to say, my apologies for being late, but I forwarded to you this afternoon so that you can have the information that was given out to chairs and vice chairs by the Appropriations Committee last week about how they're hoping that we handle our budget testimony.

[Rep. Anne B. Donahue (Ranking Member)]: It's quite a lift. That is a lift.

[Rep. Theresa Wood (Chair)]: When you read that. I think honestly we've been doing a lot of the stuff. I think there's stuff that we will do more of. And then I'm going to encourage you to also look at last year and you can find it right on the side of our committee page, what our recommendations were last year. So you can see the format, we had a chart. So you're gonna get to fill in the chart in your budget teams, okay? We'll be putting together a new chart that has blanks in it so you can work to fill it in. And although it's hard to cut and paste that into that chart in the end. So I'll think about that. We're ways away So from read the two memos that I sent you from appropriations and let me know if you have any questions, but those should help guide you in your work when you're sitting down and meeting with your

[Rep. Brenda Steady]: individual department teams. Okay? All right.

[Rep. Theresa Wood (Chair)]: Great. We'll see you all on the floor, and we'll go there and support Zon.