Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: You're live. Alright. Good morning. This is Senate Health and Welfare. It is Friday, April 3. We are going through the budget with Joint Fiscal Office, Nolan Lyons and Amy Pope. Thank you both for doing the work behind the scenes and bringing us the information. So why don't we just dive into it and see what we have? And just for the committee's sake and others who are interested in our process here, we'll be hearing testimony from folks today after we hear from joint fiscal, we'll hear from folks who have either been underfunded, they believe they're underfunded within the budget as presented by the governor or the house or both, or not funded at all, and then we'll listen to information, We'll try to put together some recommendations on behalf of the committee. Our goal in here over the session has been intentionally looking at prevention, primary care, substance use disorder recovery areas. And some of those things, as we saw in the handout from joint fiscal, are already covered in the budget and there are separate funds available for substance use disorder, but there are not separate funds that have been appropriately defined for prevention or for primary care. So we'll be looking at those. I'm establishing priorities that the committee has been looking at during the session.

[Nolan Langweil (Joint Fiscal Office)]: Thanks. For the record, I'm the director of the fiscal office.

[Sen. Virginia "Ginny" Lyons (Chair)]: And Amy Puck for

[Nolan Langweil (Joint Fiscal Office)]: the director the fiscal office. So Our plan today is we're gonna do a very, very, very high level overview of things that are in the budget. There are a lot of things in the budget. What we tried to do was break it down by the various AHS departments. We have Diva, VDH, AHS Central Office down, ECFs. Then we tried to also flag this was in the gov reg, house didn't do anything. This was in the gov reg, the house adjusted it. And then this was not in the gov reg, and the house didn't. So we tried to kind of highlight so you get a sense. Just because it's not listed doesn't mean it wasn't important. We could have had agents of agents of agents of just DMH, right? Or Diva. So we just try to be very high level. Just because we did or did not put something doesn't mean it was a priority to us or anything like that. We just really wanted to just kind of give you a sense of the types of things that are we're gonna bounce back and forth. And again, feel free, I think we'll have it in a way where ask us questions as we go. And we have a lot of time this morning. So with that,

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay,

[Nolan Langweil (Joint Fiscal Office)]: so we always had the flag that we're a nonpartisan office, so we're unbiased, blah blah blah, you know, all this. And this just reiterates what we were trying to say, that it's not inclusive, and this doesn't absolve you from having to read the budget yourself.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, and did you have to? Yeah. Just

[Nolan Langweil (Joint Fiscal Office)]: because we didn't present. So just as I mentioned again, overview, made changes, and this kind of highlights how the state has got wrecked and changed. On the hand, how it's changed is to go wrecked and how it's changed if not included in the background. The other thing we did was if it's a new cost, it's highlighted in black. If it's a reduction, it's a negative in red. So if you can see the difference of the various ups and downs. And then we also tried to flag, is it general fund, is it local commitment, is it gross? And finally, there may or may not be typos. Yeah. If you find any typos, it's your fault for finding them, and not my fault for making them. I'm gonna move this morning. I had an electrode at this morning, so I'm gonna see you guys. I don't think we need to go over this slide per se. This is really just for your overview, to give you a sense of the total budgets of each of the different AHS departments. DOC is in here because it's AHS, but you don't have DOC oversight, and don't, I don't focus on DOC combined portfolio. Amy does everything,

[Sen. Virginia "Ginny" Lyons (Chair)]: but

[Nolan Langweil (Joint Fiscal Office)]: she staffs set up her information. So this gives you a high level sense. Amy, feel free to type in. Okay, so we'll start with AHS Central Office. There's not a lot that happens here. At the same time, everything happens here. And the reason I say that is because the HS Central Office is sort of the command center of HS, but it's also where all the global commitment matching happens. So the policies mostly happen in different departments, and you'll see the different changes, but all of the matching happens at AHS Central Office. So that's why I sort of flag. And then there are a few things, sometimes like initiatives. For instance, the underutilization of the refugee resettlement program. The governor proposed cutting 500,000 in general funding. That is actually an AHS Central Office thing. The other thing I'll flag too is there's the FMAP rate change. I think I did an FMAP overview in the committee and then I did it with the newer senators, but just a reminder that this is the matching rate from the federal government when it works both ways. When times are good, every dollar we draw brings in more federal match. When times are bad, or we'd lose when the FMAP goes down, it costs more to provide the same line of service. In this particular year, we had a rate change where the FMAP, the state share increased, which means that we had just, based not doing any changes, we had a $13,600,000 hold. So just in the absence of the FMAP going down by point 74%, less than 1%.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, in Wall Theater Package cost, I guess.

[Nolan Langweil (Joint Fiscal Office)]: Yeah, to your point, good. I always say to people, when the FF goes in the wrong direction for us, it means that we're doing better per capita. It is an average three year per capita income relative to the rest of the country.

[Sen. Virginia "Ginny" Lyons (Chair)]: Get peopleized for doing well.

[Nolan Langweil (Joint Fiscal Office)]: Or it's helping you when you're

[Sen. Virginia "Ginny" Lyons (Chair)]: not doing it. We have more local tax benefits. So

[Nolan Langweil (Joint Fiscal Office)]: we have the healthcare advocate based funding increase. This was not included in the gov rec. The advocate came to the House and said they had that increase over the years. This is a weird one because it goes through both the Green Mountain Care Board for some of its matching dollars, but it's an AHS Central Office company. That's been a $450,000 increase for the Health Care Advocate. It's a $58,000 general fund. The home and community based services, DAs, SSA rate increase. This one actually goes across DCF, DMH, and Dell, but we're putting it in this one because it's matched here and it's easier than just doing it in the central office than flagging for each particular one. And you want to be thinking about it in the aggregate. And in the aggregate, the increase is a $6,500,000 growth equipment increase, 2.7%. $2,700,000 in general fund. There's also a home health increase, it's $330,000 in group equipment, 140,000 in general fund. They did a Meals on Wheels, which for another $500,000 in general fund, and a 1,000,000 gross. This is a one time, and also if it's one time, we'll flag if it's one time. So there's the Vermont Legal Aid Helpline, is $100,000 in global finance. And the Vermont Legal Aid Immigration Attorney, 200,000 in general. Again, if you guys have questions about any specific things, if we know the answer, we'll answer them. We may not know all the answers. Next we have DEFA. Under the no changes in the gov rec, one of the big ones is impacts of HR1. This was the federal bill. One of the big things in that bill is that have to, Diva has to start doing redeterminations every six months versus every year. In order to do that, it's a huge administrative burden. They have to hire more people to do the work, and they have IT stakes, all this other stuff. They need 12 positions. That's a million dollars in gross. Then there's other operating expenses that are, that's gonna be of the $300,000 So $1,300,000 just to implement HR1 changes. Consensus caseload utilization, this is when AHS, Fifth Floor and drug test will get together and try determine what are the trends they're trying to do in Medicaid. Are they increasing, are they decreasing, what are the permeable amounts? So this is the consensus estimate that's been blessed by the emergency fund. So this is a base change that's not policy. Medicare Part D clawback, this is also not state policy. This is a longstanding federal issue, essentially when Medicare Part D went into effect in the second Bush administration, it was helping states save money on the amount of money they were spending on seniors' drugs. So the federal government said, We want the states to help pay for that. So the state did a state called clawback, where they'd take money back. It occurred us because we were already providing that service, but nonetheless, this is not negotiable, this is not something we get to say, it is based I mean, not saying federal government, if this is what you owe us, we have to pay them. There's a Northeastern Family Institute rate increase for $600,000 The FQHC and RHC required rate increases, and actually required by, I believe it's federal law, is $4,600,000 in gross. And then we have the provider stabilization, $2,000,000 at one time, because it's a continuation of the stabilization.

[Sen. Virginia "Ginny" Lyons (Chair)]: So if we could characterize the funds that are on this page, the funds that are policy driven and that we could make a decision about are provider stabilization and HR.

[Nolan Langweil (Joint Fiscal Office)]: Others are The other ones on this are sort of base and we really have no control over. But they are budget pressures. Of course they are. Big budget pressures that we thought were worth flagging.

[Sen. Virginia "Ginny" Lyons (Chair)]: And this is all recommended

[Nolan Langweil (Joint Fiscal Office)]: in the Governor's budget? All this stuff is no changes. You got brag. What is the Northeast District? Have my notes. So, NFI, it's a hospital diversion program. And this was done with the provider. I'm reading the notes from the budget. The provider was an outlier and other private rate increases, and they have not received an increase since 2021. This actually falls under DIVA and

[Sen. Virginia "Ginny" Lyons (Chair)]: DMH. It's like, I think it's, and now it goes similar to our VAs and their SSAs, providing a service for the state and is contracting it out. And you can take a field trip, it's a good field trip.

[Nolan Langweil (Joint Fiscal Office)]: So those were increases, these are decreases. These are proposed reductions that are in the Governor's recommendation that the House of Dodd make changes to. So one is a dental incentive program. This is payments that Diva was offering to dental practices to try to encourage them to accept Medicaid patients. They're saying that it wasn't very successful, so they cut it. There's a cancellation of the Vermont Legal Aid Medicare Advocacy Program contract. This provides services to increase coverage for Medicare to offset the cost of the Medicaid program. The administration feels that the savings have not met to offset the cost, that was their justification. There's elimination of the $4.75 peak per member per month that's embedded in the One Care Vermont contract. The One Care, the ACO has ceased to exist. They're saying that what happened was the ACO was paying providers this per member per month, and the administration's saying, Well, the ACO doesn't exist anymore. We have no way to pay this per member per month. So they're proposing this

[Sen. Virginia "Ginny" Lyons (Chair)]: in constant. Although they've been doing it.

[Nolan Langweil (Joint Fiscal Office)]: Yeah, you'll have to talk to

[Sen. Virginia "Ginny" Lyons (Chair)]: them about I will. Just FYI for the committee. It just so happens that DIVA is part of my budget responsibility and appropriations, so I'll be meeting separately with DIVA, separately with DMH, and separately with DCF to dive deeper into their budget. So we're just getting the overview here.

[Nolan Langweil (Joint Fiscal Office)]: Yeah. So next one is there's a, so right now folks on Medicaid pay a copay of one dollar for preferred drugs and $3 for non preferred drugs. Administration's proposing increasing that by $4 and $8 respectively. That would reduce costs by $1,100,000 gross.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, in looking at some of these reductions that are here, the concern could be that we're losing federal dollars by not investing SAFE dollars on people.

[Nolan Langweil (Joint Fiscal Office)]: And then you have the Applied Behavioral Analysis Coding Change, those who aren't familiar with what ABA is. It's a method to help folks on the spectrum. It's proven to be very successful. It's also very, very expensive. Diva is saying that they're they're reducing one of the codes because they're saying it's duplicative. I know there's been some controversy about this and some articles in Bigger about this, but nonetheless, the House did not make any changes on this. Then we have the family planning rate. This was this thing where last year the house put it in that there was a ninetyten match for a certain family planning codes. So they put 85,000 in the budget, which would get matched up to $850,000 for certain family planning codes. The administration put this in BAA saying we can't implement it, it's too difficult. Legislature said yes, can. And so it wasn't in BAA, so the administration's again trying this in the budget. There's some confusion about this. I've met with DIVA and for a long time they're saying we can't implement this. And then last meeting I had, they said, well we are implementing this just not the way you want us to. So there is some confusion around this. So what happened was the house put some new language in. They didn't put the $85,000 back in, but they put some language in that basically requires them to do their best. It says, let me get to ensure all the codes. Anyway, there's language in section E307.8 that sort of tells Diva to look at all the codes that you're trying to get them in planning for and maximize it. So that was their way of sort of, not putting the money back, but trying to still keep and do something. I still need to work with Diva on this particular thing. They're still so confused about what they are and are not doing. There's this thing. Right now, a lot of school based service, Medicaid services, are billed through AOE. This is a net neutral swap. There was an actual bill in the house, but they put it in the budget. And it's a net neutral swap. It's a little complicated in how it works. But it's a big issue, that's why I flagged it here. If you wanted to hear more about it, would recommend having someone else come and talk about it. But it is in that neutral. It's something that both Jeeva and AOE came to the legislature and said, do this. And we did it, but we did it a little bit differently than they asked. Finally, health changes that are not included in the lab rec, bridges to health. Correction. We have it in Diva. It actually should be in the health department. So that's something that we'll fix. The Senate wants to do it, we'll just fix the section of the budget. That's not the drive. That's part of the other way. Great.

[Amy (Joint Fiscal Office analyst)]: I also wanted to draw your attention to the end of the presentation. There is a link to a document that AHS provided, some of the corporations, and maybe you have also received it. And it lists out all the additions, reductions, and a summary of what normal we'll be going over with the HCF Housing Initiative. So, it really dives in and easier to digest than Douglas announced. So, for DNH, these are core items here that we wanted to highlight. So, there's a lot more in the budget as we've been talking about. The first is the certified community based integrated health center. So there's two sites right now. There'll be more coming in fiscal year twenty seven. So there's some investment in continuing to do that, some rate increases as well. DNH has some, as you're probably aware, with traveling nurses and keeping the psychiatric hospital open, so there's an increase into traveling nurses, but there's also a decrease in sort of like vacancy savings, and you'll see another decrease in the next slide. So, that's part of how they're continuing to keep the hospital open and running. There's an increase to the forensic examination increased costs. As you're aware, they're sort of more pressured in forensic examinations. So, governor provided $645,000 of general fund for that. And then another increase for the alternatives to emergency departments, which is around the state. There are different facilities and organizations providing those services. So that was a $578,000 global commitment investment, and the governor recommended that the House agreed with these items.

[Nolan Langweil (Joint Fiscal Office)]: I don't understand. Can you go back one more minute? Alternatives to emergency departments. I'm lost on that.

[Amy (Joint Fiscal Office analyst)]: So these are, this is a new initiative for DMH, and it might be better to have them come in and talk about what their programs are that provide these services, but it's sort of alternatives to going to the emergency room for any sort of mental health Yeah. So, summary, can I just ask a question here while we're at the, oh, there we go, keep it going one more stop, transition to donation? So these are the reductions to identify in the Department of Mental Health, and I'm highlighting elder because this is, it's a little bit different, you'll see in the next slide. There's specific outpatient investments that DMH has for TBI, elder and reach out participants. And so the testimony we heard is that they felt that they could do a reduction and use very specific programs so they can use traditional services that are in the communities. And so that's why they need this reduction. With the elder care specifically, house bought that specific investment back. So I'm going to show you that in the next slide. There's a reduction in utilization at DMH level one at the Brooklyn Regional Medical Center. And then another part of the savings that DMH is doing is they're closing some of the beds. So that's the ability to have fewer staff to manage those beds. Why are we producing beds? It seems like everything I hear is that

[Nolan Langweil (Joint Fiscal Office)]: we don't have enough beds.

[Amy (Joint Fiscal Office analyst)]: I I think great question for DMH to have that conversation. But I think that the other piece that we didn't talk about, I bring it up because it's sort of HS's story, they had, excuse me, about a 75,000,000 general fund hole in their budget when it came to putting their budget together during, you know, November when they're working with the governor's budget. And so they were making specific choices, and this was one of the options that they're chose. I think we did have a man and they did talk about this a little bit, so we can go back and double check that. There's a lot. Yeah, there is. Every number here has a long story behind it. Yep. And then the final one that we're just Again, there's more in the budget than this, but obviously the Chittenden County Community Outreach and a phone based outreach program, which predated the nine eighty eight Immobile Crisis Team. So, there's a reduction there. However, if we go to what the house did, so this is where I was showing I mentioned they did do it does say one time, but it's actually a base, so that was my error. The elder care program is sort of being bought back by the house for a 150 paying general fund. And I always talk in general fund, NOLA talks in global committed. So we have both those numbers there. And then there was also a Howard Center community outreach program that I believe was a reduction in the budget, which I didn't show before. There's only so much room on the slide. So, the house did increase, but this was a one time solid factor. And then there was an additional 469,000 for the Community Valley Office of Economic Opportunity. So for the elder care program, did that include reach up? Because it's $40,000,000.40 ks less than reduction. So my understanding is there's three components to the outreach program and the only one that they added back was the elder

[Nolan Langweil (Joint Fiscal Office)]: care. Got it. DCF. Not a lot happening in DCF. That was bad, Jeff.

[Sen. Virginia "Ginny" Lyons (Chair)]: Wait till we get to the 09:38. They have a bill in here that's gonna lead us into the budget. So

[Nolan Langweil (Joint Fiscal Office)]: no changes to house rec. So there's 6,200,000.0 in general fund to backfill child care special fund shortfall. So this is relatively new tax and as Senator Cummings knows, and that takes several years to get a sense of

[Sen. Virginia "Ginny" Lyons (Chair)]: This year there's a shortfall because last year there was a surplus.

[Nolan Langweil (Joint Fiscal Office)]: Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay.

[Nolan Langweil (Joint Fiscal Office)]: Well, it also depends on what you're budgeting. So if there was too much because of the timing, we knew there would be, and now we're in it, and now there's a shortfall, I think we'll get there. Then there's transportation for kids in custody contract pressures of a million dollars in general fund. There's a reach out caseload adjustments. What they did was they adjusted the budget to the lines of a consultant with the low range projections. What happens is a lot of times when the contractors come in, they say, here's a higher range, here's a lower range, and usually they pick somewhere in the middle, and they're going with the low range. Then there's tier treatment facilities. There's 4,000,000 in general funds for West River. There's 4,000,000 in one time for Red Clover. Also, what happened was DCF has plans to build what's called the Green Mountain Youth Campus as part of a permanent facility. The House recommendation includes lighter weights that percadence DCF and BGS spending more money on the project until certain conditions are met. What often happens is the administration, they're working on this, they sign contracts and then they come to us and they say, Okay, need the money to do it. And the legislature says, Wait, wait, wait, what are you doing? And so there was a sense with this because how controversial it is saying we don't want you to sign contracts until after you've asked for the money, so we have some say in it. So that's what that is. Yeah, they didn't change this. The cuts to strengthened family programs. I wrote these down because I wasn't sure what they were. That one, so this would eliminate a program for families, supports, and childcare programs targeted to some sort of funds more equitably distributed. Additional funds for the childcare are available at seven. I'm just reading the notes from what they had said. Yeah. There's a kind of the post permanence program, 25%. This reduction in funding, this program, it supports services for families who joined by adoption of permanent guardianship. This would limit the eligible population served by these contracts to only those families with adoption fulfilled facilitated by DCF. So this would be a loss of services for families who adopted children through private adoptions such as NFI, LONDER, East or South. So just be specific.

[Sen. Virginia "Ginny" Lyons (Chair)]: And so even if an organization like LONDER or NFI is supported by the state through contractual relationships, this funding, this support is not available to

[Nolan Langweil (Joint Fiscal Office)]: As I heard, the support's only available for families who adopt through VCF threat. Right, so whatever we got. That's how I interpret it. If I'm wrong, go correct.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's okay.

[Nolan Langweil (Joint Fiscal Office)]: This is helpful. Then there's the post adoption consortium. So this would eliminate funding that supports post adoption events organized and hosted by this consortium of providers who work with the adoption families. They say DCFs at over $2,000 which utilized in fiscal year twenty five. I know we have the nurturing parent program. This one's kind of funky because it's a mix of general fund and GC investment, which by the way, GC investment also has state dollars and federal funds in it. It's getting too complicated. It's just maybe less complicated. But just know it's $195,000 cut to the program. This would reduce the program by 50%. It provides parenting classes to eligible households and is administered by Prevent Child Abuse Remodeling.

[Sen. Virginia "Ginny" Lyons (Chair)]: Johnson would have been camped out.

[Nolan Langweil (Joint Fiscal Office)]: I

[Sen. Virginia "Ginny" Lyons (Chair)]: have a personal interest in this. I'm sure we're gonna hear that. Live free date.

[Nolan Langweil (Joint Fiscal Office)]: Two one one, where's the housing fall, there's been a lot of conversation in the house. The governor's rec reduced the hours, like twenty fourseven to just the hours between 8AM and 11PM, and the House restored the funding. So it was $332,000 cut for the amendment, and the House restored it. And then Senator Lyons alluded to this, there's the Vermont homelessness continuum, H nine thirty eight. The way that they did it in the House is the money is appropriated in the victim, and then H-ninety nine-thirty eight said this is how you will spend that money. So what we did in the budget, we said, and by the way, it's the same amount of money the governor recommended for his housing initiative, and it puts it in all the same buckets of base one time federal funds. The goal in the House was to just be able to keep the money where it was appropriated or within the same functions, but just change how that money was spent. So this basically keeps the funding in place, but age ninety-thirty eight will say this is how you spend that $82,000,000 And

[Sen. Virginia "Ginny" Lyons (Chair)]: we're looking at that bill on Wednesday and Thursday next week. We're gonna start diving into that bill. I'm not sure what we did last year in the end with homelessness. S 91 was vetoed by the government. There's a lot well, that I know. For the last two weeks, the shelter on my street has been full of cars and I wonder it's not because it's sub zero, I'm wondering if people using up their eighth days before they end at the end?

[Nolan Langweil (Joint Fiscal Office)]: Yeah, winter ended at eight, what kind of day? April. April 1. So there may be some links that I couldn't speak to.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, but I mean, it's been like three or four cars there all winter and suddenly I'll bet there's 15. I was just wondering if there's going be some deadline. April 1.

[Nolan Langweil (Joint Fiscal Office)]: There was an April 1 change.

[Sen. Virginia "Ginny" Lyons (Chair)]: They're there this morning.

[Nolan Langweil (Joint Fiscal Office)]: It's also they can put in resets maybe. People can reuse their days, put in resets. Then this, under the governor's, he vetoed at age 91, and then he did an executive order.

[Sen. Virginia "Ginny" Lyons (Chair)]: There's a lot going on here,

[Nolan Langweil (Joint Fiscal Office)]: so I have

[Sen. Virginia "Ginny" Lyons (Chair)]: to think about

[Nolan Langweil (Joint Fiscal Office)]: What I will say about the Vermont homelessness continuum is that the, I won't speak for the administration, but they haven't, they've been working with the house to try to get to a place that everyone agrees on. So,

[Sen. Virginia "Ginny" Lyons (Chair)]: just, they talked a bit about this, and they'll talk to what they've obviously said in the corporation, so I just wanted to make this note about the nursing home system, that some have closed, some are opening, and that there's this net loss, and there could be some future expenditures, what that would look like. What is this is what's going on with this? It's been 33 and a half beds. No. 33 period. And then 50 beds. Oh, okay. 23. Sorry about that. A half a bed. I know. That would be very sing. Wouldn't be the first time we've done something.

[Nolan Langweil (Joint Fiscal Office)]: Forget the shirt blanket.

[Sen. Virginia "Ginny" Lyons (Chair)]: As long as you get a double bed, then it goes to a single bed. It's all handy. Alright. I'll take it. As you are probably, I'm sure you're aware, the disability payment reform conflict management was live in its current fiscal year. Based on the restructuring, there's now two new independent case management entities that are part of this now, and based on caseload pressures in the budget, they had about a $4,100,000 increase. They also, I think this is a newer program, the Opioid Recovery Employment Program for hireability. This is about five sites across the state, with an increase of $875,000 If

[Nolan Langweil (Joint Fiscal Office)]: I can actually hear you real quick. Sure. So, with the opioid fund, one of the goals of the stuff with the opioid fund is that there's a program that everyone deems successful, the idea is to move it out of the opioid fund and put it into the base of each department I told you. And so, this is what the administration was doing. They're saying, there's a program that was funded with opioid dollars that they've shown to be successful, so they're moving it into becoming a base permanent program.

[Sen. Virginia "Ginny" Lyons (Chair)]: And that is some of the conversation that we were having the other day regarding the distinction between the funding sources, substance use fund, then we're gonna try to define that fund better in here. That's right, because there are a lot of people going after all those dollars as a concern.

[Nolan Langweil (Joint Fiscal Office)]: And with the opioids fund, because it's defined it, the idea is, the thinking is that you use that defined to determine what programs are really good, and then make them permanent by moving them out of the finite program to a one month base.

[Sen. Virginia "Ginny" Lyons (Chair)]: Two more on this slide, DS caseload increases and some statutory nursing home inflation rates will result in an increase. And then they did mention, and I believe you might have a bill in your community or the house is working on a bill, I think maybe now, around the APS statute and updating for federal compliance. We have that in here. We went through

[Nolan Langweil (Joint Fiscal Office)]: it as we covered it.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, other reductions that the house did not change, there was some caseload utilization decline in adult day. And there was some comments around that folks are slow to come back to these services after COVID. And then, I have payroll benefits. So, the department does some estimating on what the FICA and those types of benefits would come. And they felt that they just had enough, they had more money than they needed. And they're rebalancing it and they feel like the amount they're budgeting is more in line with what they're expecting to pay out. So they can still cover the needs of the adult base. We did have testimony about adult base and we asked them. Have to keep an eye on that. If we have So then the house added a disability housing coordinator position and some additional funding for Deaf and Blind service supports and then another one time grant for home share grants for $275,000 And then we'll go to VDH, and I have Nolan pump me out with AFI.

[Amy (Joint Fiscal Office analyst)]: So there is an increase in revenue and forecast of the cannabis substances, or just cannabis funding coming in. And so 30% of the excise tax right now goes to BDH's cannabis substance misuse sort of program and fund. So because of that increase, they made some investments and one of them is increasing the amount going to school based programs. So, it looks like a little under $2,000,000 And then, the immunization program grants, there's a large amount that is funded, they increased that by $1,800,000,000. And then for AHEC, the governor, well, governor's budget removed all the money that was in the loan, the prepayment around grants to VSAC and the AFAC grants or program support, physician recruitment, education loans. You can see the list there. And then there was a discontinued effort to implement an unused drug repository. The department had tried to do a program. They put an RFP out. They didn't get any responses to the RFP, so they felt like maybe it's time to not do this program and go in this direction. They are recommending removing the funding from the budget. Yeah, when we worked on that a few sessions ago, we understood that it would take time for implementation. It's not, this isn't the time, that's probably 350,000. Last slide. So, the house did add back some money for primary care loan repayments and doctor placements. I think there may be some I think maybe your committee or appropriations might be looking at if this was the right place for the money. So, I think there may be more more work to be done in this specific area. Did you wanna say

[Nolan Langweil (Joint Fiscal Office)]: anything? No. I'll take the one. It's okay.

[Amy (Joint Fiscal Office analyst)]: And then house changes, not included in the gov rep one is for the funding for free in referral clinics, which is a $50.50 split between general fund and federal fund. Power reduction services for $45,000 They also added a one time for 150,000 for automated external defibrillators, but we're thinking this might actually go to the AOE, to education rather than EDH, so that's just the Yeah, makes sense, doesn't it? Is it a pass through, or would it just go directly? I think it's going directly to schools. That's what the grant is for as the House proposed. So that's, I think, a point that you could look at. Yeah, because it's part of the school plan, emergency response plan that schools have. Then health of the the the house also added a $140,000 to the Vermont State Booth Council. That was part of the I think it was part of, like, the public hearing request, I think, was one of the items.

[Nolan Langweil (Joint Fiscal Office)]: So again, that's just highlights. There are many other things that were in there that were not included and not for any particular reason. We were trying to keep it not too robust. Understood. But, you know, I'll speak for Amy, but, you know, we're here to work with you. If there's anything you want to understand about the budget specifically that we did talk about, or did not talk about, or you're getting questions from folks in the room and you wanna understand better, feel free to ask us to help you understand some of the issues. Some of them are pretty straightforward, it's a cut. Some of them are a little more complicated. AI has been getting a little complicated this year. But nonetheless, we can help you untangle, understand what the issues are concerned with.

[Sen. Virginia "Ginny" Lyons (Chair)]: I think one of the untanglements relates to the substance misuse fund, excise tax fund. So some of the things that we're seeing in here are funded from that place, that fund. And so it would be helpful to know how, and you've

[Nolan Langweil (Joint Fiscal Office)]: done that, you started doing that for us. So that's one big deal for us here. Just to have a little overlap, on six sixty, which is the opioid fund bill, the Human Services Committee had recommended, so the opioid advisory committee had made some recommendations on where to spend that money. And there were four things that totaled $640,000 The Human Services Committee said, you know what, these are substance misuse fund things, and more appropriate there than the opioid fund, and they put it in there. House appropriation said, We can't do that apparently because health department has already called for, or already determined how to spend that money, they didn't have time to get into it to sort of offset it. So I think that's what Senator Cummings is getting at. There's an increase this year. Health department said this is how we plan to spend it. And Senator Cummings is saying, I'm sorry, Senator Lyons is saying, well we'll look at that. Can I articulate that well?

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, thank

[Nolan Langweil (Joint Fiscal Office)]: you. Go ahead, Chittenden. Thank you for that. This is a broader question, though. So as I recall, the eleven fifteen waiver's gonna be up? Yep. Year or two? '27. Calendar. And then as I recall earlier on in the session, showed that it's gonna decrease over time. Was it for like ten years or I can't remember, it's gonna be a reduction in federal dollars. Yeah, that's provider tax. Coming in for the state's able to collect over time. When does that start? 'twenty eight, fiscal year 'twenty eight. Which is next year. Which is next year. So we come to next year, we're gonna have $15.18000000 reduction just from the inability to inflect because of the reduction in the provider tax. Now, as I said to people before, when you have less dollars, it's going through general fund. You have three levers. You can reduce Medicaid services, you can raise the revenue, or you can find general fund from elsewhere within government. Generative. Those are your levers. Each year is gonna go down, because I recall. It's gonna continue to go down until 2032, the final level of that. What happened is we're at this level called 6% provider tax that you can do, that patient revenue. There are many new rules about what it can and can't do, and blah blah blah. What that's doing is reducing by point 5% a year until it gets to 3.5. So we're gonna go from 6% egg fishing revenue to 3.5. Oh, and a half. Yeah, so Over ten year period. Now, we have four different providers that provide it, but the bulk of it is the hospitals. Mostly it's the hospitals. Yeah, nursing homes are in there, Nursing homes are in there, home health is no longer on there. There's pharmacy, and then there's EMS. This is gonna be a lawyer. And then to make things work, because while we're on this happy subject, When the new, so this year, so in this bill, sorry, in the budget, we give AHS authorization to start to negotiate with a little bit of money for them to work with contractors, as they always do, because it's a long process to negotiate with federal government. There's not a lot of optimism that we're going to have global commitment the way that we are used to having it. But that's Medicaid, right? That's the cost coming in for Medicaid? So the waiver is how we implement Medicaid program. We're the only state that does our whole Medicaid program through the waiver. Like 98% of our money flows through the waiver. Most states, if you're like, oh we're gonna do a waiver for 2,148, we're gonna do it for elderly, we're doing it for everything. So that's what makes us unique. It's been good for the state. We've enjoyed it. It's gonna hurt more than It's we're gonna hurt more, but also, depending on how it gets negotiated, we'll see what global When we first did global commitment, think in 'six, I think it was the first year, what global commitment looks like today is different than what it looked like then, because it's continued to evolve based on the needs of the state and political decisions, not policy makers, right? It's evolved with the needs over time. It's a little different today than it was then, but what it looks like after this next one remains to be seen. We're always nervous going into negotiations. It doesn't matter who is president with administration. We're always nervous, are we gonna get as good of a deal? So we don't know what to expect, regardless of the federal administration. The timelines of the waiver? Usually there are five years with two or three year renewals. So we did, first one's five years, we've been renewing, then we've renewed seven times. We like the framework of it, we just work with them.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's better than ready to go over it again.

[Nolan Langweil (Joint Fiscal Office)]: Yeah, so I'm not saying that this administration's gonna do anything different. I'm just saying we're always nervous going into these negotiations.

[Sen. Virginia "Ginny" Lyons (Chair)]: And it's a difficult time to ask for additional anything. Right now. Yeah. And on top of it, one of the things that we will have in here is a kind of an overview of where we are with the World Health Transformation process, grant process. That'll have implications for the budget and that hasn't been considered yet. So our job in here is to consider what are the things that we value and that we'd like to either add in, add, subtract, maintain within the budget that we're looking at. And the future does loom very, it's a dark cloud out there. And some of that apprehension has to exist throughout the building, but a lot of it's gonna be down the hall, an emergency ward, joint fiscal committee, all of us. But, Jerry, you got the $105,000,000 you can

[Nolan Langweil (Joint Fiscal Office)]: now be made in the HS?

[Sen. Virginia "Ginny" Lyons (Chair)]: We don't have anything yet. It has to be expended, it has to be obligated by October. So we're gonna hear from Jill Mazza Olsen. I've talked to her about coming in and giving us some information about where they are with that. We can't make decisions here based on what we hear there, although we can listen and obviously Jazz has to be very cognizant of their decisions for the grant as well as budget. So there's a lot of juggling going on. When the governor proposed this budget, we didn't have that grant.

[Nolan Langweil (Joint Fiscal Office)]: Right.

[Sen. Virginia "Ginny" Lyons (Chair)]: So it's all brand new. So now there's a little pressure on us to make recommendations that fit better with what we hear, and now we're hearing pieces and parts and how we're supposed to put together, which is the fun part, right? Yeah. Fiscal, I just signed up. Didn't want work for 12 part time limited service positions to implement.

[Nolan Langweil (Joint Fiscal Office)]: Yeah. Was all here. Yeah. That's different.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's different. Totally different, and we knew that they were going to need to do that when they reported the grant to the last joint fiscal meeting.

[Nolan Langweil (Joint Fiscal Office)]: And they'll be paid through the grant. Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right. So there's we're we're beginning to see some encumbrances on the grant, and the only way to have the grant monies deployed is to have well written requests for proposals, those are being finished up, and then allocation of funds to people who can run these grants and oversee them. The other problem with A lot of stuff going on.

[Nolan Langweil (Joint Fiscal Office)]: But the other problem with RSTP is that it's a lot of money and there's a very short window to spend it. If we don't spend it, they take it back. That's part of why we're like, we need people, we need to move on this fast because we want to get that money out the door so we can help our rural providers. So that's why there's a pressure to move on this. And this is a five year dissolve. All the funds come in at one time.

[Sen. Virginia "Ginny" Lyons (Chair)]: So can I make a suggestion? Hold that thought. You'll come back to it. It is a big deal. There's a lot of work going on and one of the reasons I haven't asked folks to come in and testify about it is because they're working hard outside the building. And so once we get our arms around the budget here, what's in the budget, what's not in the budget, what do we value here as a committee, then we're gonna listen to folks in a little bit of time and sort out some of our priorities. Then, after we've had some thinking, then we'll bring Jill in and others in and talk about the grant process and see how that has the sugars off. It's all a human process. It's called chaos. No, it's not. It's hard work. We've got control. A lot of use. Need to take a break. Is there anything else that you want to say before we take a short break for 10:00?

[Nolan Langweil (Joint Fiscal Office)]: Nope. Just

[Sen. Virginia "Ginny" Lyons (Chair)]: I always say, what I wanna say is thank you for your time in putting all this together. Absolutely. I guess, senator, before you leave Yep. Just standing up. I'm gonna say we take a five minute break. And Nolan and Amy, do you mind, could we come back to looking at the substance use fund data that you brought us earlier, or is that something you're not prepared to do today?

[Nolan Langweil (Joint Fiscal Office)]: Because I'm happy if you don't.

[Sen. Virginia "Ginny" Lyons (Chair)]: Would recommend we do another time, but that's okay. I'm good with that.

[Nolan Langweil (Joint Fiscal Office)]: I could do it, I'd rather wait.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. We're on schedule to take

[Nolan Langweil (Joint Fiscal Office)]: a

[Sen. Virginia "Ginny" Lyons (Chair)]: break till 10:30.