Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons, Chair]: You're gone. All right, good morning. This is Senate Health and Welfare. It's Thursday, February 5, and we've had to start a little bit late due to some technical issues, human technical issues. Yeah. Technical. And this morning we have a forum of three. Two of our members are out for personal reasons, but they will be catching up with YouTube. So Katie, thank you for being here. Why don't you introduce yourself for the record and tell us a little bit about S-one57?

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: Will

[Sen. Virginia "Ginny" Lyons, Chair]: do. Katie McLennan, Office of Legislative Counsel. I'm going to share the bills introduced first. Okay. So, just to refresh your memory, S157 is our recovery residence bill. If you remember, you also received a markup from the health department with changes, and I was asked to kind of flip between the two documents and compare and contrast what is different about them. So, the most significant difference is that your section one in the bill is introduced, sets out a process by which the health department oversees voluntary certification process, and you have a list of everything that a recovery residence must do to be eligible for a voluntary certification. So that is your section one. The health department section one, or proposal eliminates this section one. So I'll stop sharing and I'll jump over to their document. Okay. There we go. So they have slightly modified but moved the definition of recovery residents into another section because the section we just went over wouldn't exist in their proposal. Instead, what would exist is we have this existing section of law that says the Division of Substance Use Program shall plan, operate, and evaluate effective programs for substance use of programs. And then in subsection B, it lists everything that the division is responsible for. So the division shall be responsible for the following services: preventionintervention, project crash schools, alcohol and drug treatment, and recovery residences. So that addition of recovery residences to the list of what the division is responsible for would replace the voluntary certification proposal that's in the bill as introduced. Does that make sense? Yes. I was trying to get this up on my screen so I can follow along. Maybe just go back up. Okay. I have two, three people. Sure. We have plenty. So again, the health department section one, they have moved recovery residents to this definition chapter instead of having it tied into the section on certification of recovery residences because their proposal doesn't have a section on that topic. There are a few smaller changes to the definition. So recovery residents, the proposal as introduced, it means a shared temporary living residence supporting persons recovering from a substance use disorder that provides, and here's another difference, it says provides residents with peer support, it says, and the bill is introduced, says provides care through peer support and assistance accessing support services, community resources available to persons recovering from substance use disorders. Okay, so let's ask a question there about, so peer support. So we're only looking at a single one level of recovery residents here. I'm looking at you Jessica. So why do we have peer support in the general definition of recovery residents? Jessica Chittenden, Director for the Department of Health. The definition that we are proposing in our draft is aligned with the current definition that, is in Act 163. So the the changes in s one fifty seven were different from what the current statutory definition of recovery residents were, so we just had it's like the our changes are just consistent with what is already in Act 163. But when we talk about recovery residents, are we talking about the four levels? Yes, it would be any of the So all four levels must have a peer support, system of peer support. All four levels. What's the top level? The level four recovery residents and I have, Emily Truter should be on the Zoom, and maybe she can jump in and answer. Emily, are you there? I'm here. Can you hear me?

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Yes. And I did the video to work. I apologize for not being on camera. The as far as so peer support that speaks to activities being coordinated in the community. Okay.

[Sen. Virginia "Ginny" Lyons, Chair]: Got Martine. Oh, Emily. Yeah. The the sound is a little bit garbled as you're talking. It's really hard to hear you. So maybe talk slowly, that might help. Let's just see if that works.

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Can do. Is that better?

[Sen. Virginia "Ginny" Lyons, Chair]: Yes.

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: The definition includes peer supports and then activities coordinated with the community. So, it's all encompassing. It's all four levels. The highest level, level four, does speak about clinical supports as part of that. So, that work would still all happen in the community. Peer support is a key piece of, to be quite honest, all of our programming, even in the clinical space. So, I am in support of the definition as it stands, and to me, the way I read it, it covers all supports that could happen for an individual who is residing in a recovery residences.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, so I have a question then. Do we have sufficient peer supporters, certified peer support folks, to provide these services whenever someone goes into acute care? And so I'm just worried that if we promise this and it's not available, then what?

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: I think workforce, no matter what across the board and no matter what field you're in, I think is struggling. I would say the one thing that we really have going for us in the state of Vermont is we do have statewide ness with our recovery centers, soon to be recovery service organizations. So, we do have statewide coverage for peer supports alone in the recovery centers. Some of our providers also have recovery specialists within their space and so will the CCBHC for the designated agencies.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. Is there any reason, should we be including a comment about the different levels of recovery residences within the definition or sub pedigs under the definition?

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: In my opinion, I don't think we need to. I think that would be covered in the certification exercise and rule making. Don't think it needs to be in the the one in 157 language itself.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. All right, let's go. Thank you for that. Don't go away, please. I'll be here. Okay. So, again, we're looking at the Department of Health Workout. You've covered the definition. You've covered how this section two would be the replacement for the bill as introduced to section one, which sets up the certification program. This does not set up a certification program. This just has the division being responsible for recovery residences generally. So, just to stop here, we don't have a copy of this on a webpage. This is pulled up from your webpage. It might not be posted from today, though. No. We don't have the red we don't have the markup. So, I just got to Let's see. What date is this from? Let me I'd share any no. Let me send I'll send you a link right now. Yeah. Go ahead. You're sending it to. Yes. We would be in I would not be able. Okay. So I sent the link to. Great. We'll Should I keep moving slowly? That's okay. So the next section in the Department of Health's proposal is the language about exclusions. That is also in the bill is introduced. That's section two in the bill is introduced. That was what Cameron Wood took us through yesterday. Yes. It sounded like that was very helpful too. Yeah. It was. It was very Okay. So they the department had a few changes. So there is language let me follow-up with my phone topic. This word language about what is in the residential agreement that everyone entering a residential recovery residence would have to understand and sign off on. So this language is added explaining the recovery of residences program rules and social standards. You have, there's similar language in the bill that's introduced. The bill is introduced, it reads, explaining program rules and expected residential social standards. Makes sense. So, little variation there. Explaining the recovery residences program rules instead of just program rules. The bill is introduced, talks about expected residential social standards, and this just refers to social standards, not the expected residential social standards. Makes this this is better. I like this better. I was wondering about that. Like, there's.

[Dr. Evan Eyler, Psychiatrist]: This is.

[Sen. Virginia "Ginny" Lyons, Chair]: She really gets you actually. Yeah. She did. We'll be on the same page. What is it? There how's it for? That's another We have so many public people on the list today. Are these these are not people who just Oh, I see it. I've got it now. Emily. God. Great. Okay. We're on the same page. Katie, thank you for patience. Oh, yeah. I'm on page three. Yep. So are we. Okay. Yeah. We are literally on the same page. Okay. So we've talked about that item, rules and social standards, and it's Roman numeral five indicating that by signing the residential agreement, a resident acknowledges that the recovery residence may cause the resident to be immediately exited or transferred into alternative housing if the resident filings the recovery residence and substance use policy, regularly refuses to engage in services or programming, commits a crime, engages theft, is interfering with the recovery of other residents, or engages in acts of violence that threaten the health or safety of other residents or recovery staff. So they have a lot of that language and that those introduced. Your language reads, I'll start where there's the red. Regularly refuses to engage in services or programming, commits a crime, engages in theft, is mentally or physically interfering with the recovery of other residents. And this and the others, same. So it's just that clause is mentally or physically interfering that has been eliminated. My only question is should it be interferes with? Yeah, instead of his interfering with the That's enough. Us scramble for. Regularly refuses and then that's regularly interferes. I know. I don't know which one works. I can make that change. K. So it sounds like you want to take the the past the prior two suggestions from the health department. I'll make this change. I'll make this change using interfears. Okay. Then we have language that tracks the previous section we just looked at, so I'm assuming you wanna make the same change here. Interfears with. Got it. That's good. Keeps all the births. Yep. That gerund is out of place. That gerund is out of place. It did. Okay, there's a proposal to remove this phrase or clause, relapse of a substance use disorder resulting in exiting a recovery residence shall not be deemed a cause of the resident's own homelessness for the purpose of obtaining emergency housing. Great. Great. Wait. Where are you? Because I don't have as huge. Oh, I I the one above it is what I'm asking. Subdivision relapse of a substance. Okay. We're taking that out. That's the Yeah. I think that is in conflict with of the previous violated the substitute policy. I think there was an explanation that this was no longer a part of the GA emergency housing program. Don't entirely remember what Jessica said last time. I to apologize, Jessica, but I believe it had something to do with a change in how GA emergency housing was administered. Not sure if I have that correct. Yes. Jessica Chittenden, Department of Health. And this was a, in collaboration with DCF colleagues. Their suggestion, so if you have further detailed questions, they would be the right ones to answer it, but, their explanation is that it, the language that's currently in statute really referred to only one element of the GA Emergency Housing Program eligibility, and that is no longer part of that program's eligibility determination process, that causing your own homelessness is not part of the process.

[Jessica Chittenden, Vermont Department of Health]: That's fair. Yeah. Yeah, so this existing language was intended to give people that determination for that piece of the process, but, you know, the it didn't guarantee that anyone would be able to access the program and just provided that interpretation for one component of prior eligibility that now does not exist in the determination process. Okay. It's with the dam, but what, I mean, I don't what was the harm that he was leaving it in?

[Sen. Virginia "Ginny" Lyons, Chair]: Well, it's it's directly related to homelessness. Right. Thought that I have, I don't know what emergency housing will look like in future years. Right now, we're on a year by year, every budget cycle brings a different, slightly different iteration. So that's one thing that I'm sort of thinking through. I don't know how this issue would be treated in future years. There is a bill going through House Human Services that will speak to homelessness. So I'm just thinking this is about recovery residents that already up above there is the violation of substance use policy, and then later on there's gonna be something about planning that if you if you evict someone, then you have to have a plan for housing. So this is the prison was be this for me seems redundant within the this bill, but I'm. Wait. Don't go away. Hold on. Don't go away, Paige. Hold on. Oh, wonderful. Thank you. I got it. Oh, wait. Here. And take it right back where you got it from. Thank you. Thank you. Okay. Alright. I mean, I I don't see what the. Okay. Let's leave this. Okay. Sure. Go ahead. For the record. Yeah. Candy Scale, Director of Community Relations for Vermont Foundation of Recovery. So, we just don't want anybody exiting our recovery residences being prevented from being eligible to any other services. And so, that's that's why I think removing it makes sense, but that's Oh, you could be do you think removing it as more of the infection? Oh, okay. I don't understand that. K. Can we put can we put a parenthesis around this, and we'll come back to a forward discussion on it? Sure. But we haven't resolved this one? Okay. That didn't really occur. Can you explain why you think it offers greater protection? Yeah. Because we basically, each program will determine their own eligibility and you just don't wanna stand in the way. Like, you just don't want them to interfere with you being eligible for a co program. So, okay. So what does that mean? It's bigger than just emergency housing. It's, you know, in general, if they're going to another program, we just don't want any disputing or lump from families because it's also there. Are you thinking that if someone does violate the substance use policy, they could be moved to a higher level of care? And if this is in there, they wouldn't? Okay. I'll step up instead of a step down. So it's we're in kind of our own lane. Recovery residences are kind of in our own lane. You just don't want it. I can't speak to it outside of that. It's just that we, we don't want to interfere with others, and I'm happy, like, if someone wants to testify with them. Let's, let's do that. Go ahead, Senator. But what I was hearing is at some point in the statute, we said that you weren't gonna be eligible for GBA housing if you caused your own homelessness. Like, I cracked my apartment and got thrown out, or I could live with my mother, but I'm choosing not to. What this is saying, and, god, I heard that that's not part of the That that we can't because it has been taken out, so we don't need that in here. Think that's the argument that the department is negotiating with DCF is saying that because this is no longer a component of emergency housing, that they don't feel that it's necessary. I hear that, but I guess I worry that that could change next year. Well, there's more. Mean, we know, emergency housing is not in statute. It's a budget issue, so it changes. Every day. The construct changes slightly from year to year. But what this, you're right, what this language does now, it's saying if there is a criteria for emergency housing that says you can't get emergency housing if you've caused zero homelessness, that sort of creates an exception that says, but if it was because of a relapse to substance use disorder, you could still receive that emergency housing. So, you know, I think the question is, is there a harm in keeping it, even if there isn't a corresponding requirement in emergency housing, in case in some future time there is, or is that not a policy decision the committee wants to make? Interesting. Okay, so let's leave it for now. Let's not put this new room. Let's just leave this as a a question mark. Well, know that we'll hear testimony So on this Subdivision 2 is a cross reference to the definition of recovery residents. The cross reference we use depends on what decision you make up above with regard to whether you want a section, a standalone section on certified recovery residents, or if you want instead that sort of one subdivision that says the Division of Substance Use is going to oversee recovery residences. So, that will be sort of a natural choice, depending on your policy decision. This is the same change that you have when the bill is introduced. So those are the primary changes that you have proposed by the health department versus when the bill is introduced. So, the last one then you have three set as That's not a proposed, I mean, that matches the bill as a Yeah, that's just matches. Okay, yeah. Yes, ma'am. For the record. Hey, I'm Candice Gale, Director of Community Relations for Vermont Foundation Recovery. Is it pay if you send this link to the call to David Rebel, our Executive Director at Vermont Foundation Recovery? Well, you have it.

[Candice (Candy) Gale, Director of Community Relations, Vermont Foundation of Recovery]: We now have it on our webpage. So you can so you can speak. If you can they can bring

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: it up and look at

[Candice (Candy) Gale, Director of Community Relations, Vermont Foundation of Recovery]: it and do an analysis for it. That'd be good. So

[Dr. Evan Eyler, Psychiatrist]: when you testify.

[Candice (Candy) Gale, Director of Community Relations, Vermont Foundation of Recovery]: Alright. Okay. So Katie. Yes. Those are the things.

[Sen. Virginia "Ginny" Lyons, Chair]: Can we so now we should integrate the changes that we've made. I can do that. You've decided on two changes from the health department. I think those aren't easy to make. The big policy decision that you may not be ready to make today is whether you want to replace having a voluntary certification program with having this language instead that the health department's proposing, that the division shall be responsible for the following services. Can we go back and look at that? The bill is introduced. What they have up here for the changes. Where is that? I'm on page two. Yeah, this is, that's pretty much the Subdivision five, which would a replacement. This is a whole new Replacement? Yeah, so basically what the proposal is, when the bill is introduced, You are directing the health department to oversee a voluntary certification program for recovery as a disease. And there is a list of criteria that a recovery residents would have to meet to achieve the voluntary certification. So, it's a little bit more prescriptive in terms of there is going to be a certification program, it is voluntary, here are the criteria that we have set out in legislation. This is not creating a certification program. This is just saying that the division is responsible for recovery residences. So you're not creating a list of what would be part of a certification. You're not saying there would have to be a certification. There could be, but there wouldn't need to be. This is just giving the health department general oversight and responsibility for recovery residences without sort of establishing a structure. I can see value from both. This is tough. We hear testimony. Yes. Well we're going to hear testimony from the copy residents and they can put on this. I guess what would be helpful is to go back and look at the underlying, the original as introduced, just briefly look at that and see what the criteria are. And maybe there's some, maybe there's a balance of between, in between we can put them. Okay. So this is section one, the bill is introduced.

[Katie McLennan, Office of Legislative Counsel]: You have a definition of recovery residence. And then here is your certification language. Upon receipt of an application from a recovery residence in the state seeking certification, the department shall issue the requested certification if it determines that the applicant meets the following minimum standards. The applicant is certified by either a Vermont affiliate of the National Alliance for Recovery Residences or another organization approved by the department. Can I ask a question right there? And I'm not looking at you, I'm looking beyond. Okay. So what we need to know is what what are the requirements by for Vermont for certifying a recovery business? That's a question that we need to have answered, that's all. I'll have the answer. The applicant demonstrates the capacity to operate recovery residents in accordance with rules adopted by the health department and in a manner that ensures person centered care and resident dignity. So this We would be eliminating rules if we Yes. Figured this There wouldn't be any rules about that. I suppose there could be under more general rule making authority that the department has, but this is a requirement for the adoption of So you wouldn't have required rules. Okay. The applicant shall fully comply with standards for health safety and sanitation as required by state law, including standards set forth by the state fire marshal, the department, and municipal ordinance. Question here. Would a recovery resident that's in the state currently have to meet standards for health and safety and sanitation? Jessica or Emily, can you answer that question? For the record, this is

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Emily Truter, the health department's division director for substance use programs. Website is to the preferred provider space. So we have a-

[Katie McLennan, Office of Legislative Counsel]: Wait, Emily, we're having trouble again. We'll wait a-

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Okay. The similar to our treatment programs across the state, we have a preferred provider system that through a rulemaking process that we we certify them through the division. I'm seeing space here that includes things like that. The safety and welfare of individuals, the program standards, potentially reporting depending on what that may be. So I anticipate that process to be developed in a similar fashion if this if this, language gets us there to be similar.

[Katie McLennan, Office of Legislative Counsel]: We lost you. Envision it

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: to be similar to how we oversee the certification of treatment providers across the state. Having safety and programming standards within a rulemaking process.

[Katie McLennan, Office of Legislative Counsel]: So if we included recovery residency in that part of statute then we would be covering this number three.

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Yes.

[Katie McLennan, Office of Legislative Counsel]: Okay. That's that's something we might be able to do. But depending on where we land with all this. Okay. Thank you. Sorry, just for clarity. So that's just what all this struck me. Let's see, Subdivision 4. Once certified, the recovery residents, including the buildings and grounds, shall be subject to inspections by the department with a ten day prior notice. Is that something that fits with other sections of state law for programs that you oversee and facilities you oversee? I guess I'm asking Emily again.

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: I'm not sure of the answer to that. I would have to get back to you on that one.

[Katie McLennan, Office of Legislative Counsel]: Okay. That's good. Alright. Subdivision 5, the applicant shall have a clear process for responding to resident complaints, including a method by which each resident shall be made aware of the complaint procedure, an appeals mechanism within a recovery residence, a published timeframe for processing and resolving complaints and appeals within a recovery residence, and periodic reporting to the department of the nature of complaints filed and action taken. And the applicant shall fully comply with 9BSA Chapter 137, which is the landlord tenant language that you looked at yesterday. If you ended up keeping this, you might wanna have something that says, the references, the exceptions that are made in section two. We can cross the bridge if you decide to keep this language. Okay. Well, I mean, I'm not sure we wanna keep all of this language, and I'm not sure we wanna do exactly what the department has said. There's some value in some of the language of my my thinking at this point. Senator Gulick, you said it probably seemed help me out with it. There's also then, you keep going. Okay. Keep going. There's language that the voluntary certificate cannot be transferred or assigned, which shall only be issued for the premise named in the application. There's language that governs renewal. Annually, the recovery residents seeking renewal of its certification shall submit an attestation to the department that it continues to maintain its certification through the Vermont Affiliate of NAR or another organization approved by the department. There's your rulemaking requirement in subsection E. Subsection F, have reporting that on or before January of each year, recovery residents certified under this section is to report to the department with the following data from the previous calendar year, and that data includes the number of residents served, the average length of stay, exit or transfer of a resident by the recovery residence, and the asserted basis for exiting or transferring the resident, the number of residents who gained or lost meaningful employment during their stay at the recovery residence, budgetary needs, and any other information the department deems appropriate. And then a month later, the department is required to consolidate that information collected from certified recovery residences and submit an aggregated report to the general assembly. That would be an annual process. The recovery residences provide data to the department and the data, the department aggregates and provides to the general assembly. On this one, we think it's a definite. I do like the idea of having some data and some information, particularly as we're, you know, beginning this process and investing because there'll be huge investment in recovery investments in through the bill of the capital of the settlement in the budget. So rather than have annual report, I'm thinking we have the initial report in two years, One year or two years, depending on what folks say. And then or maybe a presentation, but but on The US. I'm not I just went through all reports again last night. But if the health department takes it over, there won't be this report, correct? If you go with the language that the health department is proposing, there's no reporting requirement. I'm trying to figure out how to incorporate a lot of what is here without having an onerous, bureaucratic open program. What the current certification process? Or if it carries in a certification process, what is the process now for recovery residency? Go ahead, Nat. I'm Ginny Lyons, Foundation of Recovery. So, right now, before, as an operator, it requires extensive documentation complying with national standards. So this includes and is not limited to our vision, vision statement, proof of legal entity status and insurance, membership agreements, which is basically the recipe you're gonna get, member applications and agreements, grievance procedures, medication and drug testing practices, relapse planning protocols, health and safety practices, personnel policies, background check policies, member rights and responsibilities, exit and transfer policy, substance use policy, prohibited items policies, good neighbor policies, and signed attestations and codes and ethics. And then we also do an annual safety inspection and recovery home walkthroughs, and the executive director of VTAR meets with our members at the home. So that's, in a nutshell, what the That's process looks the VTAR. That would be the, yeah. Yes. So your health, so all of your policies, they're not sent to the health department currently? No, I don't see them. They're for the D. R. And then D. So it's a national accreditation that is included in the language from the Department of Health. Okay. Alright. Pay it. Do this to you. We don't have time, but let's take a minute to just walk through this section one more time. Sure. Very briefly. The certification section. Yep. Okay. So, you have your definition section. Talked about that. Subsection B is your certification. So, this language says that a recovery resident that would like to be certified submits an application to the department, and the department has to determine and issue a certification, if it determines that the applicant meets the following standards. Item one, the applicant is certified by VTAR or another organization approved by the department. Two, applicant demonstrates the capacity to operate a recovery residence in accordance with the department rules and in a manner that ensures person centered care and resident dignity. Three, the applicant shall fully comply with standards for health and safety sanitation required by state law, including standards set forth by the fire marshal, the department, and municipal ordinance. Four, once certified, the recovery residents, including the buildings and grounds, shall be subject to inspections by the department within a ten day prior notice. Five, the applicant shall have a clear process for responding to resident complaints, including a method by which each resident shall be made aware of the complaint procedure, an appeals mechanism within a recovery residence, a published timeframe for processing and resolving complaints and appeals within a recovery residence, and periodic reporting to the department of the nature of the complaints filed and the action taken. And lastly, full compliance with 9BSA, Chapter 137. I learned that. So, a lot of that is the Department of Economics with what happens at the national level. That's why you check this. But then except for the nine DSA of.

[Sen. Virginia "Ginny" Lyons, Chair]: That's not something. And then the transferability and then some yearly update. Preneuropathy. Yeah. Yeah. The making. The rule making piece that seems nonessential at this point. And then the reporting piece, we can talk about. So okay. I think we got it now. Great. If you go with a new language that the health department would like, does it take the BFAR piece out of it? That, no, that space? It's silent on it. Okay. So, it probably would maintain the status quo for the time being, but there isn't a requirement to maintain the status quo. Okay. This is Emily. I offer a statement? Emily, go ahead.

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Thank you. It is our intention to continue to partner with VTAR and not interrupt that process that I think has been building on some great success there. Again, a lot of the stuff that's in here is very similar to what we do in the treatment and now in the recovery center space. They recently went through a rulemaking process to become recovery service organizations. So we would be ducked in a lot of this was itemized here, all falls in those similar spaces. So I did wanna make sure that the our goal is to continue on the good work that's already happening.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. All right. Well, that's good. Thank you for this. This is a good start for us. We'll be getting toward testimony, and I'll look to you to bring in some testimony, both of you. I guess my ask of you of the Department of Health and the recovery folks is, is there a way that we can blend the language that we have to ensure that all the things that are in the certification are overseen or reported to Department of Health, that there's some update there that our recovery residences are in compliance with what VTAR would want. But that's what started all of this. Honestly, we just were okay. And then compliance with nine BSA 137, I think it's going be important to us. That's something we'll probably. Then data collection and to what extent, when, and how frequent are reporting. So if you Jessica, I'm looking at you, is there a way that you can get together and maybe bring us something that is a blend that doesn't leave recovery residences alone but has some reporting or connection? I know there's gonna be huge connection with the project of health but sort of reinforces it in the statute of that. Katie will be helping us. So I'll tell you what we do. All right good thank you. So we're overtime on that bill but that was that's this is an important bill to us and we want to get it out ASAP. So let's move on to SP 43. Alright so our first introduction and the sponsor of the Dallas Gear.

[Sen. Martine Larocque Gulick, Vice Chair]: Hi

[Sen. Virginia "Ginny" Lyons, Chair]: Allison, I'm happy to introduce to 43, it is a bill that would support, offer some support to the Vermont Language Justice Project. They are an important part of my community in Chittenden County. They are integral in keeping folks safe when it comes to everything from a pandemic to a measles outbreak to flooding, they are just an interesting part of health in a lot of regions in our state. So I'm really pleased to put this forward and I hope we can find a way to support this really important entity. Is there any money in this bill? There is. So whatever we do with it, it'll walk down the hall. Yeah. Hey, you? How You want P Tech to walk you through it? It's a long It's a very long, complicated bill. So here it is, S-two 43, and we have an appropriation of 150,000 from the general fund to the Department of Health for distribution to Vermont Language Justice Project to prepare informational materials for Vermonters to speak languages other than English in the event of a disease outbreak or other public health emergency. And that would be for this coming fiscal year. Okay, question on. So, question. I, you know, might be the sponsor. The 100 what is the $150 you tend to do? Should we listen to testimony first? Let's listen to Allison. Okay, take over. Yeah. Allison, why don't you go ahead and Okay. What the appropriation would do and get into a little bit more of what you all do to keep Okay,

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: thank you Martine for putting this bill forward and thank you for choosing to listen to me this morning. There's going be one other person talking after me. Hopefully, she'll get on the call soon which is Doctor Andrea Ginny from the Pediatric Clinic for New Americans and I'm just getting my thing. Here we go. Okay. I'm just going to read it. Good morning. So, name is Allison Seeger and I'm the founder and director of the Vermont Language Justice Project. I launched the Vermont Language Justice Project almost six years ago in response to the COVID pandemic when it became very clear that the emergency communication and accurate health information was not reaching communities of people with language access needs, which as we all know are some of the most vulnerable and most isolated people in Vermont. Vermont has a history of welcoming newcomers to the state as refugees, immigrants, migrants, and asylees. And this diverse group of individuals and families speak a multitude of languages, some which are written and some which are not written. BRJP produced videos on all aspects of COVID on a shoestring budget using accurate and scientific facts sought from the Vermont Department of Health website and the CDC. In November 2021, we were fortunate to receive a CDC racial disparities grant through the Vermont Department of Health. And I began to develop a small team over the next few years so that VLJP could continue to produce and expand on our lifesaving, and it was lifesaving, health information in video format in collaboration with community partners in the Vermont Department of Health. This included a multitude of videos about COVID and COVID testing, videos on vaccinations, their importance and how they work, videos on MPOXX, preventing mosquito bites, videos about keeping yourself safe during flooding, hot weather, cold weather, cyanobacteria, wildfires, ticks, and many, many more. All these videos were made in anywhere from 10 to 21 languages, which are commonly spoken in Vermont. And as I said earlier, they were all made in collaboration with the Department of Health. We've also worked with other state departments as well as community partners and UVMMC and Brattleboro Hospital. We've produced videos of mental health concerns, know your rights with ICE and the Border Patrol, videos on autism, latent TB, maternal child health warning signs, mammograms, drugs and alcohol concerns, accessing and paying for childcare in Vermont, cervical cancer, climate change, the ER, and so many more. In total, we've produced over two twenty unique videos, each one in up to 21 languages. We've had over 409,000 views, on our YouTube channel, have over 2,700 subscribers to our YouTube channel, and developed an app for iPhones and Androids where all of our videos can be accessed in 18 of our languages, including ASL. And then, of course, the CDC abruptly ended our grant last year in January 2025. And so now we are solely funded by donations from individuals and foundations and feed the service work. On 10/30/2025, the Vermont Language Justice Project was asked to support Hunger Free Vermont in their outreach to Vermonters with language access needs to create a video explaining the details of the impending cuts to SNAP benefits that would occur two days later on November 1. Within thirty six hours, VRJP had produced 17 informational videos in 17 languages about the cuts to SNAP benefits and how the state of Vermont was gonna provide the benefits for the first fifteen days of November. The playlist was immediately put on social media and within the day had reached over 4,000 hits. The same day the playlist was sent to the task force colleagues by 80 organizations and the audio files were sent to the Wannuski and Burlington School Districts for distribution through their robocall phone system. By the end of the weekend, our videos had been viewed over 500 times. So what I'm trying to say is in case of emergency, VLJP is able to respond to a crisis usually within twenty four hours with information in multiple languages, in multiple formats, translations, audio files, and videos. And we use our wide distribution network to push the information out to people with language access needs throughout the entire state of Vermont. I know I can say that no other organization can do this in Vermont, and maybe no other organization can do this in The United States. And as an aside, it's really important for you to know we do not use AI, but we work with community leaders who understand the nuances of what we are saying and have wide outreach to their communities. I recently saw on social media that there is a rise in whooping cough in Vermont. The Vermont Department of Health website said back in November, whooping cough is spreading in Caledonia, Lemoyle and Washington Counties. The Vermont Department of Health recommends that people in the impacted counties takes extra steps to protect themselves and their community. The website then goes on to explain what those extra steps are in a lot of detail, which is great, but it's only in English. I believe that had our CDC grant still been in existence, we would have been able to make a video in multiple languages and got this information quickly and efficiently to folks throughout the state of Vermont. Instead, I had to apply for a grant through a foundation to make the video. And we're still waiting to hear if we get that grant. We don't know what health issues are gonna be hitting our communities in the next year. However, we do know that there's been an already been five eighty eight cases of measles in The United States since January 1, which is over twenty five percent of all cases from last year. It is that time of year that many of us remember the beginning of COVID and how terrifying it was, and now we had to search out scientifically accurate information so we could keep ourselves and our families safe. We appreciate and thank Senator Gillick in introducing two forty three, which proposes to require the Department of Health to distribute funds to VLJP for the creation of informational materials related to the disease outbreak or other public health emergency with a $150,000 appropriation. The state of Vermont needs to be prepared for the next health emergency, whatever that might be, ensuring that all residents are informed in a manner that is linguistically appropriate. When it comes to health, we know that time can be of the essence. The LJP has already done the extensive groundwork to be ready for whatever comes next. We know that our work saves lives by informing all of our communities of diverse language speakers throughout Vermont. And we hope, we really hope, that you will support S two forty three, and it will move through the Senate for funding. The end.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. That was great.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: So are you able to stay on Zoom while we hear our next witness?

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: Yes, definitely.

[Sen. Virginia "Ginny" Lyons, Chair]: Terrific.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: My colleague, Andrea. Yes, definitely.

[Dr. Andrea Green, Pediatrician and Director, Pediatric New American Program (UVM Children’s Hospital)]: Hi Alison. Hi. Would you guys like me to read my testimony or would you like to have a discussion? I didn't know how.

[Sen. Virginia "Ginny" Lyons, Chair]: No, read your testimony because we're naive in all of this. You have to so that would be good.

[Dr. Andrea Green, Pediatrician and Director, Pediatric New American Program (UVM Children’s Hospital)]: Okay, perfect. So hello, everybody. I'm Andrea Green. I am an outpatient pediatrician and the director of the Pediatric New American Program at Dallas Sano Children's Hospital at the University of Vermont. I'm also a professor of pediatrics at the Larner College of Medicine at UVM. And for the past twenty two years, I have cared for my practice is solely the care of immigrant children in Vermont. I'm a national expert on pediatric immigrant health, and I'm the past president of the American Academy of Pediatrics Council on Community Pediatrics. And so I'm submitting strong testimony in support of S243. And the reason I'm doing this is because access to accurate health information save lives, but only when people can understand it. Approximately 5.5% to 6% of Vermonters speak a language other than English in their home. Although we are a small state, Vermont ranks six per capita in refugee resettlement, and our governor has recognized the important role immigrants play in our Vermont economy. When health information is available only in one language and only in written written format, it creates barriers that lead to confusion, delayed care, medication errors, and preventable illness in addition to our conversations about emergency things that are coming out. Multilingual video health information is not a luxury or a courtesy. It is a public health necessity. When patients health receive information in a language they understand, they are more likely to follow medical instructions, attend follow-up appointments, manage chronic conditions effectively, and seek care early instead of waiting until emergencies arise. Clear communication improves outcomes, reduces hospital readmissions, and lowers overall health care costs. In contrast, language barriers increase strain on emergency services and deepen existing health inequities. Multilingual health information also builds trust. Communities are more likely to engage in health care systems when they feel seen, respected, and included. Providing translated materials, interpretation services, and culturally appropriate messaging sends a powerful message that everyone deserves a chance to be healthy regardless of the language they speak. This issue becomes especially urgent during public health emergencies. We saw the recent crisis of COVID in the Vermont floodings in the Vermont floods that delays or gaps in translated information can leave entire communities vulnerable. Timely, accurate, multilingual communication ensures that critical guidance about vaccines, treatments, prevention, and available services reaches everyone at the same time. Investing in multilingual health information is an investment in equity, safety, and effectiveness. It strengthens our health care system for everyone, not just those who speak English. Ensuring language access is one of the most practical and impactful steps we can take to improve public health outcomes and uphold the principle that healthcare should be accessible to all. Furthermore, video materials are especially important as they are accessible to everyone regardless of literacy level or language spoken. Around forty six percent of adult Vermonters struggle with intermediate or low health literacy, which means that almost half of Vermonters have difficulty understanding complex written health information. While we are emphasizing multilingual materials, it is important to recognize that Vermont Language Justice Project's videos are in English as well as other languages. When information is accessible in plain English, everyone benefits. Videos eliminate the need to read in any language and can be viewed again and again by everyone regardless of their preferred language. As a member of multiple national immigrant and refugee health organizations, I consistently hear from colleagues across the country their strong admiration for the quality and effectiveness of Vermont Language Justice Project's materials. Their reach is international, and their work is grounded in collaboration. Every script is rigorously vetted by medical professionals and contact experts, ensuring accuracy, cultural relevance, and trust. During the COVID-nineteen pandemic, I volunteered with the previous Vermont Language Justice Project iteration to help produce multilingual videos in real time so that communities could receive life saving public health information without delay. I have since secured grant funding to partner with Vermont Language Justice Project to create multilingual video explaining what is autism, which does not exist in the country or even nationally. So we were the first to do this. And I'm currently working with them on a video that demonstrates proper use of metered dose inhaler technique for asthma management. These resources simply do not exist elsewhere. They fill a critical gap in patient education, particularly for families with limited English proficiency. And they are essential tools for improving health outcomes while reducing preventable emergency visits and overall health care costs in our state. In our clinical setting, we actively encourage families to enroll in IFY. This is the app that the Vermont Language Justice Project has created so that our families can have access to the VLJP's trusted library of health information in the language they understand best. In summary, multilingual health related videos improve health and reduce health care costs by providing timely, relevant, and important health information for all Vermonters by addressing health literacy barriers. Thank you for recognizing the importance of this issue and for taking steps to support inclusive language accessible health care. Sincerely, Andrea Green.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. This is great. So it's a little tiny bill with a huge impact. Amazing. And so as you're speaking, Doctor. Green, you're offering two tracks here. You're offering one a track of information regarding specific types of health conditions, but then the other track is on emergency issues. So your testimony is slightly different from what is in the bill, because it's for the bill is really more about the public health emergency, but you're also including some things that I've always been interested in. How can we give patients a film that tells them about the upcoming surgery or the medication they're taking or whatever. So there are two things here. Yes. I'm hearing from you and I see Alison is also shaking her head.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: I mean, yeah, I think you're right. I think, but I also think that there's so many things that can end up as a health emergency. If you don't know about how to use your inhaler, for example, that ends up a health emergency. So there's public health yeah. So I think both are both are related, but one is definitely related to getting something out very, very quickly. I think it's what we're talking about.

[Sen. Virginia "Ginny" Lyons, Chair]: Understood. So the questions that I have are I think number one, it will be helpful to expand the bill just a little bit to talk about the things that are included in the disease outbreak such as or including and then the other public health emergency such as including floods because that may not be apparent overall. So that kind of expansion for us in thinking about what's covered here. The other bigger question is about how the 150,000 is going to be used. So suppose we send it down the hall, down to appropriations, the first question that will be asked is how is that money going to be helpful when we don't have a pandemic in front of us? What's the use of that money initially by the Department of Health? How do you envision that? That's my first question.

[Dr. Andrea Green, Pediatrician and Director, Pediatric New American Program (UVM Children’s Hospital)]: You want to start Allison because I can easily give ideas on this.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: Well I think there's some public health emergencies kind of lurking. There's one around measles. There's one around whooping cough. Mean, I think those videos need and should be made. Do we need to wait for something huge to come? I don't think so. I think there's a lot of stuff. And I'll go over to Andrea. I'll let you finish.

[Dr. Andrea Green, Pediatrician and Director, Pediatric New American Program (UVM Children’s Hospital)]: So I think from a pediatric standpoint and the way we're looking and surveying the health care landscape at this time is that we have, unfortunately, a lot of misinformation and perhaps even, I can say, disinformation that is being disseminated to the Vermont public. And we have chosen as a state to uphold, for example, the AAP, or we are it looks like I have to say it's not gotten all way through, but we are probably going to go with the AAP vaccine schedule as opposed to the CDC vaccine schedule as a state. And we're doing a lot of sort of state decision making around a lot of health issues. And so I think there's a place from a public health standpoint to think about how that messaging happens in a multilingual way to combat a lot of the misinformation and disinformation that's being given in the health space right now. That is leading to things like measles outbreaks. We have a culture in Vermont of people who are reticent to be vaccinated. It's a slightly different culture than some of the other culture in The United States where we see some vaccine challenges. But definitely, that's trickling down. I never used to have my patients be reluctant to get vaccinated because they knew what these diseases looked like in their home countries before they came to The US. But nowadays, they're watching all this misinformation, and we're having to do a lot more education in that space. So I think there's a lot of public health information that we are going to continue to need to put something forward as a state. I think the more we put forward this information, the more from an appropriation standpoint, we save money down the line. All the money we can spend in prevention and education and preparedness means as a state that we are going to be a healthier state when different things happen. So yes, there will be floods. Yes, there will be measles outbreaks. Yes, there will be these things. But there's also this sense of making sure that we are giving public health information that ensures the health of our state in a way that helps right now when we have health care dollar issues in our state. Our health system is expensive, and we've got a lot of conversations going about that. And again, this is a way where we can change utilization and do a lot of prevention work from a public health standpoint up front. So that's sort of why I went with this idea of not just when an emergency is known and going, which definitely is something that Vermont Language Justice Project can do in an agile, quick, and very responsive way. But also the fact that we want to be thinking about getting information out in English for our low literacy population in video format, and then also in all sorts of other languages to really benefit the population of Vermont to get accurate information from our Department of Health, which has good trust. Unlike my friends in lots of other states in the country, our public health department here is respected. And I think this really supports them in their work and lots of other ways.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, thank you. So what I'm hearing you say is we need to get data form videos out so that people understand the current status of the health the public health environment. So that's the kind of language we might wanna include in the bill somehow. And then the and combating information that is not data science informed. Something I like know I'm getting it. So we still need to have a little budget there or we need a line item that's put into the budget for the Department of Health to do this on a regular basis. And then when an emergency hits us then we need to have some understanding of the distribution of the information. So you have these videos but it seems that it sounds like you'll be distributing the videos to local organizations or statewide organizations that can coordinate and work with other language, folks who speak another language. I'm trying to summarize what I'm hearing as you're talking and the questions that I have. I'm trying to answer my own questions.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: The one thing I would just say is when we complete a video, the distribution is always part of the process. So the distribution goes out. All the videos go back to the translators who then send out the information to their own communities. That's one thing that we do. It also goes out in a newsletter to over 400 people. It goes on social media. There's many, many ways that the information about the video gets sent out. And it's not just to organizations. It's also to communities and community members.

[Sen. Virginia "Ginny" Lyons, Chair]: So being cognizant of the time, and this is our first look at the bill, what you have just said is not in the bill. So then we'll want to add in some of the language that will be such as distribution, such as through, and then there's also going to be disease outbreaks such as or including, and then also other public health emergencies such as including. We're gonna have to put in the two tracks that you're talking about because this makes a whole lot of sense to me. I'm really thankful for Senator Gulick for bringing this to us. This is great. So we're going to have to move on of our time of where we are, but please stay available to us, both of you, because as we work through this, if you have ideas for sharing further how this would be implemented, that's important.

[Dr. Andrea Green, Pediatrician and Director, Pediatric New American Program (UVM Children’s Hospital)]: Critically And the Department of Health puts it up on their website too, So they have it. So it always gets put on the Department of Health. And I would say we send it out actually, goes out nationally because it goes out on a lot of listservs nationally and is used in other states as well.

[Sen. Virginia "Ginny" Lyons, Chair]: And we could charge other states for that.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: I know for now. We need to figure that out.

[Dr. Andrea Green, Pediatrician and Director, Pediatric New American Program (UVM Children’s Hospital)]: Yeah, no. But just so you know, Allison's services are used by lots of other very reputable organizations nationally.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: Thanks for your time. Really appreciate you listening.

[Sen. Martine Larocque Gulick, Vice Chair]: Thank

[Sen. Virginia "Ginny" Lyons, Chair]: you very much. Thank you.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: Take care. Bye bye.

[Sen. Virginia "Ginny" Lyons, Chair]: Katie, did you get all that? I did so. We have a bit of a ways to go, but we'll we'll try to work on this one. It's a little fail. We'll update it. Yeah. Yeah. It's great. Okay. Let's move on to page two thirty seven. Just see here. Professor, School of Pharmacy. Is here?

[Dr. Phil Hughes, Assistant Professor, Binghamton University]: Ann, good morning.

[Sen. Virginia "Ginny" Lyons, Chair]: Who is it? Budd Vanna is a psychiatrist. He's here.

[Dr. George Vanna, Psychiatrist]: Am. Nice to see you all.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. So the order I understand is for you to go first. Alright, we are moving on to the bill two thirty seven, and activating to prescribing doctoral level psychologists. And so, Doctor. Vanna, thank you for being here. I thought you'd feel great about it.

[Dr. George Vanna, Psychiatrist]: Sure, thanks for having me. I'm George Vanna officially. I'm a resident of Jericho, Vermont, so it's nice to see you as always, Senator. And, you know, I'm in sort of opposition to this bill, but in support of my psychologist sort of colleagues. You know, I I think we know that this issue of psychologists wanting to prescribe has been something that's around for a long time, and the data that we've seen is that it really hasn't improved access to prescribing, whereas other things that are happening right now that sort of weren't as active or popular when we first started to hear about psychologists wanting to prescribe are happening. And those are the primary care partnerships that we have that really are improving access for people who have Medicaid and other insurances to good psychiatric care through consultants, through integrated and collaborative care, through programs like one of the programs I work with, which is called the Child Psychiatry Access Program, where primary care doctors can call child psychiatrists and perinatal psychiatrists and get just in time in the moment advice. And that we know that primary care, ninety eight percent of primary care doctors are accepting insurance like Medicaid, do have room for new patients, really sort of enhances access for the most needy and vulnerable people, and sort of provides a sort of really medically informed and sort of team based approach to mental health prescribing that isn't facilitated by psychologist prescribing. I also worry about sort of the questions about supervision. In medical school and residency, when I'm prescribing medications, I have another doctor in the room when I was in training, sort of overseeing essentially everything I was doing for at least three to four years. That's just not possible with sort of the very rigorous, you know, and impressive program that I think is being suggested as a part of this program. It's just not as comprehensive, you know, and I worry the same about physician assistants. I worry the same about some nurse practitioner programs that that level of supervision and oversight, you know, isn't built in the way that it is in medical school and residency. In fact, for some psychiatric nurse practitioners, we're looking to develop more psychiatric sort of nurse practitioner residency programs to help provide that level of support. So those are sort of among the many questions, you know, that supervision, you know, the idea that, you know, we're sort of really unleashing sort of prescribers who don't have a lot of practical experience or understanding of sort of the complexity of the medical systems and maybe not providing sort of as much access. That all being said, I think psychologists you know need to be paid better especially in Vermont and the parity really doesn't exist for sort of the compensation that mental health practitioners, know, the care that they provide and that I think drives the issue of psychologists wanting to sort of engage in some of these other practices when they probably got into psychology to do more of these therapeutic practices and, you know, helping them get to a place where they can accept more insurance, you know, products, you know, which I think, you know, psychiatrists are slightly, you know, more likely to accept insurance than psychologists but there are really financial reasons that that exists you know and I think I'm hoping and probably in other bills this year we'll be talking about you know how parity really would be important to address some of the underlying concerns that probably drive the reasons that psychologists might want to expand their practice. And I don't know if you all have those reports about how many primary care doctors accept insurance versus psychologists versus psychiatrists. It's not all recent data, but the Department of Health has done a pretty good job of to track that in the past. I'm happy to submit that to Calista.

[Sen. Virginia "Ginny" Lyons, Chair]: That would be great to send those along with your written testimony if you can do that. It's just very helpful. We appreciate your time doing this. We are probably taking you away from patients.

[Dr. George Vanna, Psychiatrist]: There's another meeting I'm jumping right to after this, but are there questions that I could answer as well?

[Sen. Virginia "Ginny" Lyons, Chair]: Questions? We're good. We're good. And we'll look for your testimony and the literature that you send along. That'd be great. Just get it into Melissa. Thank you.

[Dr. George Vanna, Psychiatrist]: Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: All right. So then we have Doctor. Hughes here from Binghamton, Sumi Binghamton. Welcome.

[Dr. Phil Hughes, Assistant Professor, Binghamton University]: Thank you. Good morning Chair Lyons and members of the committee. My name is doctor Phil Hughes, and I'm a health services researcher and assistant professor at Binghamton University. For the record, this testimony is my own and does not necessarily reflect the opinions of Binghamton University or the state of New York. My research focuses on how policy impacts mental health care, and I'm here today to testify on my research regarding h b two thirty seven. The research I'm speaking on today was conducted by a large team of experts from a range of fields, including pharmacoepidemiology, economics, psychology, social work, nursing, pediatrics, and psychiatry. First I'd like to talk about safety. I recently published a peer reviewed study comparing the outcomes of twenty one thousand two hundred and twenty eight patients who saw either a prescribing psychologist or a psychiatrist. The study used the same robust causal inference methods used by the FDA to generate real world evidence for drug safety. Compared to patients treated by psychiatrists, prescribing psychologist patients had a twenty four percent lower rate of adverse drug events, a twenty percent lower rate of using multiple psychotropic medications, and similar rates of emergency department visits and medication adherence. All of this while controlling for the patient's complex medical diagnoses, their medications, and other clinical and socioeconomic factors. So all of the kind of complexities of medical care were accounted for. So with all of that in mind, prescribing psychologists appear to be at least as safe as psychiatrists. I also want to emphasize that this study used data from New Mexico and Louisiana, and the educational requirements proposed in h b two thirty seven are more stringent than in either of those states. For example, the the robust clinical training requirements laid out in the bill, like the amended clinical rotations discussed in prior testimony, including fourteen months and five clinical rotations, exceeds the training requirements in most other prescribing psychologist states, and those states have excellent safety data. So given that information and the increased educational requirements, seems reasonable that Vermont would have similar or better safety outcomes. There's also ample evidence to suggest that prescriptive authority for psychologists can improve population mental health. Two studies have now found that suicide rates are lowered by as much as five to seven percent seven five to seven percent when psychologists prescribe. And following those two studies, a cost effectiveness study demonstrated that prescribing psychology is highly effective as a policy highly cost effective as a policy, reducing suicides while saving millions of dollars over about a twenty year span. My research also suggests that this bill is likely to increase access to mental health services. I led a policy simulation study that estimated how prescribing psychology might impact mental health prescriber shortages in each state, and the results of that study suggested that HB two thirty seven is likely to reduce the mental health prescriber shortage in Vermont by about 8%. For comparison, the national estimate was around 4.7%. So Vermont looks to gain from this bill by about double what would be expected nationwide. In addition in additional studies, prescribing psychologists appear to treat underserved patients, including patients in highly rural areas, under resourced communities, and other racial minority groups as well. I've included a map in my written testimony that shows the broad reach of one prescribing psychology clinic in New Mexico. I anticipate similar patterns would emerge in Vermont. That one particular clinic was treating patients who were 95 rural and in 75% of the counties in New Mexico despite being located in one area in the southern part of the state. Finally, I wanna also highlight research findings from Angela from a study by Angela Shoulders and Alicia Plemings that that showed states with prescriptive authority for psychologists see an increase in the number of psychologists in the state, but do not have a corresponding decrease in psychiatrists. That is the policy incentivizes growth in the mental health workforce without ostracizing the psychiatrists. I wanna emphasize this point given the collaborative care model has been referenced a number of times in prior testimony both here and in other states considering this policy as kind of an alternative to prescriptive authority. Advancing prescriptive authorities for psychologists does not get rid of psychiatrists or prevent the use of the collaborative care model. Improving access to mental health care is not a zero sum game requiring a choice between prescribing psychologist or collaborative care. Both models coexist together. So in conclusion, the research to date has clearly demonstrated that prescriptive authority for psychologists is safe, reduces suicide rates, reduces health care costs, and improves access to mental health care for underserved and rural communities. H b two thirty seven may not solve the mental health crisis in Vermont, but all of the available evidence suggests that it would improve access to mental health care and ultimately save lives. Thank you for your time, and I will be happy to take any questions.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. This is terrific. We have your research letter. We don't have your the the information that you just provided, your written testimony.

[Dr. Phil Hughes, Assistant Professor, Binghamton University]: Mhmm.

[Sen. Virginia "Ginny" Lyons, Chair]: Send that into Felista as well.

[Dr. Phil Hughes, Assistant Professor, Binghamton University]: I would be happy to.

[Sen. Virginia "Ginny" Lyons, Chair]: That's perfect. Questions committee. Great. We're good. That that was very clear. Thank you for sharing your research with us. Really helpful.

[Dr. Phil Hughes, Assistant Professor, Binghamton University]: Yeah. Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: In Bennington, New York, you're not that far from us. You're still it's still cold.

[Dr. Phil Hughes, Assistant Professor, Binghamton University]: It is. It is.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. Well, thank you very much.

[Dr. Phil Hughes, Assistant Professor, Binghamton University]: Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: We're gonna move to Evan Eiler. Here. Thank you for being here. Doctor Eiler. Is it Eiler? I agree. Yes. Thank you.

[Dr. Evan Eyler, Psychiatrist]: Well, thank you, Chair of Orleans and Senators. It's a pleasure to be here with you today. Thank you for allowing us this time together. You've kept my written testimony and therefore I'm going to summarize it briefly so that we have a little time to dialogue with you. Initial medical training was in family medicine. I did a three year residency and have practiced for thirteen years. While I was practicing medical medicine, I became interested in both in mental health very seriously and also in how things work. So first I got a master's degree in public health that helps me understand systems. And I enrolled in psychology branch of school, but did not complete the program because I decided the most effective thing for me to do would be the two second residency. So I practiced both for a number of years and now practice Badger exclusively, but did a lot of complaints about the impairment. So that is my background and area of interest. I speak in a position to this bill for many reasons, but three in particular. One is that the model that it proposes is dated by twenty years. Twenty years ago, the thought was, there's not enough access to mental health care. We need more prescribers. Let's find a way to get more prescribers. It was actually longer though, in fact, I believe the first territory to consider psychologists prior to prescribing The United States did so a way that it so thoughtless. We need more prescribers, let's get that. It turns out that that is not actually the case. That we don't need more prescribers, we have plenty. What we need is to use the prescribers and other reasonable clinicians that we have more effective. The collaborative care model was developed at the University of Washington because they realized that it was just not possible to train an army of people that would go everywhere, do everything with the model that was currently in place. And what needed to do was to approach psychiatric illnesses, depression, anxiety, PTSD, substance use disorders, the same way that we'd approach other such as diabetes. And use a coordinated approach with registries with standardized instruments with everything sharing electronic medical records working together so that we would use the resources that we have in a way that we should every morning. It was all sometimes inequitable physical or mental health. The previous model, if it goes in to use the way back machine, was that essentially you went to your internist, panel physician, NP or PA, for treatment of your high blood pressure or your diabetes or things of that nature. But then we went somewhere else such as to psychiatrists to treat depression and anxiety and trauma. And it turns out that it's, first of all, just a very false ominous second fall, not an effective way at all to do it. So in terms of prescribers, who is prescribing medications currently in The United States. I put this to be approximate numbers in my testimony. We have combining psychiatrists, psychiatric practitioners, and psychiatric PAs from approximately 99,000 prescribers in The United States. If we had primary care physicians who prescribed approximately 70 75% of all psychiatric medications in The United States along with NPCs. We have another 387,000 prescribers. If we add primary care NPCs and PAs who also do a lot of strategies, have 428,000 those professionals. So we have a proxy made, well, we have actually over 800,000 prescribing clinicians in The United States for psychiatric medications. For prescribing psychologists, have two twenty six. Therefore, with regard to several conclusions from this. One, when we have plenty of prescribers already, we need to use them in a more effective, coordinated way. Two, with regard to our colleague who just spoke, I think it's very hard to make any accurate statistical inferences when you're comparing 226,000 And I really would love to see some of that data in a lot more detail. In addition, in Vermont, if we were to go with this bill as proposed, we would gain approximately five to 10 more psychologists over time at the cost of developing an entire additional system to train, license, monitor, and manage another class of prescribing professionals. When frankly, the medical and nursing boards already have plenty to do. And I do not see this as a justifiable pause. I would also just decide to issue the previous spelling. When I finished psychiatry residency, I specifically did not look at post cancer jobs in any state that had psychologist prescribing because they've regarded it by that type as a complicated factor that will interfere with the dissemination of care. In addition, if we want to bring more prescribers to Vermont, all of these considerations are dwarfed by the effects of loan repayment and addressing the crisis in housing and childcare. That's what we need to do to bring more people here. With regard to the collaborative care model in Vermont, the third thing I would say is that this is doable. This is within reach. We can do this. A lot of times when there's a model that's been shown to be effective in this place or that place, the answer is yes. So what does that have us do with us? And the answer is plenty. At this point, all of the primary care practices in syndrome on that are affiliated with Health Network have an associated psychiatrist or psychiatric nurse practitioner and of course, apply model. This could easily expand it with funding instead of putting it into sidetracks to things that have for new benefit. The Blueprint for Health, the ULCD or Gulst, who you talked to was a pilot project that does very well. Unfortunately, there's no funding allocated beyond 2026. That should have more. The Vermont Consultation and Subpatriot Access Program, Vermont CPAP, which some of us say they're well prepared. CPAP is part of the Rural Health Transformation Grant and continues to leverage collaborative care. There also would be potential, I would think, to make grants directly available to fund collaborative care in primary care and to reimburse for consultations between primary care clinicians at St. Patrick's, whether by telemedicine, which also needs to be supported for a person who are getting the consults. This session, we have Senate Bill 197, which directly invests in primary care and continues to leverage the model we need to support telemedicine services. And also with the advanced practice with the synchronous program, the APRN program, they can be found these adequately funded to maintain the supply of psychiatric practitioners in the lungs. So there are ways of doing that. It is doable. Speaking of evidence, the collaborative care model has over 900 randomized controlled trial studies. That's the highest level of evidence supporting its effectiveness. Again and again, it's been shown to reduce patient satisfaction, to increase the satisfaction among clinicians, to reduce stigma and to contain loss. So my opinion at this point would be that rather than putting money toward creating an entirely separate training licensing monitoring system, which would yield very few additional prescribers, when we don't need more prescribers to begin with, that we put the funding for collaborative care and use the resources that we have in an effective manner the same way as it's being leveraged for diabetes, COPD, and other chronic illnesses. Thank you. Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: Good information. I do have a question for you. One of the issues that has come up that I find very compelling as opposed to on the psychologist side is that frequently there are folks who are going to a psychologist for ongoing therapy sessions. And they also have a prescription from a psychiatrist. The question for that group of individuals is why can't my psychologist put a continuing prescription for what my psychiatrist has authorized? That's a question for you.

[Dr. Evan Eyler, Psychiatrist]: Yeah, once again I would say that whatever convenience exists for a small number of people. So far, I know of two factor level psychologists in Vermont who wish to take advantage of this. I know many others who don't and want to be considered some of that. But in any case, the small advantage that combined it from an tiny number of people is dwarfed. What else did we throw so much money at to create a utility system? I would also note that with the World Health Transformation projects, that we finally have the capability. One of the proposals is to get every hospital and its deleted clinics in state on the same electronic medical record, which would be an amazing difference. Mean,

[Sen. Virginia "Ginny" Lyons, Chair]: think that would be- We should have done that and let it slow. And you know, I'm like, yeah, touche, otherwise. I

[Dr. Evan Eyler, Psychiatrist]: think that is just the best news ever because one of the keys to make healthcare work is that everyone has to make communication. One of the major proponents of this bill has said that he doesn't use electronic records because it's too much bother. That's just not okay. So my first question, if someone says, why can't my psychologist just do this? Is your psychologist in contact with the person who's prescribing these medications and with the primary care person who is prescribing their other medications. This bill as constructed allows the prescription by psychologists of any medication. I read this yesterday, that is used for mental health reasons, of whether or not it is marketed as a mental health medication. So that includes cardiac medications that treat panic attacks, high blood pressure medications that treat ADHD, and so forth. So the idea that the psychologist over here is going to prescribe medications, it sets off a situation where there isn't that linkage, particularly if there are medications that are active systemically throughout the body, which most psychiatric medications are, there should be one practice overseeing all of the medications that the patient is taking to avoid interactions and looking at adverse purposes. I think that you get your physical care here and then we send you somewhere else for your medical care. I would say it's a dinosaur of a model, except I like dinosaurs. So I want to say thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you very much. We're gonna have to move on. Sure. We have Sarah Hastings, discuss her psychology graduate. Clinical Psychiatry at St. Mike's. Welcome.

[Dr. Sarah Hastings, Licensed Psychologist and Professor, St. Michael’s College]: Thank you very much. It's an honor to be here. Yes, my name is Doctor. Sarah Hastings, I'm a licensed psychologist and professor at St. Michael's College. I'm not here speaking on behalf of my employer today, but as a licensed psychologist with more than twenty five years of experience. And I'm here to support granting prescriptive authority to appropriately trained doctoral level psychologists to improve mental health care across the state. The Vermont Office of Professional Regulation, the Board of Psychological Examiners supports this bill, recognizing that Vermonters do face long wait times, weeks and sometimes months, to see a psychiatric provider. This bill offers a solution. Doctoral level psychologists have extensive training in mental health. They are already present, often serving as the primary point of care to our patients. So the bill allows Vermont to use this existing workforce more effectively and to reduce the unnecessary barriers to treatment. Of all the mental health providers, psychologists receive the most comprehensive education in diagnosis, psychopathology, and evidence based treatment. And we've already seen prescriptive authority for psychologists being implemented successfully in multiple states, as well as within the Department of Defense and the Indian Health Service. The DoD credentialing system has enabled psychologists to prescribe within military health facilities for service members and their families. And the outcome data summarized by Doctor. Hughes today, we're very fortunate to have his expertise as a part of this process. He is a health services researcher and has reported safe prescribing practices and lower rates of adverse events among psychologists who are prescribing. Prescriptive authority also improves continuity of care. So when psychotherapy and medication management are provided by the same clinician, treatment decisions are better informed by extensive knowledge of the patient over time. And so this reduces missed referrals, overreliance on medication alone. It is cost effective as well and decreases emergency room visits and unnecessary hospitalizations. I think psychologists bring a very important perspective to prescribing as well. Our training emphasizes that medication is one tool among many. It's not the default solution. And so this leads to really the thoughtful use of medications and attention to factors that are psychosocial in nature and environmental as well. I think, too, it's important to remember that the proposed legislation is is not intended to replace physicians or psychiatrists prescribing psychologist practice within very clearly defined scopes and collaborative care models, consulting and referring when medical complexity exceeds our role. And so this approach allows physicians to focus on the most medically complex cases while improving access for everyone else. Finally, strong safeguards have been written directly into the bill, advanced training requirements, and supervised practice ensuring that prescriptive authority is granted responsibly and with patient safety as the highest priority. As a licensed psychologist, I've seen mental health treatment change lives for the better, not only for the patient but also for all of those in the patient's circle, including their families, their workplace colleagues, and the wider community. I also know the devastating effects of untreated mental illness and suicide, having witnessed the associated pain and suffering within my own circle of friends and loved ones. Granting prescriptive authority to properly train psychologists is a practical and evidence based solution to Vermonters' mental health needs. It expands access, it protects public safety, and makes better use of mental health professionals already serving our communities. So we are very glad with the collaborative work of OPR. We have a proposal that they support and that received a unanimous vote of support from the House Health Care Committee and the full House, and we are hopeful that we have your support as well to move this important bill forward. Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you very much. I have one question, and then we're going to have to move on to our next bill. So we appreciate your being here and sending in your testimony, everyone who's been here today. It's It's a lot for us to think about. One, you did talk about continuity of care. So, and the previous witness indicated that this would be broad prescription authority. What is your thinking about prescription authority for treatment of the mental health issues rather than broad authority?

[Dr. Sarah Hastings, Licensed Psychologist and Professor, St. Michael’s College]: My understanding is that the bill focuses on mental health treatment.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, thank you. Thank you. Okay, other questions? All right, taking care of St. Michael's.

[Allison Despathy, Co-Director, HealthChoice Vermont]: Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: And thank you for being here. All right, good.

[Allison Despathy, Co-Director, HealthChoice Vermont]: Thank It's a pleasure.

[Sen. Virginia "Ginny" Lyons, Chair]: All right, so we're gonna move on to the APRN bill as 163. We have two folks to testify, and we'll do that now, and then we're gonna move on to H-five 45 and hear the testimony running into life. I think Devon's remote. Devon is remote. I didn't hear that. Thank you for keeping your virus at home or in the office.

[Devin Green, Vermont Association of Hospitals and Health Systems]: You're welcome.

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Can you

[Devin Green, Vermont Association of Hospitals and Health Systems]: hear me okay?

[Sen. Virginia "Ginny" Lyons, Chair]: Yes. So why don't you just go ahead on S163.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Great. Thank you for having me in. My name's Devin Green. I'm with the Vermont Association of Hospitals and Health Systems, and I will keep it brief. As you know, VAHS represents whole hospitals, which has a sort of continuum of providers in it. In bringing S163 to our providers. I can say that we were generally supportive of the bill overall. Some of our physicians did bring up concerns around the conditions of participation in Medicare that require a physician to attend to a patient. But given that there's flexibility in this bill and hospitals can provide their own policies, we remain generally supportive.

[Sen. Virginia "Ginny" Lyons, Chair]: That's a relief, thank you. Yeah, no, thank you for that, Morley. All right, questions. And so just so folks know who weren't in the room when I announced it earlier, we have two senators who are out for personal reasons. And so we're holding forth here with the three of us and taking breaks as we need to. But all of the testimony, we will be reviewing and listening to. Thank you, Devin. All right, so Jessa Barnard is here.

[Sen. Martine Larocque Gulick, Vice Chair]: Good morning. I will also try to be brief, maybe not quite as brief as Devon, but close. I'm Jessa Barnard with the Medical Society representing physicians and PAs, and thank you very much for extending the time to take testimony on this bill because we wanted to bring it to our board for discussion, and they met until 08:40 last night. So I, between then and now, tried to write up as best I can the summary of the outcomes of our meeting. And we actually really appreciate Michelle Wade, came to our meeting to answer questions.

[Jessa Barnard, Executive Director, Vermont Medical Society]: So we had a really good discussion. We discussed this actually at two board meetings, ended a full member survey, and heard from over 95 members of comments on the bill. The sum outcome of that was last night our board voted to take an overall neutral position on the bill. The board understands the intents behind wanting to modernize the language of the statutes at issue, the two different statutes, and the goal of ensuring patient access to care, especially in Vermont's rural hospitals. That said, I was also directed to relay some of the concerns our members discussed with the bill, one of which, sort of two buckets, one in the clinical concerns. So our members do believe that team based care is the best approach for hospitalized patients. We understand that should the legislation pass, it doesn't prevent team based care, but it will no longer be required in statute for all hospitalized patients to have a physician involved in their care. We received many comments from members and line, the one that I included in my testimony, that hospitalized patients often are presenting with the most complex and evolving medical conditions that require the depth and breadth of training provided by physicians being involved with that care, and maintaining a physician as attending a record supports patient safety, accountability, and consistency, while still, while not preventing or still allowing key parents and PAs to practice at the top of their license as well. So again, just sort of clarifying, we understand that in Vermont's scope of practice, there is nothing limiting APRNs from providing inpatient care or being the attending of record. However, this has been sort of layered on top of that and providing a, making sure that a physician is also a point of contact during that patient's hospitalization, and some of our members did feel that that is a substantive change in policy. We've heard testimony that healthcare employers in the credentialing process put additional requirements in place, and we don't dispute that. However, our members are concerned that with the financial pressures that hospitals are under at this time, that that may change over time. And then just to follow on a little bit of what Devin referenced about regulatory complexity or uncertainty, We understand one of the motivations behind the bill is to streamline the statute and align with existing practice. However, our members have shared examples where removing this current requirement could actually lead to lack of alignment with regulatory requirements, maybe even to the extent of making it nearly impossible to implement for some hospitals. So I've given some examples, and as Devin mentioned, the conditions of participation with Medicare require every Medicare patient be under the care of an MD or DO, regardless of who admitted the patient. Discharge to home health requires certification from either a physician or an APPN or physician collaborative practice. And another note our members want me to pass along, many hospital practices or services, so critical care, hospitalist services, etcetera, employ both APRNs and PAs, and so having a bifurcated system where one applies to APRNs and one applies to PAs could be very difficult in practice to implement, just like bifurcating sort of Medicare patients who will require physician oversight while other patients might not, could also be very difficult to implement. I'm not sure hospitals kind of track who's on Medicare and who's not, who's being cared for by an APRN versus PA. So in summary, we are neutral, but we do wanna say our members told us that the current system of providing team based hospital care is working well for hospitalized patients and hospital regulatory structures and don't think it's necessary to change that at this

[Sen. Virginia "Ginny" Lyons, Chair]: time. Thank you for considering our comments. Thank you. So it sounds like, well, and the testimony that we just heard from the hospitals also indicate that the hospital bylaws can include some conditions for practice. Well, yes, either bylaws or credentialing requirement. Right, Yeah, That

[Sen. Martine Larocque Gulick, Vice Chair]: is true. And I think many hospitals do have those in place. Again, just our members flagging the concern that that could always, that can change at any time when the medical Got staff changes their it. Again, given sort of the pressures on hospitals to make the cost of care as low as possible, there could be pressure to move away from

[Sen. Virginia "Ginny" Lyons, Chair]: a physician involvement in care. Okay, and then, will be important, and this will be up to Jen to help us understand if we need to have any language relating to following CMS Medicare. Doesn't look like we need that.

[Allison Despathy, Co-Director, HealthChoice Vermont]: Yeah, I mean, don't know

[Sen. Virginia "Ginny" Lyons, Chair]: that that needs to be in statute.

[Sen. Martine Larocque Gulick, Vice Chair]: I think we're more pointing out that that causes complexity, and hospitals may or may not even be able, some hospitals may not even be able to incorporate this change in Vermont statute into their premises.

[Sen. Virginia "Ginny" Lyons, Chair]: But your comment about PAs is well taken. Thank you. Thank you. Okay, this is good. This adds to our testimony. We're getting really close to just sitting down and pondering the bill and for us doing markup on it. Thank you for that. So, we're gonna just move right ahead. We are gaining time on ourselves, which is good. We're gonna move ahead to H545 and the immunization bill. And we have Michelle Wade. Michelle Wade. Where's Michelle? Wade. Oh, she's on the line. Is she up on

[Allison Despathy, Co-Director, HealthChoice Vermont]: the ceiling? That's very distracting. Michelle, are you there?

[Sen. Virginia "Ginny" Lyons, Chair]: Michelle, that's There's Michelle. Is that Michelle away?

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Well, you for having me.

[Sen. Virginia "Ginny" Lyons, Chair]: Terrific. Why don't you go right ahead with your testimony on H545,

[Dr. Evan Eyler, Psychiatrist]: please?

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Thank you, Chair. For the record, Michelle Wade, President of the Vermont Nurse Practitioners Association, here today on H545, which, as you know, is related to immunizations, which is a hot topic. But on behalf of the Advanced Practice Registered Nurses and the Vermont Chapter of the American Nurses Association, we thank you for the work on H-five 45 and your continued commitment to protecting the health of Vermonters. We support H five forty five as it was passed in the house, which includes an APRN on the council as well as representation from the board of nursing. I want to share with you and re remind to this committee that APRNs and registered nurses were integral to Vermont's immunization infrastructure. In many rural and underserved areas, we are the frontline, especially when it comes to immunizations. Often, this is being discussed with parents in school hallways by nurses in the school system. Often it's being discussed in the grocery store. Immunizations and nursing and APRNs are a

[Sen. Virginia "Ginny" Lyons, Chair]: great group of

[Michelle Wade, President, Vermont Nurse Practitioners Association]: people to have all on the same page. Public health clinics, community settings, nurses are the clinicians that are doing all of the counseling at time of immunization. Therefore, it's important that we're a part of this committee, and it's important that we have the correct background to be able to share why a decision has been made at the state level versus what's happening at the federal level. Despite this central role, nursing, however, is not currently represented on the Vermont Immunization Advisory Council, and this omission does create a disconnect between policy development and frontline clinical implementation. Including the APRNs as the House did, we further proposed that registered nurses are equally included in this. Nursing input is essential to ensuring that immunization recommendations are practical, evidence based, and effectively communicated to patients, families, and the community. We appreciate all of the hard work that you're doing on this. The House did on this already, and I would welcome any questions at this time.

[Sen. Virginia "Ginny" Lyons, Chair]: Questions? I think we're good right now. We may get back to you. Absolutely. We know how to contact you. Thank you very much. Appreciate you. Have

[Michelle Wade, President, Vermont Nurse Practitioners Association]: a great day, everyone.

[Sen. Virginia "Ginny" Lyons, Chair]: You too. And we're gonna move to Laura Byrne, executive director of the HIV HCV, Resource Center. Laura Byrne? Hello. Ah, there you are.

[Laura Byrne, Executive Director, HIV/HCV Resource Center]: Thank you. I'm Laura Byrne, the Director of the HIV HCV Resource Center. On behalf of Vermont's AIDS Service Organizations, I would like to begin by saying that we strongly support H-five 45. Thank you so much for your work on this important topic. We considered proposing an amendment to this bill related to HIV prevention medications. We understand that the bill might not be the right vehicle per the proposal, but we appreciate the opportunity to share information today and hope to continue working with you to identify an appropriate legislative path forward. We do have language we're working on right now. I'd like to briefly discuss PrEP and PEP and why access to these medications is so important for HIV prevention. Pre exposure prophylaxis, or PrEP, is a highly effective evidence based HIV prevention medication. When taken consistently, it reduces the risk of HIV acquisition from sex by about ninety nine percent, and it also meaningfully reduces risk associated with injection drug use. Despite its effectiveness, PrEP remains significantly underutilized in Vermont, and recent federal actions threaten access to this critical prevention tool. Post exposure prophylaxis, or PEP, may be prescribed for someone who may have been exposed to HIV within the past seventy two hours through sex, sexual assault, occupational exposure or sharing injection equipment. Access to PrEP and PEP is a proven public health strategy that also produces significant cost savings. Preventing a single HIV infection can save the health care system approximately $554,000 in lifetime medical costs. Last June, the U. S. Supreme Court's decision in Kennedy versus Braidwood gave the Secretary of Health and Human Services authority to reject preventative care recommendations, putting future PrEP coverage at risk. While current federal guidance prohibits prior authorization for PrEP, these protections can be reversed by a future or present administration. Vermont cannot rely on unstable federal policy to ensure access to lifesaving HIV prevention. Today, barriers such as cost sharing, prior authorization and limited prescribing access continue to delay or prevent care for people at risk for HIV. We support allowing pharmacists to prescribe and administer PrEP and PEP, as many states already do. Expanding pharmacist roles would rapidly increase access, particularly in rural and underserved communities where timely care can be difficult to obtain. Given ongoing instability at the federal level, Vermont must establish its own legislative authority to ensure that access to PrEP and PEP is broad, reliable, and free of unnecessary barriers. Thank you for your time and consideration.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you very much. And if you would please send your testimony in, it will help us now, but it will also help us going forward.

[Laura Byrne, Executive Director, HIV/HCV Resource Center]: Certainly.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. Thank you very much.

[Allison Seeger, Founder and Director, Vermont Language Justice Project]: Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: Alison, Despathy is here. Thank you. We have your testimony.

[Allison Despathy, Co-Director, HealthChoice Vermont]: You know what? I will send it in, but I just printed them out right here. So, Senator Cummings, that's for you, and Chair Lyons. Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. And I will also try to be quick. I know that's the theme.

[Allison Despathy, Co-Director, HealthChoice Vermont]: Okay, so Allison, that's Cathy, and I think I was supposed to have me listed as Danville Planning Commission, but that may have been my testimony and energy. So I'm co director of HealthChoice Vermont, and thank you for having me. And I just want to say, I don't think anyone takes issue with this bill with regards to procuring vaccines and attaining them at cost savings and making sure insurance is covering them. That's already in statute. That's happening. I know they're trying to expand where they can access them. That makes sense. I've talked to Commissioner Hildebrandt and we had a great conversation. There was no issue with his attempt as obviously Commissioner of health to make sure he can do that job for Levant. One of the things, if you don't mind just taking a quick peek at the first page, my issue with the bill and where I feel like there is potential for some sort of balance and a little bit of correction or scales of justice correction, would be, so Caitlin Matten, she lived in Barton, Vermont, and her mother gave testimony in 2015. She died from a flu zone vaccine that had mercury. She ended up with myocarditis. It took eleven years, but her mom finally received $250,000 for her death. Her mother's quotes are in here. She wished that she had had more of a conversation with the doctor that she had known to seek more informed consent and information when she was at this wellness visit. So basically what I'm getting at here, as you can see on the third page, over $5,000,000,000 have been paid out since 1988 for vaccine injury and death, and that's by the National Vaccine Injury Compensation Program. The fourth page here, there's over 5,000 Vermonters who have reported into the VAERS system, and the research shows that sixty eight percent of those reports are done by healthcare providers, and eighty six percent of them are found to be accurate, and that there is a vaccine causing injury. So I think it's really just acknowledging the fact that vaccine injury is real, and people have very different opinions about it. I know it's incredibly politicized. And right now, with the move that has happened on the federal level, I think there's a lot of misinformation, but essentially, all the vaccines are available, all of them are still covered by insurance, and all of them are still protected in the sense of the 1986 federal law that passed. When I offered testimony in human services, I was allowed 40 to really go through some of the history. I know I don't have that at this time, you guys are going through a lot. But what they were very much upset about in that committee was the fact that big pharma was given a liability shield in 1986 for any sort of vaccine damage or harm. And I just wanna make sure that you know that that stemmed from the fact that there was a Diphtheria pertussis tetanus vaccine that was causing neurological damage, because there was a there was a live, live pertussis in there, live cell pertussis. And because of all the lawsuits, there was only one pharmaceutical company left, because the rest were closing. That was Ladural, it became Wyeth, which is now part of Pfizer. And because of that, instead of them going back and saying, you need to make a safer product, they gave big pharma and the administrators a liability shield for protection. There's federal laws and states who are trying to say, no, they should be responsible for the safety of the product. And that has essentially resulted in compromised vaccine safety monitoring. So in here I also show where, and this might be shocking, but I think it needs to be said, that there are no vaccines on the childhood schedule that have ever been studied with a placebo controlled clinical trial. And they've been safety monitored from five days to several months. Whereas when you look at pharmaceutical products that the pharmaceutical company is responsible for, such as Lipitor, Eliquis, Enbrel, Lyrica, they will be controlled with a placebo study, and they will also be studied for two years to nine years. So because they're not responsible for the safety of their product, there has been compromise. And so I just wanted to put that out there. And so basically, a lot of the change that happened at the federal level, and it's sad to me that science becomes so politicized and people hear the word vaccine and they sort of go into their camp and it doesn't help us to really look at the science and what has come through. But basically, for example, hepatitis B was taken and just moved into a category called the high risk population or groups. And what it essentially means, which really is what vaccines should be in all medication, is have a conversation with your doctor. This should be shared clinical decision making, talk to your doctor. So they're not taking vaccines, they're not making it so you can't get them. I think that the commissioner is taking some good action with regards to, I wanna make sure I can procure these and insurance covers them. But where the issue lies, and I'm sorry, I'm sort of launching ahead here, I just wanna walk through something with hepatitis B. I promise I'll only be about three more minutes, so thank you. Hepatitis B, I just wanted to show you guys a timeline. It was approved in 1986 by the FDA, and this was after big pharma had been given their liability shield. It was the first genetically modified virus used in a vaccine and it was only studied for five days with one hundred and forty seven children. Because of this lack of safety monitoring pre licensure, Informed Consent Action Network sent a letter to Health and Human Services requesting hepatitis B safety data. 01/18/2018, it was three months later, they received a letter back that failed to provide further clinical trial safety data. They submitted more letters to see what was the research on this done, and it was ignored. Finally, submitted a FOIA, which demanded a copy of the clinical trials relied upon to license Recumbivax HB, And they received a 1,200 page document that confirmed that this had only been studied for five days in 147 children. So because of that, on 09/04/2020, Informed Consent Action Network filed a petition to the FDA demanding the licensure of the hepatitis B vaccine to be revoked or suspended until their safety as required by law is determined in a properly designed clinical trial. So there is some of this going on with regards to, let's look at this, let's be honest about it, at this point there's nothing been taken. So my question lands in, really page 15 of what you saw come out of the house, is when there's going to be a healthcare professional that's part C. A healthcare professional who prescribes, dispenses, or administers an immunization in accordance with the recommendations, issued pursuant in subsection. Basically it's what offers the liability shield for the doctor. So first of all, there's already a liability shield from the federal level for the doctor and the pharmaceutical company. So if you were to, as a state, go down this path and say hepatitis B for safety issues came off the schedule, and the state said, well, it's not now, it's not federally protected, there's no liability shield for pharma or the doctors now with hep B for example, if it was shown to not have good safety data, or just shown to have issues. But the state decides to do a recommended schedule that has it in there. The question is, what is the responsibility then that the state or the provider have to the patient? Should the patient be made aware that we've now protected these providers in case you have any harm or damage? Should, like you buy a car as is, should you know that this is something you're getting into? Should there be a uniform standard procedure that a doctor has to go through to say, I wanna make sure you've had a good benefit risk analysis. Do you feel informed to make a decision about this vaccine? So, what is the way we balance the fact that we're giving a liability shield for a product, and should we be making sure that the patient is made aware and has informed consent? And I know that the lawyer for the Department of Health said, well, well, we already have informed consent laws. But I think that that's what we have to come down to. I work with over 200 people in my practice who are vaccine injured, and many of them never felt like they had a benefit risk analysis to talk through with their doctor. Many doctors will give what's called a vaccine information statement. And by the CDC for decades, that's been said to not constitute informed consent. So these are just some of the questions I wanna bring. I know that you guys make the laws, the executive branch executes the laws. To me, you're obviously representing the people and the patients who are going to be going in. So if you're going to give the doctors the shield, what are we doing to balance it and how are we making sure patients are aware of what they sign up for? So that's the biggest thing I wanted to bring to it and the only place that I think a lot of people are just concerned about, well, what should a provider have to offer a patient if they're gonna be shielded? So that's what I wanted to bring. No, it's really just that section on page 15 where I think the concern is.

[Emily Truter, Division Director for Substance Use Programs, Vermont Department of Health]: Okay, thank you. And did you bring this up

[Allison Despathy, Co-Director, HealthChoice Vermont]: in the house? I did bring it up in the house. I spoke to judiciary. Basic, and also Greg Burt, my representative and friend, it might be worth, if you're comfortable or open to it, having him in to talk about what is amended. No, what

[Sen. Virginia "Ginny" Lyons, Chair]: it was. We'll get our testimony. Just wanna know your experience in the house. Yes. You did testify in the House. Yes. Has somebody heard this? Yes. Did they put it in as of,

[Allison Despathy, Co-Director, HealthChoice Vermont]: they did not put it in? No, Greg tried as, I'm sorry, Representative Burke tried as an amendment to see if we could do Okay. Yeah. Okay. To try to balance it out. And I will speak to judiciary as well, but just trying to make sure that that base is covered. So, thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. And thank you for this, and please send it to the publicist so they have it online. That's lot of work in this. Okay. Appreciate it. Thank you so much. All right, and we have one more person to testify on H545. Andrew Garcia is here up on Zoom. Welcome.

[Andrew Garcia, Clinical Pharmacist, UVM Medical Center (Infectious Diseases)]: Thank you for having me. Can you hear me?

[Sen. Virginia "Ginny" Lyons, Chair]: Yes, we can.

[Andrew Garcia, Clinical Pharmacist, UVM Medical Center (Infectious Diseases)]: Perfect. Thank you so much. So my name is Andrew Garcia. I'm currently the clinical pharmacist at the Outpatient Infectious Disease Clinic at the University of Vermont Medical Center. I work closely with the Infectious Disease Physician Group to provide direct patient care to folks with a variety of conditions, including people living with HIV and those seeking, HIV prevention care. My background includes extensive training in clinical pharmacy at the University of Pittsburgh Medical Center, where I completed a pharmacy residency focused on underserved care and global health. And I'm also credentialed as an HIV pharmacist through the American Academy of HIV Medicine. I've had the privilege of working directly with patients who are marginalized or face large barriers to care, as do many of our patients living with HIV. And I'm very happy to be here today to speak in support of the amendment that Laura mentioned that would allow pharmacists in the state of Vermont to directly provide care for HIV prevention, just like our colleagues in the states of Colorado and California. As a nation, we've come a long way from the 1980s and 1990s when the AIDS crisis was hitting its peak. In 1994, AIDS was the leading cause of death for young adults in America, and the only available medication at the time, AZT, could lose efficacy and cause serious side effects. It was because of the dedication of activists and the tireless work of researchers from across the globe that many new HIV medications were developed. Today, not only is HIV not a death sentence, but the medications we have are extremely effective at preventing HIV acquisition when started either before or within seventy two hours after exposure to an HIV positive source. For exposure via sex, we're talking almost one hundred percent effective when these medications are taken as prescribed. And for folks who use injection drugs, these medications are over seventy five percent effective in preventing HIV through exposure via an infected needle. And yet despite having highly effective medications to prevent HIV, the HIV epidemic continues worldwide. In 2022, the Centers for Disease Control reported thirty eight thousand new HIV diagnoses across the country. And while Vermont has relatively low incidences of HIV compared to other parts of the country, the Vermont Department of Health reported over one hundred new cases between 2008 and 2017. This number should be zero. We have the public health tools needed to end HIV, but we still see new cases every year. What is happening that people continue to become infected when we have such great effective and safe preventative medications? Well, I can tell you what I see every day as part of my job. A patient might go to the emergency room, urgent care or their primary care doctor and report that they stepped on a needle, or maybe they had condomless sex with someone of unknown HIV status, or maybe they were sexually assaulted. Their physician does the right thing and prescribes them HIV prevention medication, something extremely effective again if started within seventy two hours of exposure. And the patient goes to their pharmacy and is met with one or multiple barriers. The copay for the medication is in the thousands of dollars. The physician didn't prescribe the HIV medication that the pharmacy has in stock, and it will take at least a day to order. The patient's insurance forces them to fill at a mail order pharmacy, or the patient doesn't have insurance at all, and a twenty eight day course of preventative HIV medicine will be over $4,000 out of pocket. These aren't hypotheticals. I've gotten every single one of these phone calls from patients or pharmacies. The pharmacy is the exact point where ideal medical care breaks down and the unfortunate harsh realities of our health care system set in. Financial and logistical barriers that make the difference between a patient's being able to start their HIV prevention medication in time or not at all. And so I strongly believe that pharmacists are in the perfect position to remedy that should the legislature empower them to do so. The pharmacist would be able to say, we don't have this medication your doctor prescribed in stock, but let me switch to a different one that's just as effective. Or this medication is expensive, but I know this other medication has a copay card available or a free drug voucher available. Let's switch you to that one. These actions might literally be lifesaving when we are talking about a very short window to start prevention treatment. And that is only talking about the best case scenarios when patients have already sought care from a physician. In Vermont, where emergency room and primary care wait times can be extensive, and visits are often accompanied by a large bill, and where folks living in rural areas may have significant barriers to quickly accessing care, patients may be discouraged from seeking HIV prevention at all. The community pharmacist might be the only healthcare professional these patients can or feel comfortable going to for help, and they should absolutely be able to do so. But you also don't have to take my personal experience with these patients as the only proof that the current system is not working. In 2022, the Centers for Disease Control published an alarming finding. Out of every patient or every American patient who would benefit from taking HIV pre exposure prophylaxis, also known as PrEP, to prevent HIV acquisition, only thirty six percent of these patients were actually given a PrEP prescription. That means almost two in three people that we should be reaching are completely left out. And unfortunately, the statistics show that these are already marginalized folks. For example, only thirteen percent of Black patients who would benefit from PrEP received PrEP, while ninety four percent of white Americans who would benefit did. Further disparities exist in other groups like women who are greatly under prescribed PrEP, as well as folks experiencing substance use disorder. We really need all hands on deck to expand the provision of PrEP and PEP and to ensure all Vermonters who need it can access it free of charge. Pharmacists have the clinical knowledge and the proximity to patients and will be a necessary part of expanding access for PrEP and PEP. For these reasons, I would wholeheartedly, and I do wholeheartedly support this amendment and welcome any questions you might have. Thank you so much for your time.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, so the amendment that you're supporting is the HIV amendment that we're going to look at in the future, just so you know that. It doesn't make sense to put it onto this bill at this time, but I really appreciate your testimony and we'll carry it forward.

[Andrew Garcia, Clinical Pharmacist, UVM Medical Center (Infectious Diseases)]: Thank you so much.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah, thank you Andrew. Appreciate it. Okay, good. Good work. We've been through this committee has fire hoses that come in each day, and this is Katie, one of those I know that Senator Gulick is upstairs at a press conference, but let's just look at the bill for a few minutes and then we'll take a break until quarter out. So we'll just go through it very, very quickly.

[Dr. Evan Eyler, Psychiatrist]: I have a

[Sen. Virginia "Ginny" Lyons, Chair]: meeting meeting. You and I have a new meeting. Right, we do. So we're gonna probably finish. I know the people who are next are in the hallway, so we'll there's Hello, Peter Ginny Lyons, Legislative Council.

[Katie McLennan, Office of Legislative Counsel]: You do have an amendment if you'd like to look at that. Let's look at that. Okay. Can you put it up? Yes. Sure. Which bill does it strike for yourself? Draft. It goes like one? Yeah, amendment 1.1. So this is an amendment that was requested by the Office of Professional Regulation. You'll see this as instances of amendment, which I know can be annoying because you're flipping between the underlying bill, but because it's a 24 page bill, it felt a little silly to Thank you. It's a good wait for us to see it. It's all there bright yellow. Yep. Okay. So if it helps if you have your pass from the house, I I think that could be helpful. So the first change is in section three of the bill. Section three of the bill has the Vermont Immunization Advisory Council, and right here we have the list of membership of that council. This is saying we're striking out subsection B, putting in a new subsection base, or striking out the membership list, or putting a new membership list. The change here is that prior to the amendment, and that has passed House version, Subdivisions two and three are the executive officer for the Vermont Board of Nursing, or designee, and the executive officer for the Vermont Board of Pharmacy, or designee. Those two individuals on the list are being removed. And the conversation with OPR was that they didn't need the executive officers because they have an APRN and a pharmacist, and that it was duplicative. They didn't need somebody from the board and also a practicing APRN and a practicing pharmacist. So the resulting council will have an APRN and a pharmacist. But not somebody from the board. Got it. Okay? So this is, here's the language that has the APRN and the pharmacist. Do you see that? I know there's so many striking roofs, but ten and eleven. Okay. The next instance of amendment is striking out section seven, which dealt with pharmacy technicians and putting section seven back in with changes. So, a lot of what's happening here is reorganization, but the change is right here, which is listing how the authority for pharmacy technician to administer immunizations. So this would now read, pharmacy technician shall only administer immunizations. When a licensed pharmacist who is trained to immunize is present and able to assist with the immunization as needed, this is already in statute, it's just from a different area of this particular section. So they shall only administer immunizations pursuant to a valid prescription by a practitioner, a standing order made by the Commissioner of Health, or a protocol approved by the Commissioner of Health under subdivision twenty twenty three(two)A. That section is in your bill. It's in section six of the bill. It deals with the pharmacist. And that ties the commissioner's recommendations to, Solve it. Yeah. This list sit there. So it's referencing the commissioner's recommendations. That section will change in six years and it will go back to CDE. That cost reference won't change. But what it's referencing will, if that makes sense. Got it. Depending on the point in time. And then three, this is a reorganization but not a substantive change. So to patients who are 18 years of age or older, and five years of age or older seeking an influenza immunization, COVID-nineteen immunization, and subsequent formulations or combination products thereof. Then we have a lot of strikethrough, but that is the end of that subdivision. So you have a list of three items. This was in the underlying bill, removing the reference to the CDC, and then we have some renumbering, re lettering, I guess, to be The third instance of amendment also deals with pharmacy texts. In section 13 of the underlying bill, that language, as it came over from the house, makes changes or tries to revert the language back as of 2031. OPR doesn't want the language we just looked at to revert back. Therefore, there's no need for a change in 2031. So I've deleted that section altogether. Meaning that what you see in the second instance of amendment would would stay even when other statutes are reverting back. Okay. I can explain that again because it is Let me know if you want me to go over that one. I get it. I think we get it, I think what we'll do is when we come back to this, because we're getting close to finishing our work on it, you can explain it then. How are you, how are we gonna have this bill? Is it gonna be a stricel or is it gonna be instances of? That is a question for you. I'm happy to do it either way. Okay. And this is, as this is drafted, if this is what you were to vote on, it would just be these three instances of amendment that you vote out. If you have a strong preference for a strike all, or if you have substantially more amendments, then a strike all might start to make more sense.

[Sen. Virginia "Ginny" Lyons, Chair]: No, I think let's leave it the way it is and let's come back to it. I think we have it on our schedule next week. Okay. I think I have preliminary schedule. Yep. Oh, there it is. Right. We have it early next week. So, we can come back to it, look at it, and perhaps we can do the final markup and go and by that time, we might have Senator Benson back. Probably. Alright. Thank you for that. You're welcome. It's good. We've done a lot of work today. It's great. So we'll go off live at the risk of going off live. We'll do that, and then we will come back in five minutes because we we have folks here for three squares awareness day, and we wanna finish up a little early. And some of