Vermont Legislature SmartTranscripts:

[Virginia "Ginny" Lyons (Chair)]: I'm done. You're live. All right, good morning. It is Wednesday, February 25. This is the Senate Health and Welfare Committee, and we're picking up S142, an act relating to a pathway to licensure for internationally trained physicians and medical graduates. And we have taken a lot of testimony on the bill and understand that we need to hear more testimonies and we're going to hear today from Doctor. Green and then from Doctor. Greenberg of the Board of Medical Projects. So we've got those two today. So Doctor. Green, thank you for being here and I know that you have sent in some testimony which we will post for the bill. Why don't you introduce yourself for the record and go right ahead.

[Dr. Andrew Green]: Sure, so my name is Doctor. Andrew Green. I am a primary care pediatrician at the University of Vermont's Dallas Sano Children's Hospital. I'm the director of the Pediatric New American Program and the director of pediatric global health. And I'm here today to find support of the licensure pathway, S142. Two. So thank you very much for this opportunity to submit written testimony and now oral testimony in strong support of S-one 142, the legislation establishing an additional licensure pathway for internationally trained physicians. I appreciate the significant upstream work that has gone into developing this bill and the thoughtful phased approach for legislative review and testimony. I submit this testimony not only as a clinician, but as someone whose professional life has been shaped by immigrant communities medicine. I provide pediatric care to children and immigrant families in Vermont. Through this work, I have met many internationally trained physicians who now live in our communities, but are unable to practice medicine at the level of their training and expertise due to existing licensure barriers. These individuals are often highly experienced, deeply committed to patient care and eager to serve. Yet they are relegated to roles far below their capacities at a time when Vermont faces significant primary care physician shortages. In my perspective, my perspective is also informed by my own medical training. I completed my medical education at McGill University in Canada, an internationally respected institution, and I'm acutely aware that excellent medical training occurs outside The United States. Competence, professionalism, and clinical judgment are not confined by national borders. In addition, I work in global health education with the University of Vermont Larocque Gulick of Medicine, supporting medical students as they engage in global health learning and service. I've also trained and worked globally in Asia and Africa. These experiences have reinforced for me that many physicians trained abroad practice and resource limited in highly acute settings, often developing exceptional diagnostic and clinical skills. This bill offers a responsible and humane solution, one that values both the patient safety and physician experience while addressing physician shortage in our state. This legislation establishes a structured evidence based pathway for internationally trained physicians to practice medicine in Vermont while maintaining high standards of care. We'll be required to have fluency in English, to pass all parts of The US MLE exams, and to have secured employment with the Vermont Hospital, Regionally Qualified Health Center or Community Health Center. The bill creates a two year professional licensing phase, which differs from traditional US residency by focusing on assessment and integration of existing clinical skills rather than duplicative retraining. During this period, an ITP will practice under a limited license, work with underserved populations, and be required to pass USMLE Step three by the end of the provisional period. Importantly, they are supported by a supervisory model that prioritizes patient safety and professional development. Upon successful completion of the provisional phase and examination requirements, physicians become eligible for full unrestricted Vermont physician license. This pathway acknowledges prior training and experience while ensuring readiness for independent practice. This approach is both rigorous and pragmatic. Vermont joins a growing number of states responding to physician workforce shortages through similar legislation. Approximately 30 states have adopted, enacted, or considering comparable policies. Several states already have live applications and issued licenses demonstrating that these pathways are feasible, safe, and effective. As a people who can care for immigrant families, a physician trained outside The United States, and a global health educator, I see firsthand both the unmet health needs of Vermont and the untapped potential of internationally trained physicians already living among us. This bill offers a thoughtful, well structured solution, one that strengthens Vermont's health care system, improves access to care for vulnerable populations, and honors skills and experience of qualified physicians. In addition, I have some further testimony, if I may submit it, that addresses some of the concerns of the Vermont Board of Medical. And I understand that I'm presenting before them and may have to go see patients unless they don't show. So I appreciate the opportunity to speak a little bit more. So one of the things I want to appreciate is the Vermont Board of Medical Practice has expressed some concerns about its capacity to fully support this bill. However, a lack of familiarity or infrastructure should not preclude thoughtful adoption. Vermont would not be the first state to implement this type of program and can look to other states for models on how to evaluate the authenticity of documentation and the quality of international residency training. The barriers to implementation are real but are solvable. I want to briefly explain how medical training works in much of the world, just to kind of clarify some of the differences. Many countries use direct bachelor medicine, bachelor's surgery model. And this is a five to six year program that integrates preclinical and clinical education earlier than the traditional US doing a pre med and then medical school pathway. So students begin their hands on clinical rotations during their undergraduate years, developing strong skills in clinical assessment and early training. Postgraduate training also differs in countries such as The United Kingdom, Uganda, Norway, France. There's many of them throughout the world. This is actually more the norm of the way people are educated as physicians in most of the world compared to The US. They will graduate and then they'll do some foundational years, what we will call an internship before specializing. So we used to have something called a rotating internship that all physicians would do once they graduated, where it was this additional year. And it is still what we call, if you think about resident, the first year of residency is called an intern year. It's your internship year. So we still use this terminology, although historically that year has been folded into residencies in The United States. Well structures vary internationally. Physicians who seek to practice in The United States are still going to have to do the standards of passing all the USMLE exams. And so I wanted to just note that. The Vermont Medical Board suggested that having ACGME one international accreditation should be a prerequisite for participation. But I want to recognize that this is often not the reality of resource allocation globally. There is a cost to doing that accreditation. And while it's a worthy goal, participation in international accreditation systems are expensive. And for many foreign institutions, limited resources are directed towards patient care and local workforce development. They are also not interested in a brain drain. They're not interested in having their graduates go and work in another country. They like to keep them locally. So ensuring competency is essential, but mandating a specific accreditation pathway may not be very practical or equitable way to achieve that goal. Competency, professionalism and quality assurance can be addressed through structural oversight within Vermont. Mentorship and supervision are key and the board could have a directed oversight process that would include submission case records. So patients that people had seen or surgeries that they had completed, minor surgeries, quarterly reviews by supervising physicians, direct supervision during that initial transition period, and the use of specialty specific standards modeled on those ACGME residency competencies. Professionalism is not static. It's the same, it's an ongoing obligation for all physicians and international graduates should be held to that same standard of medical practice as they are in Vermont. So that would be continuing medical education and professional work that others would be also doing. I would also urge caution against underestimating the quality of training in non US healthcare systems. Many countries operate within national health systems that emphasize prevention, cost awareness, and evidence based decision making. Physicians trained in limited access settings often develop exceptional skills in history taking, physical examination, diagnostic reasoning, and clinical assessment precisely because they cannot rely on extensive ancillary testing. So cost considerations are routinely incorporated into shared decision making conversations, something that's not built into The US practice. These strengths are especially relevant in rural communities where access to advanced diagnostics may be limited. As an aside, although not written, I would also say that one of the advantages of this is that it does allow people to enter our systems who have other ways of thinking and can really help us to modify and better our systems around As to vetting concerns, The United States already conducts extensive vetting as part of admissions and visa processes, the most rigorous in refugee admissions. Many of the physicians we have actually came through that system. In addition, as the board has stated, any criminal background concerns while practicing in The United States would appropriately fall under the existing state oversight mechanism. On a personal note, my daughter, who's a fourth year medical student at the University of Pennsylvania, recently completed six week obstetrics and gynecology elective in Tanzania. She trained alongside students from Norway, Germany, Switzerland and Austria who are completing extensive rotations under Tanzanian physician supervision. The experience was rigorous and collaborative and usually these are set up very bidirectionally and that is the way we do it at our university. And so high quality education and strong clinical training are something that are valued in these institutions around the world and often why we send our medical students there to get some of that experience. In closing, international medical students already meet national standards. With thoughtful oversight, structured mentorship, and clear expectations for competency and board cert, they safely and effectively serve our Vermont communities. The question is not whether excellence exists, abroad does, but whether we are willing to build responsible pathways to welcome. Thank you for your consideration.

[Virginia "Ginny" Lyons (Chair)]: Thank you. And we have your testimony, I think, already. I'm having trouble getting up onto my webpage. I believe you sent it in. Thank you

[Dr. Andrew Green]: for I sent it in last week, the additional like sort of add on in response.

[Virginia "Ginny" Lyons (Chair)]: Okay, good. Questions committee. Good. Very clear and appreciate your time that you're taking away from your practice to do this.

[Dr. Andrew Green]: No worries. Yeah, and I do know people have some insecurities because it feels different and unfamiliar, but in my experience in working with immigrant communities, it really is a strength to have this training that's done in other parts of world. It really brings new perspectives, new ideas and lots of strengths to our community, including our physician community.

[Virginia "Ginny" Lyons (Chair)]: That's I may be

[Dr. Andrew Green]: able to stay on a listen, I'm just going look and see whether or not my patients are

[Virginia "Ginny" Lyons (Chair)]: That's fine. Thank you for being All right, so Doctor. Greenberg. Yes. You've been here before, so welcome again. Thank you. Good to see you. We also have your testimony. I believe you sent it in, and as soon as I can get to my webpage, I can follow along. Okay. Great to have you introduce yourself to the record and then give us your, the Board of Medical Practice, I understand, has a position on the bill and we would like to hear what

[Dr. Matthew (Matt) Greenberg]: it is. Sure, thank you, Madam Committee members. My name's Matt Greenberg. I'm an emergency physician. I've been a physician for twenty five years. I've been practicing in Central Vermont for the last fifteen years. I'm here to speak on behalf of the Board of Vermont Medical Practice that I currently chair. I apologize, I'm a little disorganized since in the air till 01:00 last night, trying to keep all my thoughts straight. I guess what I would say is that the Board had a good discussion about this. I believe you've got the testimony that Mr. Herlihy has submitted with our sort of very individualized concerns that are directed at some of the very specific parts of the bill. I think looking at it from a larger perspective is we're not opposed to the idea, we clearly have a shortage of physicians in this state, we have a shortage of primary care physicians in particular, we have this population of highly trained physicians from foreign patients that potentially could fill some of those slots. It would provide them an opportunity to work. We're not opposed to that idea. It comes more down into the details of how we do it. I am by no means a thought leader in how you credential and how you train. I do know is the process I had to go through, and what I can tell you is that from public high school to state college to Dartmouth Medical School to my residency, every single step of that way, I was overseen by an educational institution that was credited in this country by some organization. And on top of that, had some sort of national testing that went along with it, whether that was the SAT from high school, the MCAT to get into medical school, The US. In this country we have these multiple different tiers to sort of ensure appropriate levels of training, professionalism and that sort of thing. The concern is that, not that people are coming to this country that don't have amazing training, but that the board would be, basically, have the responsibility of ensuring all of these credentials that currently for US trained medical professionals is being done by multiple other organizations that are very large with lots of resources. Resources that frankly the board does not have to do. So, you know, the paper trail behind my education is huge. And it didn't stop when I graduated from residency. If I have a lawsuit, I get reported to the National Practitioner Database. If I do something wrong at my hospital and I lose my privileges, that gets reported. So there's a lot of inherent checks and balances within the framework here that basically, from our understanding of this bill, would now be taken upon by the board to perform all of those separate duties. Again, the number of people working at the board right now is pretty limited, and the amount of work involved in this is concerning, and even how we approach, you know, there's some lines in here about showing that a person has practiced for three out of the last five years. How do we find, you know, if somebody was working in Afghanistan, for example, how do we get the documentation to prove that? You're asking, this is the process, this is what you need to do, you need to show that, but we need to find a way to prove that.

[Virginia "Ginny" Lyons (Chair)]: So, and I'm thinking while you're talking, because I did read through your comments earlier, I have it here now because my little spine pad isn't happy, but as you're talking about this, understanding that there are national exams or other procedures that other states have that would validate the medical background for some of these folks? Can you envision a process? I mean, could you envision looking at what other states are doing and just,

[Dr. Matthew (Matt) Greenberg]: yes. And I think that's exactly it. And one of the states we looked at was New York. And so for example, Doctor. Herlihyde put some of the details in the appendix at the end talking about the New York program. So

[Virginia "Ginny" Lyons (Chair)]: I

[Dr. Matthew (Matt) Greenberg]: think we can all agree that comparing Vermont and New York is apples and oranges, they are, I mean, with New York City, shining international community, right? So New York State has approximately 120,000 licensed physicians. Provide has about 6,000. So New York has a process that they use. It involves seven different boards, and it is combined between the Department of Education and the Department of Health. They, on average, through this program, license 150 to 175 licensees. With Vermont being, you know, looking at the ratio of how many licensees to how many you would, new recruits you would get, it would be less than 10 a year. But again, the amount of resources that they're using, so or Mr. Herlihy, talked to the New York, his counterpart in New York, and they could not give us a financial estimate on how much that was costing, but did note that it's multiple different departments that are doing it, education and the Department of Health, and that the individual person has to go through seven different boards to get that license. We could look further into that process.

[Virginia "Ginny" Lyons (Chair)]: Are there other states that are smaller that might offer a better example? I honestly don't know the answer to that question. And I you know, I asked the question because I think the group that has brought us the bill, including Doctor. Ginny, Ginny. They have looked at other states, and there may be some models out there that would fit better with the state of Vermont. I think that's what we were hoping we could do. And then the relationship that people build, obviously we have many physicians who are trained outside of the country already. Absolutely. So maybe there are relationships that physicians build with physicians within, they might not be working at the top of their practice scope, but they also have capacity and you can begin to understand that. There might be a process in there that other states have developed. I don't wanna put pressure on the Board of Medical Practice, but I will just share with you that this committee is very supportive of the bill and a lot of the work that's gone into it from the coalition of folks. And I hear your comments. Very sensitive to the need for resources to meet the goals. And so one of the things I would ask is please carry the message back to the board and to David. I know he's a very hard worker and I know he's very interested in making sure we have the data we need. Carry the message back that we would like to know what other states, and I think actually Doctor. Tree may be able to help with that, or Diana Gulick, if we say her name wrong, who's worked on this in Southern Vermont, they've accumulated significant amounts of data and information from other states. I'm not trying to sidetrack your testimony. I wanna hear the rest of your testimony, but as we're thinking about what's possible, so what are some other smaller states doing? Is there some program that works and fits with Vermont? And what resources would be necessary to make it happen? And we do know that we have refugee populations in our state, like in Winooski or Southern Yubon and other places. And they welcome an opportunity to work with a physician who understands their culture. At the same time, any physician we have who want to relate with everyone equally, whether it's an immigrant population or whether it's an old time Vermonter. So we have all of that. So I'll let you finish, but I just wanted to ask that question and stick that message to the Certainly,

[Dr. Matthew (Matt) Greenberg]: and I can talk to David and see if there are other states that are smaller that are more similar to ours that have a process. You know, the board is charged with the protection of the safety Absolutely. Obviously we take that seriously. And it's looking at all comers that could come through this process, and it may be easier for the country, people coming from countries that we understand better because their culture is closer to ours. Completely understand that. Reality is that most of people we're talking about, they can't, know, a lot of those folks go through existing systems. The refugee population might not be coming from those kinds of countries, just supporting backgrounds is the concern. And again, I've worked with many Martine trained grads there are, and I absolutely agree with Doctor. Green, mix on the culture, let's hear about more physical exam, let's, you know, people that are used to using CT scanners on everybody, it is great to mix those things up together with our own practices here, and there's certainly some benefits, but it comes back down to, you know, we're gonna be tasked to make sure that all of these people are appropriate in providing safe care to the state of Vermont and people here, and how are we actually going to be able to perform the duties that are laid out in the bill, and I think that's really a heart of our concern. I will say there was some additional discussion during our looking over the bill about some cultural differences, and the way that the current system is set up through, for internationally trained physicians. Most of them that are going to get certified in this country go through the DCFMG and they wind up doing a residency or a partial residency here in The United States. And part of the benefit of doing that is sort of getting people used to our system. I think we all recognize that the system, if you want to call it that, is broken in this country, but it's also very different than every other country in the world, and learning how to adapt to our system and our culture. And part of the residency is learning that culture. Now, if somebody was going to be embedded in a different program, say, maybe having practice or whatever, they would get some of that, But it is really important that people learn the culture and people will be coming from different cultures. And there was some concern about things like relationships towards, between different genders, homosexuality is not taken well in some cultures, and being able to get people embedded in our own culture for better acceptance prior to licensing to understand how we practice in this country and be a little bit more in line with some of the things that we need to

[Virginia "Ginny" Lyons (Chair)]: We have two questions. Yes,

[John Benson (Member)]: no, just talking to screen.

[Virginia "Ginny" Lyons (Chair)]: Yes, all right.

[Martine Larocque Gulick (Vice Chair)]: But I also wanna say something I can speak on. Me too.

[Virginia "Ginny" Lyons (Chair)]: Yeah, so Doctor. Green, go ahead because I know you're on a tight schedule here.

[Dr. Andrew Green]: No, my patients have slept in on break. So we seem to be okay so far. So I just want to address that idea of professionalism, I may, because I think that this is a really important place. I do hear you that often people practice in a more paternalistic style in some of the world, not all of the world, and that's how they're trained with more of this paternalistic style. Lot of shared decision making. I think it's important to recognize that one in four children in this country is a child in an immigrant family. So I just want to put that fact out. So I think if we're thinking about the population as it gets better, having a diverse population that we're taking care of and having more diverse representation among our physicians is important. I think that learning shared decision making can happen anywhere. And I would state that we have physicians who are born in Vermont, trained in Vermont, or born in The US and trained in The US, who also have challenges around cultural differences between themselves and their patients, and some of those pieces. So I think in training people to be professional, what I have seen is that good physicians are good physicians. And I think we should not parse out this assumption about cultural difference. Because I think that that is something where we're asking people to behave in a professional manner. If they can't behave in a professional manner and they're doing that supervision time, and it's clear that they are unprofessional or unable to be, know, learning how to do shared decision making and learning how to respond appropriately to all people, then I think that that's a concern, and that would come up in sort of an evaluation. But I really strongly suggest that that not be an approach of the board to bring that forward again.

[Virginia "Ginny" Lyons (Chair)]: So I'm gonna say thank you, and we're gonna let Doctor. Greenberg finish his testimony, and appreciate your comments. This is probably a conversation that can happen offline. Think that, yeah, thank you. So I'm going to doc doctor.

[John Benson (Member)]: I'll be Doctor. Benson. I'm gone. Wasn't a question. I was just making sure that you saw that

[Virginia "Ginny" Lyons (Chair)]: Her hand's up. Okay. Was a senator who. Thank

[John Benson (Member)]: you very much. Well, promoted.

[Virginia "Ginny" Lyons (Chair)]: Thank you

[Martine Larocque Gulick (Vice Chair)]: for your testimony. It's great, and I have so many thoughts as I'm listening to you, so I appreciate it. A couple of quick observations I just wanted to throw there. If our system is broken, which you admitted, why wouldn't we welcome outside perspectives? I think that's exactly what we need, frankly, to fix the broken system. In terms of your role as making sure that providers are safe and that we have quality of medicine and that, again, safety, I think having a robust workforce is part of safety, and I think making sure that folks in rural parts of the state have adequate care is part and parcel of safety and being safe. I'm also thinking about maternal mortality rates for women of color, which are really horrible in this country. So our outcomes don't always speak to safety, frankly, for certain populations. So for me, I just can't help but look at the opportunities here as something that could be incredibly helpful to our state and to many of our folks who live here.

[Dr. Matthew (Matt) Greenberg]: And I think we absolutely recognize that we we need are, change, and we need to look outside of our current boundaries, but trying to figure out how to do that safely and what is realistic for the board to be able to do. Now, if there was a mechanism that this could be outsourced to somebody who has more experience, maybe that would be a better option. You know, thinking about one of the other comments that came up was that the majority of the refugees in the state, and I don't know this for a fact, this is what I am being told, but most of them live in Chittenden County, which is the highest concentration of physicians in the state, and very few would be in the more rural areas that are more need. That

[Virginia "Ginny" Lyons (Chair)]: answers one problem, the other problem is the need for physicians in the more geographically isolated

[John Benson (Member)]: parts of

[Dr. Matthew (Matt) Greenberg]: the state. Correct.

[Virginia "Ginny" Lyons (Chair)]: Hearing a couple of things. Not a matter of willingness to try. It's a matter of resources. You have a very limited set. Of resources. And if where our need for physicians is greatest is the place where there are fewer refugees, then that kind of cultural clash that could arise would the complaints would come to you. We'd we'd be more likely to clash. On the other hand, I had the Joy, my first childbirth, be in a communal labor room next to a woman from Vietnam. Well, according to her doctor, she was very upset, and she hadn't let him look at her in nine months, and he didn't she wasn't gonna let him. There was definitely a cultural thing going

[John Benson (Member)]: on. And

[Virginia "Ginny" Lyons (Chair)]: that's many women from might also have some connections to public health intensity. Women in other cultures would not let a male doctor. They're used to midwives. And so it's but we we need the resources because all you need is one bad incident and the whole program's gone. And it would be helpful, I think, to know some thoughts on on the resources that it could take to make this work. I think we all wanna make it work. It's how do we make it happen? How to make it happen. How to make it happen. Big question, Sandy. And the board seems important in this. Once we pass a bill, we wanna make sure that it's doable and that it will happen. So I guess to ask of you in your role on the board and going back to David and others is, are there other models? Is there a model that would help Vermont, that would work with the board? And what if any resources would be required? Some of it will be communication, some of it will be actual boots on the ground, analysis and linking folks with national organizations or tests, all the background and that stuff. So, and it does go together with the work that you did to get your credential. You know what my husband went through, big deal, takes time and it's ongoing forever. But if you could please help us with this and we will come back to the bill and we do have an interest in trying to move it along and get it to the house so that they can work on it further. So there is time in this world over the next couple months to do something that is effective. So I'll just leave it there. And if you have further comments that you'd like to send any to us please do that. Sure. But we'll invite you back in after we have crossover coming up. We're on a very short leash. So when you have something, it would be great. And if you can let Calista know, sure, we'll be all set. And I appreciate the thought you've given to this. And I know I saw your initial testimony and it was highly specific, but I could read between the lines that if we get it another way it might work, so I'm hoping that you'll have some recommendations for us that will improve the bill. Can't promise we'd accept them all but Understood. So that's good. Committee, any other questions?

[John Benson (Member)]: Just go ahead. He said something that was kind of interesting. First of there's a lot of guardrails, seems like, in this bill, for me reading it, for protections, things

[Ann Cummings (Member)]: of that nature, and working underneath other doctors, which

[John Benson (Member)]: seems like a lot in there. But it seems like to me, as Senator Cummings said, it seemed like a resource issue for your board, And you mentioned maybe another entity or a third party might be good at helping you look at some of these issues. Did I hear that?

[Dr. Matthew (Matt) Greenberg]: My own personal comment, this is not speaking for the board. Okay. Okay. Alright. Was, wow, if New York has a program, could we have people go

[John Benson (Member)]: through the New York program? Like, could we Mhmm.

[Dr. Matthew (Matt) Greenberg]: You know, basically hire New York and have them, or even ask them if, hypothetically speaking, if we wanted to send somebody through your program, what would it cost us? It might give us an idea on the cost. But, you know, if we don't have the resources, and we're, again, we're talking about maximum 10 a year to do all of this investigation and set up a whole process. It's not a huge number of people, but if we could rely on New York or some other state that's already doing it that hasn't established, could we just outsource it? That that was my own personal thought. That didn't go very far with the rest of

[Virginia "Ginny" Lyons (Chair)]: the board, but

[Dr. Matthew (Matt) Greenberg]: it was a personal thought. I think Well, you mentioned this one. Yeah. I yeah. And I think it's something you can look at, and I'll absolutely go back to David and see if we can find some other states and some other ways this is done. But I think you're right. I think nobody's opposed to the idea of having physicians, good foreign trained physicians that are already in our community, part of our community, working well below their training to bring them up to support our community. It's a win win situation. It's really about the logistics and, you know, we've charged the board to do these things. You know, even just the how do you verify somebody has worked three out of the last five years in Pakistan? I

[John Benson (Member)]: get it.

[Virginia "Ginny" Lyons (Chair)]: But we understand there are difficulties here, and there may be some barriers that preclude some folks from being acceptable. We understand that. But then there are also those that would be able to credential adequately. Well, I'm happy to

[Dr. Matthew (Matt) Greenberg]: take this back to the board and to David and then come back with any new details that I

[Virginia "Ginny" Lyons (Chair)]: can find. Thank you. Thank you for your flexibility on that. We really appreciate it. You're welcome. Any other questions?

[Dr. Matthew (Matt) Greenberg]: Thank you.

[Virginia "Ginny" Lyons (Chair)]: I hope the dry bag is okay.

[Dr. Matthew (Matt) Greenberg]: Five minutes.

[Virginia "Ginny" Lyons (Chair)]: Oh, you have the five minutes. I'm good. About it. Five

[Dr. Matthew (Matt) Greenberg]: minutes, I can still go home, get a nap, and work as

[John Benson (Member)]: well. Thank you.

[Virginia "Ginny" Lyons (Chair)]: Take care. Alright. That's terrific. Smarty doubles I am. He's my neighbor. Yeah. So we have we'll we'll hear back from them and see what we might be able to do because it is I think it's a bill that's been worked over now for a while. And we are lucky to have with us folks from CSGE. Yes, thank you very much. Hello, chair. And are you? Why don't you two help us understand how we're doing this? Okay. And we'll introduce ourselves to you, and then you two wanna come up to the table? Shirley is up on Zoom. Is she up on Zoom?

[Dr. Andrew Green]: Hi, Shirley. Hi, Shirley.

[Virginia "Ginny" Lyons (Chair)]: We work together. She's great. Hi Shirley. We're just sort of like sitting in right here on our capital visit, which we take every year. Okay, so I have a seat, and then we'll introduce ourselves to you and then we'll ask you to introduce yourself for the record. Perfect. And then we'll ask for the broader introduction and then Shirley I think she's the one that knows what he's talking about.

[John Morley III (Member)]: John So. Morley from Morley's District.

[Virginia "Ginny" Lyons (Chair)]: Nice to meet you.

[John Benson (Member)]: John Benson from the Orange District.

[Virginia "Ginny" Lyons (Chair)]: The Orange, nice. Ginny Lyons, Chittenden Southeast.

[Martine Larocque Gulick (Vice Chair)]: Oh, Burlington, that area.

[John Benson (Member)]: Do you

[Virginia "Ginny" Lyons (Chair)]: see that? Yeah, big extension. I have the way to Burlington too. Oh, do you? And? At Cummings, Washington District, right here. Oh, pretty nice. Anyway, I'm Tara Sad, and I've I was a legislator in New Hampshire for ten years before resigning because, you know, you make a $100 a year and you have to drive three hours to get there. Other than that, it was wonderful. We understand.

[Tara Sad (CSG East)]: I'm sure you do. And so I have been working for council of state governments for the ten years since. I'm as well as Brandon Boy, who is a Washington man. He is our ag person as well. He fills us in on what's going on with Farmville, any legislation that's happening that could affect the Northeast, which is our region, as far as agriculture and rural affairs. So, as you know, CSG, we put on seminars, conferences, we do state house visits, we do research for you if you need research, but our main thing that we do is to play matchmaker. We find somebody who needs some advice or some help on a particular issue from another state, we match them up. They talk to each other, they become fast friends. So that's what we do. And that's invaluable, I think, to a researcher.

[Virginia "Ginny" Lyons (Chair)]: To have another source other than a researcher, you know? Yeah, we just gave

[Martine Larocque Gulick (Vice Chair)]: you a really good example.

[Virginia "Ginny" Lyons (Chair)]: Yes, I know exactly. I know you were listening. Shirley was listening to you. Yeah, no, I very much appreciate what CSG does, and I attended several different CSG meetings. Sometimes it's difficult for us as citizen legislature to get involved, because we have outside work and so forth. Yes, exactly. But we appreciate any effort you make. And also we have trainings and seminars and things that we actually bring to the states free of charge, because you are all members. So rather than you coming out, we can come in. We should actually think about doing that. I did that with an NGA and NCSL this fall program on recovery and substance use disorder. But I'm thinking that areas that we've just been looking at and perhaps some areas of healthcare. Delivery. Moving forward. That's right. RHT, which may affect the rural work that's going on. Exactly. The rural health change. Exactly. It's dire, you know, the actual effect that aging population, lack of employees, Yes. Mean, are closed. Just listening to the last one, you know that Council of State Governments has been the leader in interstate contacts? Yes. And so that might be something as far as training for these international doctors are concerned to accept the credentials from one place to another across borders. Just saying. That's a really good suggestion. Thank you for that. You're very welcome. We'll send that along. Because we do a lot of cross border things like why reinvent the wheel. Yeah. And if it's good enough for one state, it's good enough for another.

[Dr. Matthew (Matt) Greenberg]: I really like the

[Virginia "Ginny" Lyons (Chair)]: way. So that's helpful. I'll send that note to Matthew Greenberg at the Board of Medical Practice. Wonderful, thank you. Thank you. Now Shirley, thank you for being here. Thank you. Go ahead. No, go ahead.

[Shirley (CSG East)]: Chair members of the Senate Health and Welfare Committee, thank you so much for hosting CSG today at your meeting. I know from your agenda, because I've been following it, you are incredibly busy. And I'm so sorry I can't be there in person, but thank goodness for the opportunity to be with you virtually anyway. I know most of you are familiar with CSG and CSG East and if if you're not, I did send some information that is contained in a brochure. I don't know if if my colleagues have any with them. And also, I sent you an invitation or a hold the date card. We're having our annual meeting in Puerto Rico in December for CSG East. Vermont has been involved in many ways, actually sharing across the at several meetings at several of our annual meetings, people were very interested in the efforts that you have been making. And I see from your agenda today are continuing to make in trying to deal with access, cost and quality and systems issues in health care. And you are likely to be invited again. And I thank you, Madam Chair, for letting me sit in the last time I was in Vermont because the speaker that you had about your universal coverage single payer system is someone that I'm hoping to use at our annual meeting in Puerto Rico because there's a lot of interest right now among the states about what they can do given changes that have taken place at the federal level. So there's a sharing. And I'm glad to see you're sharing with New York. Gustavo Rivera, who's chair of the Senate Committee and Health Committee in New York, also chairs the CSG East Committee. And then we have a main representative who is the vice chair of that committee. And I'm not sure if we currently have members, but please, please ask your leadership to be sure to appoint members to that committee. So for those of you not familiar with three SGEs or NCSG, is that we represent all three levels of government and all people in government, elected officials, appointed officials and staff. And you are all members by virtue of your state membership. And so we encourage you all to get involved. There is a Eastern Leadership Academy that's described in that brochure which I also sent by email. It's not as pretty as that but it has the same content. And that training is for up and coming leaders. Tara has been a participant in that. Oh, by the way, I should mention, I was a legislator in the House in New Hampshire for only one term, unfortunately, and from Lebanon, New Hampshire, and worked a lot with your state when I was there involved in politics, worked with your former governor, worked with some of your officials at the federal and the state level, and also dated someone from your legislature

[Virginia "Ginny" Lyons (Chair)]: It a while

[Shirley (CSG East)]: was Bob Harris who no with us.

[Virginia "Ginny" Lyons (Chair)]: You know? Oh, I know Bob. That was who they know. So I

[Shirley (CSG East)]: have a lot of warmth in my heart for all of you. Maybe, Tara, you can tell a little bit about ELA and that opportunity.

[Virginia "Ginny" Lyons (Chair)]: It's wonderful. I was appointed to the Eastern Leadership Academy back when I was a relatively new representative in 2009. It's free. You go to Philadelphia. You're there with only a select few, 30 to 35 people from the Northeastern States, five Canadian provinces, and two territories, Puerto Rico and The Virgin Islands. And it's intensive, intensive four days of training, exercises, tours, restaurants, great food, history. The hotel we stay at is overlooking Independence Hall. It's just incredible. And so I went there when I was a legislator. And then since I've been with CSG, I go every year, which I love, to talk about the Ag and Rural Committee with these new people. It's really, I remember and I still have friends from my time there

[Brandon (CSG East staff)]: and it's great. If I could just add that I'm sure to that. The ELA is probably our crown jewel of our training program within the region and it is targeted at not the beginning legislators, not legislators that have been, you know, in their career for a while, but the the mid and the mid legislators. And as Tara said, outside of getting to Philadelphia, everything else is covered. It's competitive. You have to apply. But it's something that every legislature in our region should have one or two people at least apply for what we

[Virginia "Ginny" Lyons (Chair)]: can do. From every state. Vermont has been well represented. Yes. Yeah. It's it's really, really good. We also have Toll Fellowship, which is the NG.

[Brandon (CSG East staff)]: That's the

[Virginia "Ginny" Lyons (Chair)]: one that is national in Kentucky. I didn't go to that one. I like regional better than that. I was invited to that at one point, but I felt like I was beyond I've had other people who were younger. Exactly. Don't need training anymore. Yeah. But it's it's a very good program. And if you don't wanna go look for somebody around, you think would be a hot tissue. Get that. Yeah.

[Brandon (CSG East staff)]: Coming out of Washington, DC, I can tell you. It's one of the few training programs that's still done nonpartisan. And there are legislators from both parties, and that's becoming rarer and rarer these days to get in the same room together. And I've not heard any of them come out of those three or four days and say that it was great to get out of this out of the pressure cooker a little bit and exchange ideas. Sure.

[Virginia "Ginny" Lyons (Chair)]: Well that's an experience I think that I've had with CSG. It's all very apolitical and really focused on policies and trying to exchange ideas. We work hard to

[John Benson (Member)]: that. That's our goal.

[Virginia "Ginny" Lyons (Chair)]: Well, you do it. I ended in Puerto Rico the last time, I think it was 2013. Fajardo? Yes. Wasn't it beautiful? It was awesome. I actually at that point, I presented on some of our stormwater legislation, on the work with Senator Sears from judiciary on GMO. GMO. Yeah. Carolyn Partridge and I Oh, and Carolyn was there. I know. I was looking at you knitting, and I was thinking of Carolyn. Carolyn, well I do too. She was on one side of the GMO issue when I was chair of the Ag Committee in New Hampshire

[Dr. Matthew (Matt) Greenberg]: and I

[Virginia "Ginny" Lyons (Chair)]: was Trying never supposed be a different

[John Benson (Member)]: to block that line.

[Virginia "Ginny" Lyons (Chair)]: She didn't like me for a while, but now presents.

[Brandon (CSG East staff)]: One issue that crosses over into your work and also our work in ag and rural America that is becoming an issue more and more for us in this region is the food insecurity. Mhmm. Most of our our region states are leading in food security by most all deficits, if you look at the economic data, and we look at it as two food insecurity from two levels. One is actually is, is there food provided for children and, you know, of adults and seniors, and how is it provided, and what's the, what are the barriers to entry to get that? And then the other is more from the ag production side. Our basic production numbers for our region are continuing to go down. We're importing more more food into our region than most any other region in the country.

[Virginia "Ginny" Lyons (Chair)]: I know in New Hampshire we've promised only 24% of the food that is required to feed our people. So in the case of any interruption in transportation or supply chain, we're in deep duty. Big trouble. Big trouble. Hurricane Sandy. Exactly. Yeah. Exactly.

[Brandon (CSG East staff)]: And then if you don't produce food, if your production levels get too low, then your whole infrastructure, people don't put money into the infrastructure, you go, why should I invest in the infrastructure if only 20% of my product is being done here?

[Virginia "Ginny" Lyons (Chair)]: Like John Deere dealerships and. Yeah.

[Brandon (CSG East staff)]: We and then and then I took on top of that, and this is something that we deal with across the board in our region, but even more so in ag is aging population. Most of the people here, I'm an agent, I'm not in the office, but most people in agriculture that are in agriculture are aging and aging rapidly.

[Virginia "Ginny" Lyons (Chair)]: I think the average age is 64.

[John Benson (Member)]: If not higher now and for our region and not a second generation that wants to do it.

[Virginia "Ginny" Lyons (Chair)]: No one wants to do it.

[John Benson (Member)]: So that's a problem we're dealing with.

[Virginia "Ginny" Lyons (Chair)]: In our budget adjustment, we just added funds for program on Meals on Wheels for those who are disabled and we understand so really crucial to this. Any questions? Go ahead, Shirley. I just want to

[Shirley (CSG East)]: make sure that we hear from you about the kinds of things that you're interested. I have started a list based on what I'm hearing today. I can just tell you that these are the same issues that are resonating across all of our member states in Canada, in in The United States, New England, the Middle Atlantic states, Puerto Rico and The US Virgin Islands. And as we're framing our committee structure, one one issue, and I'm going to sit in on on on as much as I can of your of your sessions today, because these are topics that have come up as areas of interest. And and one of the things I'm I'm really interested in is some of the things that your your Green Mountain Care Board has been has been working on and sharing that with other states. And There is a group of states who are interested in exploring greater collaboration among the states around health care coverage access and whether it be single payer, whether it be Medicare for all, whether it be some other iteration, are there things that states can do together to help to assure that their citizens have access? And one of the issues is around licensure. You're part of the nursing compact. I know I couldn't figure out whether you were part of medicine or not. I didn't have enough time to to look that that up. But the the interstate compacts do provide some opportunity to address those issues of immigration and migration and the workforce. And that is the topic that we're looking at as well. So I'd like to go ahead if there's things that we need to add to the list.

[Virginia "Ginny" Lyons (Chair)]: Well, I'm glad that you brought up the regionalization of health care coverage And that one of the components of the bill that we're taking up a little bit later, S. 197, that we haven't had testimony on from the treasurer's office yet, is the expansion and working with other states to understand how we can build a broader coalition, expand our risk pool, build whatever it is, whether it's Medicare for all, and how to do that. And this builds on the work that we've done in this committee very deliberately on hospital reference based pricing and now moving into I'll also be adding in, I hope the committee will have a discussion on expanding our, putting together our public employees into a broader risk pool, and then have, so that we can increase the covered lives and then we reduce the cost within our QHPs. And so those kinds of things we are very much interested in, and Rhode Island obviously has a big step forward, Maryland, Pennsylvania, and global budgeting we've been working on. So all those things that if we keep talking we'll identify all the things that you've talked about as well with workforce and so on. So yes.

[Shirley (CSG East)]: Senator, if you have a couple of people who are really interested, we're sort of putting together an ad hoc committee, if you will, of CSG East members who are going to begin exploring these issues before we do some formal programming and and sharing. So if you want to send me names of people that I should reach out to, that would be great.

[Virginia "Ginny" Lyons (Chair)]: Okay, we can do that. And you're thinking not just of legislators, you're thinking of Yeah, we could do that. And Calista will remind me that we're going to do that. Thank you Calista for helping set this up

[Shirley (CSG East)]: by the way.

[Virginia "Ginny" Lyons (Chair)]: Other questions? Thank you for being here.

[Shirley (CSG East)]: Well thank you. Thank you.

[Virginia "Ginny" Lyons (Chair)]: This is a nice break because we're in the middle of a really chaotic time and we're feeling carried and stressed this has been a pleasant thing.

[Shirley (CSG East)]: Let us help you.

[Virginia "Ginny" Lyons (Chair)]: We will.

[Shirley (CSG East)]: Because we can get you in touch with people. As Tara talked about, that's one of the great things we do because we know what's going on to some extent in our states. I get the most bizarre questions sometimes and I go out and dig out and see what's happening out there and get it back to you. So are questions.

[Virginia "Ginny" Lyons (Chair)]: All right. We go, we just wanted to invite you to a reception that we're having tonight at Hugo's at 06:00. I know it's a busy evening. There are a lot of things going on, but I mean if you want a drink before you go get started on the other day. Yeah, I

[John Benson (Member)]: said I would be there and maybe some others will be there.

[Virginia "Ginny" Lyons (Chair)]: Invite everyone. 06:00 until eight. I know that there are state employees union, and then there's agriculture night and everything like that. If you can squeeze this in, it's too fun. Lots of nice orders. Thank

[John Benson (Member)]: you so much for the time.

[Virginia "Ginny" Lyons (Chair)]: Thank you. Thank you. You.

[Shirley (CSG East)]: And I'm gonna mute myself, but I'm gonna stay on and listen in on the rest of your testimony. Vice

[Virginia "Ginny" Lyons (Chair)]: Please do and send those recommendations if you think there's something you're hearing that would benefit us from other states. It would be lovely to hear, so thank you. All right.