 Good morning. Welcome back to the Vermont House Appropriations Committee. It is Tuesday, February 7th, 2023, 8.30. We are hearing testimony from budgets throughout the FY24, starting off today with the Green Mountain Care Board. So we welcome them in the room. And I just want to make one comment that our two screens, I think I was halfway through yesterday before I realized that it was up here, but not up there. That's right. Yeah, the slides are always up there, and this is just us. So we get to look at ourselves, but not at the slides. But we have the slides. I don't know. I was just going to ask, Karen, is there a way? I will. We don't really need to see ourselves, do we? I will work with IT to see if we could, even if we got a corner, so we could. I know people from other committees always had theirs up there that they could track, that they knew. Gives you an idea if you either went ahead. What page are we in? All right, and then anybody tuning in, the slides, information are also on our webpage under today's date and Green Mountain Care Board. So thank you. Welcome. We haven't had you in yet. And I think we'll do some introductions, if that's appropriate. And then you can introduce yourself and get started. I'll start with myself. Representative Diane Lanford, live in Virginia. I represent Addison. I'm Robin Shaw, and I live in Middlebury. Tiffany Blumlee, and I live in Burlington. Tristan Flano, Brattleboro. Carrie Dullard, and I live in Wastefield, and I represent Ducks Creek, based in Los Angeles, New York. Lynn Dickinson, I represent San Robins Town. Mark Mahaly, and I live in East Calus, and I represent Calus, Plainfield, and Marshall. What do you pay for this work? Rebecca Holcomb from Norwich, Stratford, Sharon, and Pepper. So my left is Representative Jim Harrison, who had an appointment or somewhere to either present a bill or do something with a bill, at eight o'clock or something. So he'll be in shortly. And he represents, chitin' in a lot of other towns, and then Representative Squirrel, who also is maybe coming in now. Representative Brennan. Oh, Brennan. From Colchester. So welcome, introduce yourselves, and for the record, we'll get started. Hi, I'm Susan Barrett. I'm the Executive Director of the Mountain Care Board. I've been in this role about 10 years, believe it or not. And I live in the lovely town of Norwich. And I'm Owen Foster. I'm the Chair of the Care Board. Started October 1st, 2022. So I've been there for about four months, and I'm from the lovely town of Jericho. I'm Gene Stutter, and I have worked at the board for four years, and I live less than a mile from here every month. Great. Walk us through whatever you would like to present us. We have you with us scheduled for an hour. So what we're gonna do is, because some of you are new, and Owen also is new to the board, we are gonna spend a few slides going over an overview, and then we'll get into the budget numbers. Right, so I'll give us a quick overview of what the care board is, and what we do in some of our priorities and focus for the upcoming year. And if you wanna fast forward into the budget details, we can do that. Just cut me off if you'd like. So first, the care board was established in 2011. We have five board members, and we have six year staggered terms. We are an independent board, and I'll walk you through a little bit of what that means in practice. So we are appointed the board members by the governor, but we go through first the nominating committee process, the nominating committee itself is made up of representatives from the community, from business, from both aisles, both parties here at the legislature. Only folks that have gone through the nominating committee process and whose names have been passed on to the governor can the governor select from. And so it's an apolitical process in our selection. And then once we're here, our terms are six years and they're staggered such that we can cross over through different administrations. Although Governor Scott has had a lot of electoral political success. And I think at this point all five of us have been selected by Governor Scott. The administration is not involved in our decision-making. They do not opine on what we're doing. They do not influence us. We have our own processes that we go through and the governor, we don't report to them. They do not involve themselves in our day-to-day work in our hearings. We are from various parts of the state, Washington County, Chittenden County, and Addison County. And we have diverse backgrounds and experiences. Jessica Holmes is an economics PhD and teaches at Middlebury College. Robin Lunge is an attorney and healthcare reform expert. David Merman is a physician and currently practicing at CBMC in the emergency department. And Tom Walsh is also a healthcare reform expert and a physical therapist. Our staff, we have, I think it's about 27 staff members. And we have various disciplines that relate to what we do. We have accountable care organization experts. We have hospital finance experts. We have public health experts. We have data scientists and analytics experts. And we have experts and certificates of need. I'll talk about those processes just a little bit. One of the unique features about the Green Mountain Care Board is how we do our work and that we are independent and we have very transparent processes. And what I mean by that is that we are subject to the open meeting wall, which means the board members can't get together as a group and make decisions or influence each other prior to a hearing. So when we have a hearing on a particular issue before us, it's the first time we've really heard where any of our colleagues are and where they're voting. And that's pretty unique because the public actually can come to all of our hearings and participate and they see in real time what's happening and the decisions that are made. We debate with each other in open meeting. We're on camera, it's recorded. Prior to our hearings, we have public comment periods where the public can send in letters on whatever the issue may be. And during the hearing at the end of our deliberations, prior to a vote, the public can actually come in and raise their hands and say whatever they'd like. We have pretty impressive attendance. I'm always amazed at how many people come and how many people raise their hands to share their views. So it's incredibly important because I think sometimes we get locked in on what's before us and the voices that come before us are very loud. They have lobbyists, they have PR people, they have data people and they have very good positions that are well thought out and experienced. What's sometimes missing from that process is hearing everybody else, the community, patients, independent practices, primary care providers, everyone else in the community. And this process allows them to have a louder voice and to make sure that our decisions are balanced by that process. And I really enjoy it. We actually have a group of healthcare advocates out in the universe in Vermont that send us letters and they're almost like independent think tanks and they work, they send me packets of stuff that's so loud. I bet we have the same kids. Yeah. Yeah, we heard of them. They bring important perspectives. We also have the healthcare advocate that brings the voice of the consumer to the care board. And I wanna talk a little bit about the major things that we do at the care board. The first is we regulate and mostly what that means is we certify and review budgets. Bless you. That will be mostly for the hospitals, 14 hospitals for the accountable care organization. We also regulate insurance plans and we review the budgets for hospitals, ACOs and then the insurance rate requests. The next piece is we have a data and analytics team and they provide all sorts of information that feeds and informs our regulatory decision-making. Beyond that, they also provide information for the legislature, for public research, for entities we regulate if they wanna go and look at it. We have a healthcare expenditure analysis which talks about how much money is being spent and where and on what. We have what's called the HRAP, the health resource allocation plan which tells you if you go online, you can see how many primary care positions per 100,000 people, 10,000 or 100,000. I can't remember. Anyway, how many healthcare providers you have in your different health service areas, right? So you can see where the resources are allocated across the state which is really important to understand. And last, we have what we call the innovation bucket which is really these days focused on Act 167 is the reform efforts that are currently going on. Representative. Can you talk to us a bit about that because I know one of the primary pieces of Act 167 was to do an engagement process. And we heard yesterday from the secretary that that has not yet, that no contract has been issued and I'm concerned because it looks like there are a number of healthcare reform initiatives coming out, but that engagement process hasn't happened. And I have a follow-up question after that. Sure. We have a slide on that. I will talk about it now and we can get in. So the short answer is we have received bids. We are reviewing the bids and we believe the bid selection process will be concluded pretty soon. Once that bid, once someone is selected, the vendor selected will have a contracting process. The state contracting process is appropriately detailed and a bit lengthy. I don't know anything about that. Okay, yeah, right. So we anticipate having someone selected very soon and then we'll be in the selection but contracting process. And just, you know, I'm looking at your slide here. You've got this innovation reform but your regulatory touch is primarily on hospitals. And I'm wondering if you feel that there's an asymmetry between what you touch and where we need to go in terms of more attention to primary care. I don't know if that question makes sense. So one of my priorities as a chair is primary care. This is something that we think is, so for myself, for example, I don't have a primary care provider. I've been trying to get one for years in Vermont. This is a problem a lot of Vermonters are experiencing. We are also hearing a lot of issues from independent practices and primary care providers about their level of reimbursement, what they're getting from Medicaid, what they're getting from Medicare and their ability to negotiate with insurance companies on reimbursement rates after hospitals have taken or negotiated their piece. The argument is that they're not getting enough money because a lot of money is going to the hospitals. And so the first thing we're doing is we're trying to get data to understand that in detail to see if it's borne out and by the data. The second thing to do is understand how our decisions as a regulator with the hospitals are having these collateral consequences if they are. I'm sorry, what was the other part of this? I think you're speaking, maybe I'll come back to it, but it's difficult to move to a value-based model if you don't have robust primary care and you can't have robust primary care if you can't figure out how to direct the investments to that frontline care. So I guess it can be interesting to hear what strategies you have. Time to go to address that and I'll let you go on and come back to it. I think it's a really critical point. I think it's one of the most important points we have is we can't focus on just one piece to help ecosystem here in Vermont. They all need each other, right? The hospitals need primary care. The hospitals need mental health. Hospitals need long-term care. That's why we're having some of the problems we have in the emergency department because people can't go to primary care providers and they can't get shifted out. So the hospitals need these other entities as well. And these other entities need the hospital. So you have to make sure that when you're looking at the system, it's all working together, not just siloed. What we talk about a lot is the hospitals. And what I'm asking is maybe later on, you can address how we move the conversation just from a hospital-centric conversation to one that's looking at the other providers in the system. Agreed. I'll make sure to touch on that. So. Representative Dickens. Quickly. Before, maybe around the time of the Green Mountain, before the Green Mountain Care Board was formed, primary care was independent. Pretty much a lot of the physicians were independent. There were some QHCs that were established. But since then, most of the physicians, most of the primary care are employed by the hospitals. So they're part of that thing that you regulate. I mean, there's a small number, mine perception is that there's a small number of primary care that's very different from the one you put up at the hospital. They're sort of baked into the cake when you do the regulations. That's true. That most primary care providers in Vermont are associated with hospitals. UBM has a large primary care practice. Can I add to that? Many of the primary care providers are employed by federally qualified health centers as well. They were spun off by the infant. So the bulk is either in the hospitals or in the FQHCs and we still are seeing independence. And as Chair Foster said, he has really focused on the impact of our regulation on primary care. My memory is that the FQHC hospitals hired the doctors, pulled the doctors in, brought them practices. They were spun off into the FQHC. Some of the people were spun off by some of the hospitals into the FQHCs because they got hired first. I don't know if that's the case now, but that was the case then. That's the way you are. Just one thing I wanted to represent and welcome to loop back, which segues into what Chair Foster was talking about with transparency. You know, you were talking about the RFP for the community engagement work. And there were two unusual things about that RFP for us. One is that we were collaborating with the Agency of Human Services on it. So we were working with them. And then after we'd incorporated their feedback, we spent about a month getting engagement and feedback from the healthcare advocate, healthcare people. So they were providing feedback on the RFP before it went out. So we did take some time on that, which is both the transparency and the kind of collaboration. So I just wanted to share that one piece. So I'll loop back. I think to the question, you know, on the RFP there was engagement with the healthcare advocate, the legislature, hospitals, VAZ, EMS. And so we're hopeful that the work that was put up front made it so it wasn't entirely hospital centric and that the whole universe of youth was incorporated before the RFP went out. The RFP went out right after I started, I think mid-October. So real quick, I'll go through these quickly. The regulation we do, 14 hospitals last year, two accountable care organizations, 11 health insurance premium rate filings, and seven certificates of need. Next slide, Jim. And just to give you a scope of what this includes and doesn't include, the financial scope is large, $3.3 billion in system-wide hospital net patient revenue is regulated by the care board. According to the health expenditure analysis, that's about 47% of healthcare dollars in the state of Vermont. 700 million in health insurance premiums, representing I think about 87,000 people. $49 million in approved certificate of need applications and then over $1 billion in total cost of care managed by ASP on fiscal year 22. The numbers are changing. I mean, we've seen health expenditure in Vermont increase pre-substantially. I gave a slide to send health and welfare. I think the number for the hospital net patient revenue has gone up from about $2.6 billion to 3.3 in the last five years. So pretty substantial increase in spending at the hospitals here in Vermont. And I anticipate that the certificate of need numbers will be larger this coming year. I think it'll be quite a bit larger. The other point on this slide is just to point out what we do and don't regulate. We don't regulate FQHCs, independent providers, ambulatory surgical centers, urgent care centers, out-of-state providers, Medicare Advantage plans, Medicare Medicaid, self-insured plans or out-of-state insurance plans. One of the focus areas that I have is to make sure we really understand, though, how our decision-making influences and touches all of these other things. That's an area where the board has directed some effort currently going on in our hospital budget revamp process. We're revamping how we review hospital budgets and also just in our collective thinking. We wanna make sure we're understanding all the collateral consequences of every decision we make. I guess this is what that relates to. Representative Page? Yes, I was curious. For your CON applications, what is the trend towards, what are you seeing, what these individual hospitals are looking to do with these applications? I mean, in terms of one of the services, they're gonna work, yeah. It can vary from my perspective. We have a few right now. Can I speak to this publicly? Yes, and I'll stop you if you can. You'll see replacement of equipment. You'll see MRI machines, CT scanners. You'll see adding an adult primary care provider in Essex. You'll see moving a dermatology service off campus to a larger location. You'll see buildings. You'll see surgical centers, those types of things. I don't know if there's a particular trend. You know, the trend during the pandemic was obviously things came to a standstill and then it really picked up because folks were getting back on their feet. But it has been a little quiet, but as Chair Foster mentioned, I anticipate them picking up over the next several months. But that, I would agree that it's really, it's not predictable. I was just curious whether there's any trends related to work force providing space or rooms for those patients that are mental health concerns. Are you seeing any movement towards that area? We have, and I can speak to this and Chair Foster can add. Over the last several years, we've had emergency room renovations that have addressed just that the mental health needs in these emergency rooms to accommodate the pressures they're feeling and to, you know, unfortunately, the ERs are experiencing heavy traffic with... Are we all caught up with all those issues? We had, off the top of my head, I can recall two or three emergency rooms in the state that have renovated in the last four to five years. I think hospitals that you probably have heard are dealing with some financial challenges here in Vermont, a lot of them acute, serious financial challenges. It wouldn't shock me if there are certificates of need that relate to lines of care that are needed because we have access issues and two that are profitable because we have financial issues. So it wouldn't shock me if we saw those things. And alleviating access and improving finances is not a bad thing. And since you raised the issue of hospitals with financial needs, what does the Green Mountain Care Board doing to help our rural hospitals stay relevant and stay in existence for the next... Well, right now we're quarter of the way through this century to be able to resist through this century. I mean, I think the biggest thing that we're doing together with AHS is the hospital sustainability work, which you get underway, but will be soon. And I think it's looking at what the communities need, what the gaps are in care, where they need services and how they can ensure that their financial positions are stable, right? I mean, we can't continue on the trajectory we are with 14 hospitals, with nine or 10 of them having negative operating margins. We have slides on the trend line. I didn't include them today for this hearing, but the trend lines are days cash on hand. The financial metrics we look at for hospital health are not in a good direction. Are you looking at closing hospitals in the future? The Green Mountain Care Board doesn't have authority to close hospitals. But do you see that on a horizon? I mean, if we have financial issues with some hospitals. Whether or not hospital should be closed is not something in our authority. So it's not something I've considered. We haven't done the Act 167 work. So I don't know what the results will be or what they'll say. And I don't think it's the Green Mountain Care Board's position to decide whether or not a hospital should open or close. But you are trying to keep them. Absolutely. Drawing basically. It's important that they exist and that they're stable. Yes. That's a critically important board. And I don't have the exact date, but recently, part of what we do is we try and educate the board as well as the legislature. We recently had two nationwide experts in rural hospitals, rural health care, speak at a board meeting, and I can get you the date. It's available the video is on our website, but really trying to educate not only ourselves, but also the broader community on what are the issues, what's available nationwide, and really think a lot about it. It might be helpful because it would spark an interest, but then let me forget if you could send that link, Erin. Because that's what we do when we get up at night. Representative. Thank you. Chair Frazier, just to pick up on representative pages concerned about mental health. I know in 2017, the Green Mountain Care Board allowed UVM Medical Center to retain some 21 million in profits contingent on it being used to support some of the mental health needs in the state. They've since decided not to proceed with that. We have now appropriated another nine-plus million to support potential development elsewhere in the state. What's gonna happen to that 21 million? So as I understand it, that was an enforced action from 2017 and it's still outstanding and UVM still has the money. I think they spent $3 million on planning a mental health facility at CVMC, which didn't come to fruition. So as I understand it, there's about $18 million left and the care board needs to take an action on what's going to happen with that. Mental health is an acute issue right now in Vermont. So we'll be taking that up soon. Thank you. Representative Brumley? Thank you, welcome. I am part of my ignorance, but I, healthcare is and it's a vitally important issue and I've spent a lifetime focused on other issues and avoiding this one. And it, so this is a question about the, you know, who makes decisions about whether hospitals live or die? And what is the role of the state in, in thinking about those decisions and participating in them? So I think in terms of hospitals and sustainability and mere existence, I think there's gonna be a lot of information that comes out from Act 167 that tells us about where some of the financial problems lie, where some of the caps and care lie and that will inform some of the decisions that need to be made. The Act 167 doesn't provide authority to close hospitals or change service lines or any of the such. I think one, the hospitals have their own management, they have their own boards of directors. The boards of directors get this information and see that they're bleeding money on X, Y and Z and there's a way to solve it that's, that comes about and you expect that they'll want to do so because it's in their own financial best interests and the best interests for their community. So whose role is it to just make those decisions? I think first and foremost, it's their management and their boards of directors. Understood. And I guess I'm expressing some concern about that fact because it, it is, it begs the question about what the state interest is in looking at the big picture and participating in those kinds of decisions. And so I just leave it at that. Thank you. I'm good. Excellent. Representative Page, thank you. Yeah. Oh, who's next? Oh, oh. So I think one thing I was going to say and I don't, I don't want to speak for the committee but what I observed as the legislature last year was considering and discussing hospital sustainability. What I observed is the reflection of how much, how much funding it costs the state to keep Springfield afloat. Like if you're dealing with it in a crisis, you know, keep the browser or treat. So my observation of your conversations was, you know, we can look at it, perhaps in a more systematic way as opposed to, you know, understanding the true cost of, if it gets to a crisis, just how much money it costs. Is that a fair reflection of what you recall from Representative Page? Yeah. I just like to add on to what Representative Loomis says about the hospitals. I realize you don't have control over whether a hospital lives or closes, you know. But because you're a regulating authority and your regulations that you put forward, they do have an effect upon our hospitals, whether they live or not. So I just wanted to make that point, which I'm sure you're aware of. Yeah, I think that's, yeah. The way I would conceive of that is you're right. We have authority over their budgets and we could vote no on a budget. We could vote no and that would cause financial problems at the hospital. We could vote no to rate increases and that would cause money. We could limit their NPR, right? And that would have financial repercussions. So yes, we can definitely influence the budgets that the hospitals have that would dictate exactly what they can do. So what we have, you know, if you look at our guiding principles and the statute, we have the primary ones are access quality. So that's what we're really trying to balance. And we continue to just give huge rate increases that are predominantly borne by 80,000, 90,000 commercially insured for monitors. Well, that hurts affordability. It also hurts access because people forego treatment when they can't afford it, right? But if you close a hospital or limit a service line or then they don't have the care, they don't have the providers, they don't have the nurses, they don't have the facilities they need to provide the care when people need it, right? So yes, we do have that authority to limit the budgets, but we are guided by access, affordability and quality, right? And they all interrelated. And that's the huge challenge. We're in a situation right now where affordability, so far as I can tell, is at its lowest, right? It's very difficult for people to afford health insurance right now. The rates have really gone up significantly. Meanwhile, hospitals are in a very difficult financial position and not to be forgotten. So are the independence and the primary care providers very difficult financial positions. So what do you do? That's the conundrum. And I think in terms of like, do hospitals close, do lines get limited? Really, if the vision is to bail it out with more money for a hospital, that's really the legislature and the governor's decision on whether or not to appropriate funds to do those things. But I think you're totally correct. We can limit the growth at hospitals. Historical purposes, we have not. I had a slide at the Senate Health and Welfare. I think the number was the Green Mountain Care Board in the last five years has supported the budgets proposed to us to 99.7% of what was proposed. The care board has proved of the net patient revenue that was requested. So by and large, the hospitals have been getting historically 99.7% of what they've requested for their budget. That's not to talk about the rates. The rates have not been supported at the same level, but the budget that they've put forward has been supported that I think it's 99.7%. Representative Hulcombe and Representative Shaw. So this may come out wrong because I'm not, I'm still learning this politics. And I have experience running an agency that had two bosses. We heard testimony yesterday about somebody from AHS about their role in healthcare reform. We're hearing testimony today about your role in healthcare reform. Who's on base? Who's driving this bus? And are we set up structurally to support meaningful reform in healthcare in the state of Vermont? My perspective would be who should be driving healthcare reform is patients, payers and providers. Those are the most important points in terms of like the government structure. You know, Act 167, I'm the lawyer, I read the statute, we follow the statute. Act 167 directs the care board what to do in its role in healthcare reform. That's what we're currently talking about it. We have a new all-payer model that's being negotiated. We speak with AHS daily as an office and I speak with the secretary at least weekly if not more. We have meetings together, we strategize together, we negotiate together. They are the lead by statute. They are leading those decisions. We give them data, we speak with them, we work with them. But that lies with AHS. In terms of the community engagement, that is the care board's lead. We are leading that work. It hasn't started yet, but that's our lead. So I guess to answer your question, who's in charge of healthcare reform? I think of healthcare reform right now really predominantly being the new all-payer model and how we're going to change how we pay for healthcare. And that would be AHS. Representative Shawty, I'm the representative of Dickinson. And then it's five after, we'll let them keep going. Yeah. I think I'm making more of a statement than I am asking a question because I was in this room last year, there were four of us that were having those conversations sort of following up on a number of things Representative Page has talked about. If we were designing a healthcare system in this data from today from scratch, it would not look like the healthcare system we have. And we have places where we have multiple hospitals within 30 minutes of each other. We have places where people have to drive a long way to get access. So how do we end up with a system that includes quality, affordability and access based on where we are today and where we want to be? And I think that's what the community engagement process is about. So, whether hospitals close or not, I can't imagine a hospital that's in a rural area that doesn't have anything else near it. I mean, that's in a hospital you want to support because people need access. In Montana, people have to get airlifted or drive four or eight hours to get to a hospital. We don't want to be like Montana. We want to be Vermont and we want to have those things. And I think we can do that. And so that's going to be the challenge. And anytime we try to make a change in anything that's near and dear to us, it's very difficult. So thank you for taking this on. So I mean, a perfect example is also people's thinking in the community. I was at my brother's house in Middlebury and he was mad at me because Porter didn't have all the services he wanted. We can't afford it. And I said, do you want to pay a lot more in your health insurance? And if everyone does that, you can have more services at Porter. And I said, you don't go to Porter for all this stuff anyway. You choose to go to Burlington or Dartmouth or Boston for whatever it is you're doing. And he said, you know, you're right. But I think every of all of us intuitively want the school at the end of our street and want the hospital. And we need to make sure we're thinking about what that costs because it's not... Right, right. And Porter, for example, has shifted over time. It's a critical access hospital. And so you go there for most of the stuff you need an emergency, right? And then if you are having a heart attack, for example, the ambulance is right there and it takes it right up to Burlington and you get taken care. So we have plans in place. And I'm grateful that we have the hospital. We have... I don't feel that we need the entire... Sweet of services. Sweet of services, exactly. I love the urgent care. Living in Virginia. Me too. Yes. Thankful. Just... Yeah. Representative Dickinson and then Representative... I just want to point out the critical access hospital designation was a reimbursement tool. That had nothing to do with the care I provided. That was a reimbursement tool. You can explain that. But one of the things I want to ask was when you talk about what you're doing or what AHS is doing and who's driving the bus, what the legislature does also has an impact in creating the Green Mountain Care Board. They put both the hospital regulation and the financial regulation and the insurance regulation under one year. You guys. And one of the questions that I ask is that that gets into... There's people talk about healthcare. They're talking about healthcare. But a lot of times what they're really talking about is the cost of health insurance. Commercial insurance. They use the word for both of them. But they're two different things. So can you talk about the paramex and the impact of what the legislature has done with the Medicaid? You talk about affordability. What impact that has on your commercial insurance and your employers? Those kinds of things. But that is also something you regulate. Sorry, the question specifically is the... The impact of the legislature and the way the paramex has changed over the years and you're doing both the insurance regulation and the hospital cost healthcare administration. Regulation. I can start and I'll say first the benefit of having rate review, hospital budgets. We have a... We're stewards of a large data set. We have a broad spectrum of authority. So each of those processes inform each other. And so we see that when we're looking at the hospital budgets we directly relate that to the insurance rates that we passed earlier in that year. The other thing I just wanna point out about the... We don't have authority over all insurance rates. We have the qualified health plans on Obamacare which I'm sure folks are familiar with. These are in my mind, the most important plans because these are the plans that are for individuals, small businesses that can't get plans anywhere else. So we have a very public and go through a very lengthy process over the summer to approve those rates. So I would say last in terms of the medic I think you're talking about Medicaid, Medicare. We have seen in the past that Medicare and Medicare rates not keeping up with commercial rates. And I think that's what Chair Foster was alluding to with these rates going up at the hospitals when they're asking for increases in commercial rates and those falling on the backs of a smaller and smaller cohort of folks. So that is one of the goals in Act 167 as well is to understand that and to fill in those gaps in care. So I don't know if you wanna add anything. I mean, right. It's a limited pool that you're getting money from. If Medicaid rates go up, that alleviates the pressure on commercial Medicare rates go up, same thing. We haven't really seen that historically in the last five years and we have seen the commercial rates go up significantly. They are very interconnected and all of those are being driven at least by the care board's decisions. The hospital budgets, which is the big driver, 47% of Vermont healthcare spending. So when we do a 10%, 15% increase of the hospitals, that's going to have a huge impact on those rates, especially if it's part of the static. So the commercial insurance rates will go up. Correct. It's not dollar for dollar, but yes. And you have no control over the risk of rates or the essay. Correct. We'd love to get underneath the hood of almost every subject and it's like education, it touches everybody, everybody's lives. Representative Page, and then I wanna make sure that we hear your budget. Not, we get an education on what you say. Like, what does it cost to actually operate what you do? Go ahead, Representative Page. I've got to hear the budgets. That's important. So I just wanna make sure that Representative Dickinson has this budget area, right? Am I right? Okay, good. And that's your connection. And as we further develop this, we'll be there. So why don't we, we'll move along. I got a quarter after and you're here to 9.30. And I know we wanna get you back to where you're doing all that good work. So I am going. Skip, skip. Yeah, skip that. Okay, yeah, that's, so our budget, the governor's executive branch set a target of a 3% increase for initial budget increase. The Green Mountain Care Board met that and then subsequently they gave additional general fund dollars for increased internal service fund costs, you know, the ADS and also, you know, some benefits related. So that's why we ended up at a 4% increase. So we are completely in line with what the governor recommended. You can see that our fringe increased at a greater percentage. That's something you're gonna see across the board. Obviously, like all entities and state government managing the salaries in this current hiring market has been incredibly challenging. And we're just exceptionally fortunate to have a fantastic, well-educated fund and very young staff, you know, even though Vermont doesn't have a lot of young kids, we have a lot of young kids and... I wouldn't call them kids. Okay, but the workers have a lot of kids. Yeah. We've had about 10 years. Oh, sorry. What I was trying to say is that's good clarity. That's good clarity. What I was gonna say is our colleagues have a lot of young children. So we're not only helping Vermont population, it also makes it incredibly fun on Zoom meetings. And we have a real window into the childcare issue. So, and that's a fake. That's a fake. That's a fake. Oh, sorry. I thought it was... I should have not. So, it's okay. You're good. It's okay. It's okay, you're good. Sorry, it's real. I'll just say, it's real. So our base budget is really, you know, it's us figuring out like how to live within the guidelines that were set forward. And we were able to do that. There are some, what's unusual for us is we have some one-time IT funding requests. So we had first, we'd followed the process for the state. So we'd first, ADS has a fund, you know, like a revolving fund to help with these things. We first sent it to ADS when we submitted our budget. They have, there's so many needs across the state for IT. And our small request didn't make their list. But then as the governor's, the executive branch and commissioner Gresham's office was looking at the money, they realized that they might be able to put some one-time funding towards these requests. And so there's three things here, and these are separate line items, like our base appropriation is B333. Thank you for putting that in there, because that is our language. Okay, yeah, 345, and you know, it's low, it's about $8 million. So we're, oh, I'm so sorry, that's my phone. It happens to all, yep. So anyway, so the first two are, we work with the agency of digital services. We have, you know, database solutions. And per the contract cycle that ADS has set forward, we need to go out to bid every so often for these things. So we're putting these out to bid. And if we select a different vendor, we will need to run parallel for like the old system and the new system. So we're budgeted to run one system all the way through. And if we select a different vendor, we'll need additional funds to be able to run parallel for the appropriate period of time to ensure data integrity and steps. It's the best practice. And then additionally, there are some ADS enterprise management costs that are incurred anytime you make a switch like that. So that's what we position for. I'm happy to talk more about the databases. And then the third one is the health research application plan. It's also known as H-Rack. We, in the past, it was a book, you know, kind of looked like a phone book that was done every few years. We worked to make it more interactive. There's a spot on our website. But since the pandemic, we have really not asked the hospitals for much information to update it because, you know, they've been focusing on everything that they need to. So we were looking for perhaps, you know, just a small amount of money to enhance our interactive tool to be able to visualize data from multiple sources. And we could also send you like a link to what that looks like. But those are our one-time IT funding requests. And they're in the budget. They're in the budget. And so if you see, like, if you were to look, you'd go to B-1100, A-15, and then they're ABC underneath it. And we'll understand there are 70, 70 zero in that, I know. So thank you for including that. And when you said request, I wasn't sure if it had made it or if it was something you were asking us to break in. Okay, yeah. So just to clarify. Sure. All of these are in the budget, all three of them? Yes. Okay. Yes. And is it the 70,000 or the 50,000 on the database? What is EPMO? Oh, sure. So it's both, what we were trying to do is break out the cost to explain what they are. So for the first one, which is the database that collects all the information from the hospitals that we use to regulate their budget, it would be the two costs together. So the first one would be it would, we're estimating it would run, it would cost about $50,000 to run the system parallel. If we choose a different vendor and then the about $70,000 is for the agency of digital services, we have to use their basically project management office. So they do that. So there's consistency. Yeah. On the state. And so it's that cost. So what's EPMO stand for? Enterprise project management office. And I apologize. It's funny that it costs more than the actual new contract, but okay. That's the cost to run parallel. The redundancy part. It would be like three months worth or something. Yeah. It's like a relay race. You've got to be together. So the EPMO is a one time? Yes. Yes. And then they're, I didn't have ongoing costs. These are all one going. Okay. But these are all one time costs. Okay. Yes. Holly. Let's build back. So I mean, I'm just looking at your budget. Yeah. Yeah. And actually let me get to, that's an excellent question. Is, are you on the crosswalk? Yes. All right. Let's, we'll go to the crosswalk. Okay. Great. I'm sorry. I'm just going to take a quick look at my clock. I want to make sure we have enough time. So, so in statute, the green mountain care board are, are main operations are funded except to 40% general fund and 60% go back. Those are state funds that they are built back, you know, based on a formula to the hospitals, to the insurers and to the accountable care organization. So you're regulated entities. Yeah. Okay. Thank you. That's six. So I'm sorry. Just making notes. Representative Harrison. So looking quickly at your crosswalk, oh flags come out at me pretty straightforward. It doesn't look like you're adding staff. I can staff. So my question to you is, I mean, it's still a lot of money, eight million, whether it's billback that we pay in a different way or general fund and I'll just be the devil's advocate for a minute. You have a five member board, you know, quasi judicial. You see has a three member board serve a similar function in a different area of things we regulate. Have you looked at whether five member adds anymore to the conversation or do most business come out? Whether it comes out five zero or three zero, does it matter? And if you look at whether or not, that should be something that should be considered. I'm not looking to take any board member's position. I'm just asking the rhetorical question whether or not five is the right number. I think it's a fair question, right? I mean, there's really no reason you couldn't technically do the work with three. I think the value add with five is what we regulate is exceedingly complex. And there's a lot of different things that we regulate, right? Like you see, we have many different industries actually before us. It's just in healthcare, but there's many different industries. I think I don't know the history of how the votes come out, although I've only been on really one big vote and it wasn't five zero. And I don't anticipate the ones that we'll have coming up are gonna be five zero. I think you get a pretty good diversity of thought and experience and background that really, when I go through a board hearing and I hear the questions all of my, if I'm not that well prepared, I let those four go first and I get to choose. And they are so smart and bring so many perspectives that I didn't think of. So each of them, each of them. And so I think the value is really that diversity of experience in different disciplines given the breadth of what we regulate. But if you're done with three, I don't really see why not. Is it better with five? My personal view is it is. I think the strengths of the decisions is. And that's fine. This is an area where we don't wanna be penny wise and dollar foolish because you do regulate a huge segment of our economy, which I get we all pay for one way or another. My other question is, and I skipped ahead a little bit. You had some information on your performance, maybe. I mean, when the Green Mountain Healthcare Board was formed, the impetus was we've gotta bend the cost group. Gotta bend the cost group. How have we done compared to other states in that regard? And certainly most recently, this past year, it's all we see in the news is we need a 20% increase and we need a mid-year adjustment. And you tried to modify some of that, but I don't know if we're successful. I mean, if York is going up at 10%, we're going to 15%, we're losing ground. And I don't mean to compare to York, it's just, you know, how are you doing? For us. It's a good question. I think, but I don't have the slide here. Pre-Amount Care Board, I think the rate of growth from that was 6.5%. I think since the care board, it's around three, is that in my? I'm sorry, that tone, you see on the light is the Green is calling the Senate to the floor. That is the house and yeah, it's, don't be worried. So I think post-Green Mountain Care Board, the rate is more around 3.5%. So there are data and statistics that say the cost curve is coming down. The pandemic in the last two years certainly threw everything for a loop in healthcare finance. Do I think we've done a perfect job? Do I think there's room for improvement? I think there's a lot of room for improvement. I think part of it is to represent Holcomb's question of how we consider the whole universe of healthcare and how our decisions are influencing those. Because I think, by and large, the general theory is shifting to value-based will improve costs. That's something that we're working on. It started with all-pair model one. I think it's gonna be a much deeper engagement with that and all-pair model two. And I think that also we're incorporating, we're working on global budgets, it's part 167. That should make a difference. And we're also thinking about currently with the board how we're allocating resources across things that we don't directly regulate. But to answer your question, that 3.5%, which is certainly much, much better. And if that's because of the Green Mountain Healthcare Board, you folks are the best investment, in a sense, slice bread, I mean, or power to you. But if everyone else around us is only going up 2%, I mean, it's just, we don't get those metrics. How are we comparing? I mean, New Hampshire is a rural state like us. Maine's a rural state like us. Upstate New York is a rural state like us. You know, I just, I want to have confidence that whatever we're spending, the 8 million, 9 million, whatever it is that we're getting a return on it. And we've given you a lot of responsibility and maybe too much responsibility, but we just like to know how we're doing it. So is it totally fair question? I don't have the comparisons ready today. We can certainly see if we have that data available or come up with the data as best we can. I don't have comparisons ready today. No, I'm just, it's an ongoing question we need to keep asking ourselves. I think it's a totally fair question, the right question. Board needs to look at what we're doing and making sure that we're providing Vermonters that return. That's our job. And then you got kind of the quality metric. So it's not all about money. So I get that. Yeah, I mean, right. What are we doing on affordability? What are we doing on access? What are we doing on sustainability? How do we grade ourselves out on those? And then second, what's the care board's role and responsibility on each of those? Do we have 100% responsibility to, you know, we're not the lead on certain pieces. We're on some. How are decisions impacting these things? I think we should be evaluating them. That's what we're paid to do. Thank you. Representative Shah and Representative Holcomb following up on Representative Harrison's question, which I do think is a good one. I would also want to be sure that if we compare ourselves to the costs, it's also what are we getting for the costs? And that's really important too, because otherwise, if we just talk about the numbers, you could end up like Montana. It's a lot cheaper, but you have to go eight hours to get to the New York hospital. And that's not what we're, so you do have to kind of look at it more three-dimensionally and look at the affordability, access and quality for what we're getting to the cost. So it's complicated, but I think it's a really bad question. Good luck with that. One of the things that I can get for you is Kaiser Family Foundation does an evaluation every year on insurance and coverage. And just to your point, sometimes we come out a little lower of affordability because we cover so much more. So, but we can get that information and give you the explanations as you compare it to other states. Absolutely. I think to that point. By the way, if you're here from Montana, we still look at it. I think you're black, you're here. Stay. But only if you're staying. At that point, if I may, if you look at affordability, we might be fairly low on the ranks in the states. However, we have 14 hospitals and we have a lot more availability to go. So is it just costs that you look at? Maybe we're really bad. Is it access? Is it quality? If you cut the costs, are we losing a hospital in Springfield? Are we losing a hospital somewhere else? Are we limiting what you get at Porter? Right. And so that's that balance and why it's just isolating one element isn't necessarily a useful exercise by itself. Well, as long as you're not impacting Ruffin. Yeah, well, that's a good one. I mean, that's a good, representative local. And then I think we're closing in on the end. I just want to respond a little bit actually to my colleague, Representative Harrison, because I think one of the things I'm struggling with is who's responsible again. So we say, what have you done? It's also clear you're not leading and you don't have authority on some of the issues or some of the letters. So I just wanted to acknowledge that. And one of the things I'm still trying to get my head around is the fragmentation of the system. And then my own experience working with census block appropriations. If you are fragmented within that, you can create very provoking census, which actually undermined your affordability goals. So I don't want to let us off the hook on this one as well. And I hope we can continue that conversation. Anything on your final slides? Oh, the biggest thing that I want to show is, and we can send you more resources in your packet, which is also online. So these are all hyperlinks. This is information. If you want more like regulatory process explainers, they're basically one to four pages overviews. They're quick overviews of our work. So we just wanted to provide this as a resource. Thank you. That is very helpful. Always reach out if you have questions. Well, we do. And then we're very glad that we have, we have the distinct honor of actually seeing every budget. So we can, we sit in that place of seeing it all and wanting to know everything all the time. But it's not always possible. So thank you for your time. Thank you for your work. Representative Dickinson, this is from the budget. So as we work with this and look through it, we will filter our questions through her. If you don't have all of us asking you questions, we'll go through her to have one voice. Please. The one other thing I want to say is I did forward this to Nolan Langwell in Korea, just so he said. Yes. So just so that they're seeing what you see. So just wanted to talk about that. And stay in touch. If there's anything that comes up that you want us to know too. Sure you want. All right. So with that, I think you are free to go. Thank you. Thank you. You're welcome. Thank you all for having us. So committee, we have, oh my God, a little boy. I'll tell you, Aaron's going to earn some. We got a little bit of a break, 10 o'clock. We have healthcare, 1130. We have Department of Corrections and we have lunch. And then in the afternoon, we have a commissioner of Vermont Health, a lot of health today, I'm feeling healthy. Diva, we end with the Department of Public Service. So in our schedule now, we do not have time to talk. Check in with anybody. Welcome back to the Vermont Health's Appropriations Committee. It is Tuesday, I was going to say January, February 7th, 2023. 10 o'clock, we are going to hear from Dr. Levine on the budget from the Vermont Department of Health. So, sir, I don't think you've met everybody in this committee. I can't remember if you were in this. Almost, we can, the names, we can go around. We'll go around just to be sure. When we end, then you can introduce yourself for the record and then start us off. I think we all have a nice handout. If you're watching, you can find materials on our appropriations webpage under today's date to find all of what we're looking at. So I'll start off. I'm Representative Diane Lanford. I live in Virgin's and I represent Addison 3. I'm Robin Schae from Middlebury. I'm Pat Brennan from Colchester. I'm Tiffany from Burlington. Kerry Diller from Waitsfield and I represent Daxbury, Fyston, Moortown, Waitsfield, and Warren. I'm Dickinson. I represent Seattle, Miss Townsend. I'm Mark Mahaly from Dallas. I represent Plainfield, Marshfield. I'm Trevor Squirrel, Underhill, and Jericho. Woody Page, Newport. Rebecca Holtem, Norwich, Sharon, Stratford, and Beppford. Jim Harrison, Chittenden, Bending, Killington. And I'm Mark Levine, Commissioner of Health. I'm accompanied by Anna Swanson, our Financial Director at the Vermont Department of Health. We thought what we would do this morning is just a brief introductory part to our department. So you have that perspective as we go through the budget. And then we'll do a little bit of a tag team presenting the actual line-out of the design of the budget. That works very well. Please go right ahead. Super. So because we do have the coolest mission statement in state government, we always put that on first, protecting and promoting the best health for all Vermonters. You can also see our vision and some of our values expressed on that slide. But to bring it into focus, the definition of public health traditionally has been sort of fighting infectious diseases and epidemics. You may know something about them. Preventing environmental health catastrophes because indeed we have as a collective planet, trashed our planet. And thirdly, preventing chronic disease. So promoting good health, keeping people from the chronic diseases that really occupy the biggest proportion of healthcare budgets. The more modern definition continues to incorporate all of those, but incorporates also developing strong intersectoral partnerships because health can't do it alone. We need to essentially do all of our work across every sector in state government, every sector in society to really be successful. A little bit of the breadth of that is evident on third slide here. Let's focus more on communities and kids, but that's fine. So you'll see some of those themes that I mentioned as you go around the circle with the slide, but you'll also see things that are important to keeping people healthy like doing adequate screening, preventing them from abusing substances from nicotine on up, making sure that the environment, as I said, is quite safe, going from infectious diseases to preventing those diseases by immunization campaigns, et cetera. So there's a whole host of activities and you'll see a little more of that as I go through the different divisions of our part. When we look at what our job is all about, which is keeping people healthy, we look at what are the factors that determine that people can be healthy. Most people think that adequate healthcare is the answer, but if you look at this pie diagram, you'll see that only 10% healthcare determining health. The things that determine health when you ignore genetics, which we're kind of all programmed in with from the start, are really how do we practice healthy lifestyle behaviors, whether that be nutrition, activity, substance use, et cetera, and what are the socioeconomic and environmental influences that surround us. Those are really the major determinants of health. When we look at what can we do about those things, this is a so-called healthcare pyramid where things at the top have the smallest impact and things at the bottom the largest. As a practicing physician for decades, I was really mostly preoccupied with the top three tiers of this pyramid. Did a lot of counseling and education and indeed, those are always necessary but never sufficient and they succeed. But counseling for someone to perhaps quit smoking might not be an overnight exercise, it might be counseling for a decade. Clinical interventions are those chronic diseases that I managed all the time, heart disease, blood pressure, diabetes, you name it. And then the long lasting protective interventions are what goes in what we call the health maintenance part of practice. So making sure people have gotten their immunizations, making sure that age appropriate screening tests have been done for cardiovascular disease, cancer, the big ticket items, et cetera. But now in public health and increasingly in healthcare, we need to focus on the bottom parts of this pyramid. Changing the context means making the individual's default decision the healthy one. So if you wanna have good teeth and you live in a community that has chosen to fluoridate your water, well, you don't have to worry about too much beyond brushing your teeth, beyond that. But if your community doesn't do that, we need to think of other strategies to help your kids make sure that their teeth stay healthy. If you wanna go into a restaurant and not die of lung cancer, you need policies like secondhand smoke avoidance that we've already done here in Vermont, which work quite well. If you wanna have people suffer less from the ravages of tobacco use because that is the number one cause of most bad outcomes in our country and disease expense turns out you can do things like legislate, increase taxes, which have had profound effects. We did that trifecta a few years ago on vaping, you know, increasing the tax to equal what combustible cigarettes would use, making sure the internet was a free environment that an environment free from allowing young people to access electronic vaping devices on it and raising the age to 21. So those kinds of things are what's changing context. And then the bottom one is the really heaviest lift, but it's the so-called social determinants of health, which are illustrated on this slide and they're all the things that I think most legislators are pretty acquainted with. Whether it's access to wealth versus poverty, whether it's access to housing, whether it's stability and transportation, whether it's security and painting the right food and the amount of food you need to survive on, those are the social determinants of health, which really determines so much more. Representative Holcomb. So just to clarify, if I'm reading this pyramid correctly, you're saying the most powerful things we could do as a legislative body to impact positive health outcomes are in best of things like housing, quality education and reducing inequality. Thanks. When housing equals health care, we've succeeded in our message. Representative Jolin. Thank you. And thank you for coming today and helping us understand how when you move upstream, you help identify some of the more chronic and even acute conditions of process of life. That's the sort of the take home I'm getting. But when you look at the prior slide where it shows behavioral patterns at 40% environmental exposure at 5%, I think that doesn't really give you the whole picture of what the two most societal contributing factors are to that health. True, true, because it has the 30% genetics, 10% health care. If you just ignored those and made 100% for the others, they would have a bigger proportion. And use the word upstream. So the most upstream you can get is going even beyond housing and food security and poverty to health equity. So formal definition of health equity really involves those words having a fair and just opportunity to be healthy. So what we find in Vermont, we are B or one of the healthiest states in the country. However, if you look at the level of health that we have on any parameter, it will look really good in aggregate. But when you begin to dissect that down and look at what we might term marginalized populations, suddenly it becomes dramatically different. So if you happen to be in a population defined by race, gender orientation, disability status, socioeconomic status, you don't enjoy that same aggregate number that makes Vermont look great. You turn out to have disparities in that data. And those are called the inequities that exist that prevented you from being as healthy as everyone else. It's best illustrated on the next slide, looking at equality versus equity. This is sort of a triptych, but on the left side, we have everyone getting a support to see the athletic event, but that support isn't necessarily helping every person, as you can see. If we change the level of support, we can accommodate anyone and still get a wonderful view. And then on the right side, sometimes called liberation, if we eliminate the structural barrier, we don't have to worry about anything. That's the Nirvana state. So equity is really, really critical and it's really the foundation for our whole state health improvement plan at this point. We do a state health assessment and improvement plan every several years. May have lost track of the last one because we had this little pandemic in the middle that interrupted things. What we learned from our state health assessment, which has abundant stakeholders at the table with public health, is that there were five areas that we thought we should concentrate on the most, child development, chronic disease, substance use, mental health, and for the first time, oral health, without ignoring those so-called social determinants of health that interact in such profound ways. I'm sorry, Commissioner, let me, on the housing piece, I don't know how I read it this morning in an article that Vermont is the second worst state in the country for homelessness. So, yeah, for capital, and I was a little surprised. When you walk through our towns versus you walk through California, San Francisco, Seattle. We're doing a good job of maybe keeping them a roof over the rest, which we had this discussion last week with the BAA, but actual permanent housing is, so they're homeless and maybe in a shelter or someplace, but I was actually a little surprised at that. Which is why you're seeing state governments have such a focus on it. Yes, yeah, and constituents have led us, no, for Vermont. Yes, and there's a very effective advocacy for that, but it's appropriate, absolutely. Thank you. And then, you know, the populations of focus are the ones I just described that suffer from inequities. Although, interestingly, we added morality because we have some pretty good data that shows that the more rural you are in our rural state, you can actually show disparities above and beyond the logging to one of those populations. A good example of that has been people with metastatic breast cancer requiring chemotherapy and outcomes determined by distance from a place where they can obtain that therapy, more rural not having the same outcomes as people living in a more suburban slash urban environment in Vermont. So that brings us to sort of the structure of the department, which is I'm gonna go through each of these very quickly. One slide, please, just to give you an orientation to that, but notice everything is on the foundation of health equity. So starting with the environment, thank you legislators because we had a wonderful and very successful lead in school drinking water piece of legislation that accomplished just tremendous amounts and protected a lot of kids' brains from the harm of lead. That program and environmental health is also concerned about climate change. This year, PCBs in our school construction, things like blue-green algae, et cetera. Very important focus of the health department. Maternal and child health is a real important structure. Traditionally, public health actually focuses much more on maternal and child health than on the opposite end of the age spectrum. As an internal medicine physician, I've tried to change that, not just locally but nationally because it's really unconscionable that you would ignore the entire spectrum of life, even though we have a special affinity for the very earliest part of life because data shows if you don't start out on the right foot, you may never get there. And that can be profound, profound impacts on you throughout early development years and your whole life course. So this is an appropriate focus for maternal and child health within a health department. That deals with new mothers, not just their children, as you'll hear in some of our proposals this morning that have to do with things like universal home visiting programs, embedding family specialists in pediatrics offices to attend to those determinants of health. We've talked about the WIC program, adolescent health, very, very important division in our department's way. Women, Infants, and Children, a national program that provides nutritional support for those populations who are under a certain income. They are often eligible for the things you hear about from DCF in terms of SNAP benefits is a bad sort, but the WIC program itself attaches health department and nutritionists to the mother, child, and family. Laboratory science is an infectious disease you've probably heard enough of in the last several years with the COVID response, but just suffice it to say that is but one infectious disease on a very large platform. And they cover the gamut of things that you may have had or heard about. We also have vaccinations embedded there and we have an entire public health laboratory in Colchester, actually, which is dedicated towards not only testing for COVID and other infectious diseases, but does a variety of other public health laboratory testing. Representative Holcomb. Does that, oh, sorry, we're here. I know that everything was disrupted by the pandemic, but are you having specific strategies to try to catch school children up on their vaccinations as well, the routine vaccination? So the most successful strategy is actually having them go to their pediatrician because that's their most trusted health resource and we have a wonderful statistic in Vermont. In the first six months of life, 95% of all kids are in their pediatrician's office. As you go on with age, it's 90 plus percent, not quite as high as 95%. So most kids are actually interacting in that setting as are their parents. So that's the way to catch them up the most. Having said that, though we lead the country and vaccination rate in that population, it's not an impressive number. And, you know, mothers have been very cautious. We thought they would be doing a fair amount of watchful waiting for a period of time, but that time has passed now when we still don't have the highest proportion of kids who are all eligible now getting that vaccine. Well, I was talking about also things like measles, mumps. But the second thing is really the national and international, I'll use the word crisis in quotes with vaccination rates in general, catching people up. So the fact that at least people are going to the pediatricians, they are gonna be caught up. I'm not as worried about that here in Vermont. But, you know, you hear about diseases like polio all of a sudden again, and it's like you gotta make sure that you do this. I have to say, there is a very vibrant anti-vaccine community out there and they have been mobilized by in ways we don't talk about and become very, very front center. And because there are many in our population who look at the internet in a very narrow way, they don't see true information and the misinformation is really just out there in abundance. Substance use programs gets a lot of press appropriately and it's a big focus of our health department. But as they will be fond to tell you, it's not all opioids, opioids are front center because of the tragedy of the overdose deaths. Alcohol is still Vermont's particular problem and needs attention as we are giving it. There's also a big focus on stigma because if you don't overcome stigma, there's a whole population of people with substance use disorders you'll never see because you haven't seen it in that fundamental way. We have 12 district offices in local health that have WIC at each of them have vaccination efforts. There really are boots on the ground across the state. So all of the policies in the central office and all of the great programs we wanna go statewide with, that's really where it occurs because we have great people in those areas who have great connections and collaborations and partnerships with their local community resource. Health promotion and disease prevention as an internist is a fond area for me because I treated all these chronic diseases and preventing them requires a village. It doesn't require an office visit. So really having programs in place that allow people to eat healthy can help everyone in the population. And that division also is very focused on oral health, not just all other aspects of physical and mental health. And you've heard a lot about emergency preparedness due to the pandemic response as well, but that also happens during irenes and recent snowstorms and also happens in an injury prevention mode working on things like falls prevention in the elderly, suicide prevention with our colleagues in mental health, et cetera. And then lastly, but not leastly, we are a data-driven organization and it requires a lot of important work on statistics and informatics to be able to credibly advocate for the policies we advocate for and the programs we advocate for because they are coming from the data that we see. That's your overview of sort of the department and I was gonna just do a couple of slides on where our priorities are and then we'll segue into the budget to our questions and then the mic. Two questions, so Representative Shine, Representative Mahaly in the chart. Thank you, this is a great way to look at, I hadn't seen that chart before the pyramid and that's a really helpful visual, so I appreciate that. With regard to emergency preparedness and suicide prevention, I'm wondering specifically the suicide prevention, what you have seen in terms of trends, particularly through the pandemic, through now. I'm imagining those numbers have gone up, but I'm wondering what you could- Yes, so the numbers in Vermont have never been one of those numbers we're proud of. So much in Vermont, we're proud of suicide. We've been up there with the worst things and we had one of the largest rates of abuse over a 25 year period that ended in I think 2017. So we knew it was a problem still. The pandemic fed the fuel a little more so it did get worse, though it didn't get worse at the same proportion I don't think as it was getting previously, but it did get worse just like overdose deaths got worse, et cetera. So a lot of good things have happened in a very narrow period of time, so it's too soon to give outcome changes, but the 988 number went live. The whole CDC grant that we share with the Department of Mental Health has really caused a lot of programming to be unfolded at the level of prevention, both within the healthcare system and within communities, making it evident to people that everyone plays a role and that it's not dangerous to ask somebody if they've been thinking about suicide because it doesn't cause them to go out and do it. It's actually something that identifies a moment of intervention that you might not have had. There's also a new website called Facing Suicide Vermont, which you should all look at. It's just incredible. It shows people a lot of these things that I just mentioned, but it also has firsthand Vermont-er stories. So family members of people who've succeeded, but also people who didn't succeed and their story, and now how they've come out of that and have a new life. And there's a lot of resources on there as well. Thank you. And I'll give you that question. Is that enough, Holly? What do you think? I mean, I think going back to health statistics and informatics. Incredibly important. So how do you feel about the state of things? So when you look nationally, and I get the level of the CDC and individual states, the two biggest problems are all infrastructure problems. Number one is workforce, because across all healthcare sectors, workforce has been really devastated since the pandemic and public health suffered as much. And then the second area is data monetization. We are at a state where the CDC even is decades behind, not just years behind, decades behind in data monetization, systems that talk to one another, systems that talk from the federal to the state, systems that actually look at the data in a way that is meaningful to us. And that doesn't require sort of gerry-riding to get something meaningful. So we all suffer from that. Fortunately, there've been some grants that have come out from the federal government to try to remedy that, but it's very early and it's inadequate at the time. We'll take what we can get, but at the same time, we've got a long way to go. Is our data monetization decades out of date as well? Yeah, at least a decade. Yeah, it doesn't mean we're not making do with getting the data we need, but it's behind. And the workforce issues, we have hired a fair number of people in the last year on grants that address epidemiologists, laboratory support, emergency preparedness support, health equity, these are all big ticket items. All of these are what we call limited service positions in the lingo of budgeting. And they often expire in 2024, 2025. So they rely on a wiser Congress to say, hey, we gave you these positions because we recognize public health needed this to face the next tragedy or whatever we're up against next. And we need to renew these and more. Right now, we haven't heard that. We know the state of Congress, so I'm going to find it clear if their wisdom will continue or not. Thank you. So just briefly, what everybody knows as it came out of the pandemic, major issues, clearly a crisis in mental health, clearly a crisis in suicide, clearly a crisis in substance use. Often those are driven by what I call the biggest evil in our society, which is social isolation. And you would be alarmed at the rates of people who are socially isolated of all ages, not only when we survey adults, but when we survey our youth and look at their rates of feeling not valued by their community, not really feeling stressed, feeling depressed, et cetera. And then of course, education setbacks go right along with all of this. And then the concept of health debt, people's lifestyle behaviors and choices changed during the, especially during the stay homes, they save part of the pandemic, but often didn't revert back to the previous state. So chronic diseases are actually the reason why our hospitals every day of the week are so busy right now. It's not COVID patients. COVID patients make up 4% of their beds. And even those 4% often aren't there for COVID, they just tested positive, they were there for another reason. So hospitals are filled with people who have exacerbations of their chronic diseases, production of their chronic disease because of their lifestyle changes and fear of connecting with the healthcare system during the pandemic, which delayed their, so all of those are big to, you can't solve all those in a few months after the pandemic. What is it nationally? We've lost two years on our lifespan or something. Oh yeah, life expectancy went down at again. Yeah. I don't know if we can have that data. I'd certainly like that. So things you'll observe in our budget besides the ones that we just showed, I'm always focused on protecting kids' grades, whether it be from lead, whether it be from nicotine, whether it be from other substances. We have the substance misuse prevention council, which continues on. And we have a whole program of recovery and revitalization from COVID, which is really, really important. But the way this translates into kids right now is EASIS, Adverse Childhood Experiences. We've had for a couple of years now a real focus on this multi-generational approach to focus on families and their youth. And one of the ways we've done that is through home visiting programs, especially of our most vulnerable populations with nurse practitioners and family specialists, which is a very successful evidence-based program, which as you can see by the slide has an incredible return on investment. There's also a newer program called Dulce, which you'll hear about during our budget presentation, which is embedding a family specialist in every pediatrician's office. And we've piloted that in five locations. And already seeing that the evidence we knew about is happening here in Vermont as well, because it's an opportunity to identify those social determinants of health, which the physician themselves can do nothing about, but with having that specialist in the office can have referral to interventions, resources, legal collaborations, et cetera, which are very, very useful. I ask you questions, sir. Sure. You and I actually have done some, I guess it was radio, a lot of addition, right? I know after school together, that was- That's all of that. So that's a part of this prevention and the ACEs piece, right? That's a big part. Right, that we both were, you would- Very adolescent focused, as it should be, because of the time in life when people start experimenting with maladaptive ways. Time. But I was just wondering, and I wanted to thank you because the youth council is up and going. And that was something I was just wondering how their connection to some of the issues that you speak of on the social isolation and these other, how we're working with that voice. Yeah, I think the after school programs and summer programs are key in that area. And the youth council is just, it's just up and rising, that once or twice. And that's derived from way back, the Iceland project, which really the take home lesson from Iceland besides having curfews, which we don't really need because they have a part of the year where it's daylight, like till four in the morning and then they get like an hour of darkness. So their kids were out drinking during those hours. But the take home message was the youth connection and making sure that the youth voice was heard. It wasn't just a bunch of adults saying, we got to figure out ways to, you know, prevent us. It was a pleasure to meet them with some of the others with Spurred the whole youth council bill. I've got representative Holcomb and then representative Dolan. So I have two questions related to that. And this is gonna come up obviously in the context of the CDC budget. And the first is you have a very specific vision here, which I love. Do you talk to the other departments because this philosophy and theory of action is not consistent across AHS agencies? I'm just gonna observe that and leave it on the table. And then the second question to me, the other interesting part about Iceland, which is not true in Vermont, is that they were municipal programs. So they were socially integrated in a way that our delivery has not been. By choosing the delivery model we did, we set up two tiered access with public school programs, serving kids with disabilities and a disproportionate number of economically disadvantaged kids. And the rest of the resources really creating separate environments for people. Does that have a long-term impact on children's sense of integration with their community? And why was the decision to implement it that way instead of using the existing capability and say 21 C? So we've made some decisions here and it does impact the inclusiveness of the programs. And I'm just curious if you could comment on that. So I'm gonna be able to spend more time on your first part of the portion than your second part. Second part does go way beyond the public health arena to so many other programs. However, one thing the pandemic did was bring us together across state government in a different way than it had before. So we refer to things like health on all policies, meaning we inform other policies that people may not have had the insight about to have a health lens applied to them. Just like now we have an equity lens applied to them. One of the things the secretary has done and I've done for a number of years in AHS is try to make the sixth departments talk to each other more and be more consistent. So for instance, with mental health, mental health and I co-chair of Mental Health Integration Council, which you'll get a full report on after the summer, which to do just what it says, integrate. The suicide work is all joint between our two sections. The healthy aging work is all working with Dale. The paternal child health part of our department is very aligned with DCF in terms of these programs and how does home visiting, Dulce and parent child centers all interact together because they all have different sort of people leading them. So that's the sort of theme that we have and I think is unfolding. So it's probably gonna be the best it's looked ever even if it doesn't look great to you yet just because that is the ethic that we're sort of doing these things in talking. And AOE, everything we put out during the pandemic was sort of a joint memo from Secretary French and myself about why we were saying do this or do that within the schools to manage whatever they needed to manage at that juncture pandemic. And then some of these are structural issues. I mean, the most generational post we know we're, I know our parent child centers do an amazing thing because there has been systematic underfunding, I would argue and others may not agree of the mental health system, for example, what we're seeing is a lot of that cost drop back into the education which is explicitly fired in statute from supporting multi-general additional approaches. So we're gonna pay out of our left or our right pocket but how we pay actually affects the evidence-based practice. And what I'm trying to say is that what I don't see is that vision being consistent across agencies. So I'm delighted to hear that that is trying to work on. No, thank you. And I appreciate what you just said about where we have worked to do. Representative Dolan. Thank you. My question is a bit more elementary but very concerned and I see it some overlap here between social isolation and societal impacts is on bullying. When you see how bullying either through after-school programs or social media or how it impacts the child is I think in ways that we are seeing continually play out in the worst ways and possible. And yet 10 years ago it was a major focus and I know we've had a lot of diversions with the pandemic but curious to know if you could comment on how we as something that overlaps into other departments as well and agencies how we can do better for our children with respect to addressing just that social interaction and bullying generally. Right. So it all boils down to how we get social media and our youth's involvement and engagement and social media because whether it's bullying whether it's what unfortunately happened with CVU with racist posting that was only up for two hours but it basically made a whole bunch of schools say we're not playing CVU and the principal had to do very in-depth work with not only the individual but the community and the school community and beyond whether it's the impact on youth just not that they've been bullied but just what they saw on social media that made them feel inadequate and become suicidal even though the reality was what they saw wasn't reality it's just the reality that was on social media. These are huge, huge problems and they go up they really fundamentally derive from how do we connect with one another. So efforts to improve connectivity among people which doesn't mean what we're doing with Zoom and this meeting but that's a functional way to get this accomplished but when it comes to actually people and society connecting them is the key to success and whether it's a youth who's in high school and just feels isolated or whether it's a 75 year old who lives in a very rural part of the state and still has the firearms from when they were in New York we have to deal with all of those extremes because that's the reality of where things are happening. I don't have the answer for you it's all about connectivity programs that do that. So that's why I say public health has to have abundant partnerships and collaborations because the groups we do partner with address these issues we can't address them without staff of 600 people across the lot but they can. Representative Dickinson. Yeah this sort of follows on the same question about the point issue of the social media all behavioral interaction. One of the things that I don't think we I mean I don't know if you do anything with it or if it's something but there's a quality of grit that apparently is an indicator of success in young people and how do we take that negative things to turn it into something positive. Right so that's all the work that has. Quality of what? Grit. Grit. So that's all the work that goes on with what's called resilience and actually most of the focus not just in a mental health setting but even amongst employees of the state of Vermont amongst children in a classroom is on ways to improve resilience building. So that's a protective factor but you know the risk factors and sometimes the risk factors are really hard to deal with but the protective factors if they don't exist we can introduce them and that's really a big focus. Representative Rooney. Thank you. One of the things that I'm concerned about you just mentioned all the community organizations with whom you need to partner in order to deliver the kinds of services that lead to connectivity, resilience, et cetera. And what I'm hearing is that those organizations are really hard pressed to provide those services and I'm just wondering what your impression is what your take on the kind of the health of that kind of social emotional safety net is in our state. Yeah. It's the same issue as we were talking about with workforce. It's across every sector. So whether it's within the government whether it's in education whether it's in the healthcare setting whether it's in the public health setting whether it's in the broader partnerships and collaborations who try to deliver on this it's everywhere. So in that sense the health is not good. There's great enthusiasm, motivation, desire, commitment but one can only do what they can do with the bodies they have. So there is a threat to that. There's no question. It's not something necessarily that throwing money at health in one of the areas is so poorly funded in terms of what they can pay their salaries that it could help. Well, and I think that that goes to kind of my point is that I think that it's part of the challenges that a lot of these organizations have been level funded or they receive almost no public support at all. For the organization that I ran that offered job training went from being almost all publicly funded to public funding being about 5% because of cuts that were made, changes in federal legislation that made it almost impossible to get people through all the evaluation they needed to. And so I think the workforce is an issue but that is a symptom in part of an eroding kind of foundation. Well infrastructure. Yeah. Just like in public health our workforce issues began two to three decades ago and they were continually eroded by federal legislation. Yep. Further. Now people have recognized it. Well, you can't have a rebound overnight and everything changes. And the same thing for some of the supports of the organization. So we will see that come around, that pendulum will swing again but it won't be as timely as we want it to be. Well, just do these last couple and then we get right to our budget. So obviously a lot on opioid crisis is appropriate to remain a huge priority. There's so much tragedy up in that. And I mentioned the environmental health. We're specifically focusing on PCPC schools now but also a lot on climate change and climate and health. You'll hear less of the health department and front and center there but we're sort of the data drivers behind that and bringing the problems to the table that want things like gas emissions and salt, if you will. So, Representative Sage. Yes, just going back to the previous slide. You mentioned protecting child's children's claims earlier of removing lead and drinking water and scuba. And because Vermont has a much older house close up, I wonder if that's an issue in the older homes and whether that should be included in this slide. Yeah, so the reason it isn't is because it's old fashioned. We've had a lead program so long that addresses the paint in older construction homes so that that's sort of a given. The lead in the drinking water is the new kid on the block. The lead in the paint and the lead in the old homes is something we've addressed forever. So when you look at the kids whose blood level of lead has been too high and requires intervention, that's usually the reason. And those families are very connected with our programs. There can be more done. I don't want to just say we've checked off the box but we pay attention to that. Representative Dolan, and then I've got a question. I am aware that old housing stock has lead solder and so there can be lead in the drinking water as well. With the new EPA lead and copper rule and the state newly using right now, federal funding to help in replacing those lines and there are lines to housing developments or homes. That's a priority. I agree. Is there a standard that children are tested for lead? I mean, that there's a standard that you measure but I'm thinking if you go to your pediatrician once a year, if you're six years old or 10s, are they testing everybody now saying, oh, this is. Yeah, one year and two year. What one year and that two year they're testing. So that's a capillary like a field stick in the office and then if you need a test to support that further, you get that. Not a hundred percent of kids are getting it. I can be quite honest. Over the 80% range, but at the same time, that's pretty good, but it's really a performance improvement issue for the healthcare sector. But that's hard to tell if an 11 year old at that point has been exposed. That was what I was thinking. Yeah, 11 year old would be identified through behavioral problems or learning disability problems. But it's not a part of the standard. Go for your well check every year. No, no, specifically focused on those very earliest times of life. The earliest, but. And that's where the brain can be saved. Right. That's the key. People who like, if you started suddenly unknowns to yourself, getting water that had, like Flint, Michigan, you wouldn't change overnight. And we'd say, we'd better do a lead test on you. But there wouldn't be an impact. It would take time to show that. Whereas a kid with a developing brain that would be very quick. My children are too old, but I would be like, can we just test it? You're not saying we're beyond, oh, oh, very well. With our aged brains. Well, what does that mean? I'm just gonna put it here. So I'll introduce the budgetary part of this, which is really another pie chart. Just to impress you that most of what we get is federal at the health department level, but there is this light blue chunk called the general fund. But you may be used to seeing general fund be a much higher proportion of the department's budget. Not true for us. It's really federal and sort of global commitment. Just to give you that perspective. And the special funds. And special. The idea of them. We do have variety of them. And the total budget is closing in on $217 million. We have three appropriations, which are administrative, public health, and substance use. The overall increase in our budget is 5%. And this budget provides full funding for the department's current service budget. Representative Harrison. Last year through the, one of the opioid settlements, I believe we set up a special fund for... Save the question. Okay. For the end, because it comes... Okay. You'll pay more. I'm now gonna turn over some of the line item crosswalk to Anna Swanson who introduced earlier. Thank you for putting the B number on the B311. That's talking our language now. Yeah. I cannot take full responsibility for having done that. Someone far more brilliant than I. Okay. So happy to walk the committee through the budget. So the first appropriation is administration and support. So this slide that we're looking at currently, slide 27, this shows the full ups and downs. So every single line item in our budget proposal. You'll see there are some numbers off to the left-hand side. And those numbers correspond to the detailed descriptions that you'll see on the next few slides. So in administration and support, starting in personal services, and you will see a number of these line items recur across all three appropriations. So we have more detailed descriptions for those in the administration and support. And then we've just summarized them in the appropriation. So first up is the increase in salary fringe. And so this is four positions in the admin support appropriation, the change in salary fringe cost over 23. This excludes the impact of changes in the retirement rate. You'll see that as a separate line item further down. Second line item here is a technical adjustment, position fund splits to earnings. So essentially what we've done here is we've updated the fund split for positions that are funded by departmental administration to bring those costs in line with historical actuals and what we expect to actually see in 24. That third line is the adjustment to vacancy savings. So again, just updating vacancy savings to be in line with what is expected going forward. Do you have an idea of what your rate is? Is it 4%, 8%? It's about 10%, 10%. And moving on to the next slide, some additional line items in personal services, the retirement, that's my question. Oh, yep, go ahead. Only 10%. When you talk about that adjustment to vacancy savings, rather than the, maybe I'm reading this wrong, it's an adjustment to vacancy savings is a minus coming from 6,000. Oh, I see. And then you have a global commitment. Okay, just catching up, I'm sure you know what I'm saying. But regarding that vacancy savings, can you describe that a little bit more? Are you holding positions and not filling them? No. Is it just, it's not a normal turnover? A lot of turnover. Thank you. Sure. So line four is the retirement increase. Line five is salary fringe for two new positions in this appropriation. And these are two positions that are fully federally funded and they are limited service positions. But you just said four positions under salary. It's two. Oh, it's two. Yeah, two and a half minutes at four. Line six is the FY24 estimated impact of position class action reclassification requests. I was reading a number of positions that were put in for class reclassification. One of those positions is in the admin and support appropriation. So this line then reflects that. Line seven is an internal service fund charge. And this one is workers compensation. And this reflects a slightly decreased cost or 23. And this amount was provided by finance. Next, moving into operating expenses. The first line, it's actually a five line. And so we've kind of lumped together all internal service fund charges, changes to those. The net increases about $250,000 across all five lines. And the individual line items are detailed there. ADS, human resources charges, insurances, et cetera. Representative Shine. Thanks. If I look over to the total about half of that is vision, and that's the budgeting. Vision is the financial system. Yeah, it's so much. Is it that way for, I haven't really looked at the other departments. Yeah, so I don't know if this is sort of standard. Did the rates go up? Is this a lot more for you than it is for other departments? Yeah, these amounts were provided by finance. So we... Okay, because it's coming from five different places, I see. And it's $109,000 for vision. I guess this sounds like a lot of money to me for that. Because you're not the only ones using it, so. Right. But it's making out. We're not, maybe it's more, I don't know. Yeah. I guess I'll ask Adam. Yeah, definitely. We have finance. Yeah, I'm gonna ask Adam. Ask Adam about the vision. Okay. Maybe he's listening to the answer or just we'll check. Yeah. It's okay, we're not on the floor. Thank you. Sorry, go ahead. No problem. So the second line item here in operating expenses is a net change to multiple exception codes. So essentially you'll see that this line item nets to zero. So this line reflects a change of funding mix for operating expenses, based on actual historical costs and expected funding. And then the last line item in the admin and support appropriation is in the grants major object, a reduction of about $2.3 million. During the 2021 legislative session, the general assembly appropriated one time funding for a temporary expansion of programming for scholarships for medical and nursing students will not be available after 23. So this line item reduces that amount for 24. That seems, I mean, it's complete. Is there something out? I mean, nursing scholarship and students, what else is there out there right now? I mean, when we looked at the BAA too, there's a lot of places that there's scholarships in. I'm gonna make sure we're not going backwards. Sure, the department does have base funding for loan repayment and scholarship programs. This was a temporary extension. This was a, what's left that you have for this? Left, I think circle package, you're on the table. Yeah, we just, we wanna make sure that that's, especially, you know, for the nursing students. Yeah, so we'll follow up on the base. Ahac, yeah, Ahac, yeah, other repairs on that. Oh, representative Harrison. Trying to help you with your career. Yeah, you're doing a great job. Louie, I know we, as the chair said, we invested a lot in what we had some of these federal funds to help address some of the critical needs and the medical field, especially nursing. Do we have any evidence that money actually helped or is it, in fact, if we still need people to actually fill those roles? I mean, we spent a lot of money and I hope that it had some positive impact, but I don't have anything to, thank you. Yeah, it's also, the timing is too early for you to find out if that's true. Because, this was 2020. People with impacts still have to go through their years of training before they decide where they're gonna actually get a job. But do we have any, like, rolling numbers? Like, we've got, you know, potentially 200 more people entering the field than, say, we did five years ago. I don't know what that is. No, you're justifying and asking. Well, we can get that from each other, okay. Yeah. Yeah. Well, we just got a huge shortage and we're paying for it in other areas, like traveling nurses. Traveling nurses. Yeah, tens of millions of dollars. I have representative Dolan, representative Dickinson, representative Mahalo. That was my follow-up, just the cost of traveling nurses. How do we build our own workforce to help offset that? It's always a timing issue, you know, upfront costs initially, but the long-term benefit of that kind of, you know, prevention of having to rely on travel nurses. Yeah. Do you have a heck in your budget? You do, okay. And that's the scholarships that they normally do, or the laundry payment that they normally do. The physician. They do once for nurses. That's been around with education, that's the standard. Okay. In terms of the scholarship, maybe not for the medical students, but for the nurses who address that issue, there are, have you been working with the educational institutions? I mean, VSC had a lot of, we had the critical access, critical profession scholarships, is that related to this, or is that separate, or? I don't know as much about the nurse program as a physician, but we can get answers to your questions. That would be in the college, maybe UVM, but that was a very aggressive workforce program that we did see how many more numbers they had. But the biggest impediment was getting nursing educators to master's degrees and could these guys get a master's area to more nursing? The salaries for the educators was not adequate. Yes. I'm having trouble hearing you, I'm sorry. Salaries for nurse educators was not adequate to keep that a little possible. There's a barrier. You don't have the educators that are qualified to convene for accredited institutions. You can't accept as many nursing students. And part of it is the salary barrier, which is what we just- For the teachers, for the preceptors. Well, for the educators, for the colleges. That's right, we put some money into that. Yeah, we're putting money into it, but it's not related to what you're doing. No. But it is related to Jim's question, because we don't know for subsidizing people who are already going to do nursing for them. It's a growing your own issue. You've got to grow your current staff to make them more educated. You've got to go. Yeah. So we directly can. Tuition reimbursements, I know the hospitals are doing a lot of that stuff. Thank you for letting us entertain ourselves here with this. It's very helpful. Yeah, it is. It's very helpful. Representative, if you're done. I'm done, thank you. Okay, Representative Halloween. I guess I'm following on the same thing. Let's go back to this 2 million, 1.2 million. This was money, one-time money for scholarship. If you had it, would you spend it again? I think that's a good question. That's a good question. Great follow-up on that. I mean, that's why getting the balance is what we're talking about. It's hard to assess the outcomes because we're looking for help. And thinking through, I mean, here we are hearing, we heard it in BAA. We're going to hear it again. We're pouring money into the nurses and we're going to do something but assess the value of what we have done. Representative Harrison has said we and we're looking for help. And I think maybe you could help us to some extent. We'll get through that. Thank you, guys. Either way, look up AHAC is Area Health Education Centers. We have to look it up to it, all right. There's a nice, yeah, information about it, which is... Okay, last question on that. That comes out of the global commitment. What exactly does that mean? It's a global commitment investment. So it's a federal-state partnership. Yeah, so that's that program. But that money's not there anymore. Or it could be there in the future from global commitment. It's a match for the global commitment that was one time. So the state share of this money that we're removing from the budget for 24 was money. Thank you. Thank you. Okay, so that concludes the administration in support of appropriation. So moving on to public health. So again, starting in personal services, we'll see a number of the same line items that we saw in the support, salary, fringe, retirement, that sort of thing. In this appropriation, we have 26 new positions. Again, all of these are funded by federal grants and they are all limited service positions. Where are you? I'm on site 33. You said you're all limited service. Yeah. It's line five on your... Yeah, okay. Sure. Thank you. So next up in public health is operating expenses. So the first item here is the opioid antagonist program. Naloxone is the medication that can reverse and overdose caused by an opioid and the health department works with community-based organizations to distribute that life-saving drug. There has been a significant increase in demand for Naloxone. So we are requesting an increase to meet that need. I see that's coming. Which special fund is that? So it's two special funds. So on the bottom of that slide, we have the proposed funding. First is a $400,000 increase in the special fund from the evidence-based education and advertising fund. And then second is a $1.98 million appropriation from the opioid abatement special fund, which is the opioid settlement fund. Oops, sorry. Yep, please. So lots of salary in here. Salary and fringe is almost half a million in general fund increase. And $2 million total, this is before the 26 positions. And so how many people are we talking about in that? The majority of our staff are in this appropriation. It's about $550,000. $550,000, that is incredible. Thank you. And then you have 26 new proposed positions. What are they? Or are you going to tell us? They're all the ones that I described earlier. So epidemiology, laboratory, emergency preparedness. Part of the new federal funding we're getting. Thank you. Yep, because I see they're all in federal funds. Right. And these are all being paid for by that new opioid. I don't want to tell you though, it's not. This is, these are some of the grants that involve workforce and health equity. And then your question on the opioid settlement. We have an opioid settlement advisory committee. That meets regularly. We'll be meeting again next week with a full list of what the monies are being recommended for. But that committee reports to the health department makes its recommendations. We're going to make our recommendations to the legislature. Legislature does what they want to do next. So one of the recommendations here is that a portion of the initial allotment of settlement funds go towards the locks. It doesn't be expansion and need and demand for it. You lost me. So that's not part of your budget. Recommend right here. It is. It's the way we get to it. Process, not subscribing. The 2.38 million. Yeah. Yes. So part of that is the evidence-based education and advertising fund is a fee, if you will, that cynical manufacturers pay into that has supported this program for a number of years as well as some other initiatives. The same manufacturers are now often having to do these litigation and pay huge amounts of money over years to states because of the opioid crisis. We anticipate millions and millions of dollars through that pathway. Some of which were advocating to this cause. You answer my question. Thank you. Thank you. Okay. And then just a couple of routine line items in operating expenses and public health. Another internal service fund charged for fee for space. Increased costs there over FY23. Finally, it's the admin and support appropriation of a net operating expense account code changes line that nets to zero and that line just reflects changes in the funding makes for the expense account codes. Very straightforward. Well-documented piece here. Did you have a question? No, I was just going to look at the screen. Okay. No. Finally, in the public health appropriation of two line items related to grants, the department has two memorandums of understanding MOUs with other departments within the agency, Diva and DMH. So these line items provide the spendable quality in the interdepartmental transfer fund for us to spend funds received under those MOUs. Top one is part of chronic disease management. So self-management programs for chronic disease. And so that concludes public health. Our final appropriation is substance use for grants. So this budget is represented in blue notes, three to 13. Yeah. So again, starting out with the same line items that we've seen twice before already, salary fringes increase, technical adjustment for fund splits, vacancy savings, retirement and then new positions. There are four new positions in this appropriation. Again, all federally funded and again, all limited service. At some point, it would be helpful to see all the new positions, like on a list. That would be great. And that they're federally funded and where they're. Yeah, we can definitely do that. Thank you. Can I? Sure. Oh, yeah. Maybe you're going to explain this. You're not done with this category, are you? This budget, just started. Okay, I'll wait for you to tell me what you're going to say. Okay, so next up in the substance use programs appropriation under the grants major object. This line item group converts recovery center funding from GF to global commitment investment. You'll see this as a net zero line item. It's simply a change of funding mix for the grants to recovery centers. There's no change to the amount that will be awarded. And there's still 12. And let me, I'm starting to beat some. But this, the 540 represents a level funding. Right, so we're, yeah, we're level funding the grants on the district each and how those grants are funded. Okay, next up. Oh, is there a question here? Oh, yes, please. What do you say level funding the grants? Who do those grants go to? The recovery centers. The 12 of them. So when we level fund our recovery centers and yet costs increase yearly after those recovery centers and being able to do the work when they have a level funding budget. So from a financial perspective, I would just say that there was an increase in 23. So the 23 amount that was actually $540,000 greater than it was in 22. So we're level funding from 23 to 24, but they did see an increase from 22 to 23. Okay, but it's still probably just, it was adjusted in back in 23 for, again, further increase in costs. Anyway, I've just flagged that as- Almost an unanswerable question. It relies on knowing the impact of the increase and was that satisfactory enough or not? We'll see that play out. Thank you. Okay, next up in substance use programs, we have a realignment of the SFY 23 both base appropriation, which is a general fund appropriation. This is overall reference to change in the funding mix for substance use disorder treatment. We are budgeting about $1.6 million to utilize the existing residential treatment providers and that's gonna be funded in part as Medicaid investment. And then about $954,000 for general fund for treatment expansion. I asked- Please go ahead. Sorry, my head's like on this teeny, tiny line. If it's too basic and I'll defer it all afterwards, but you have an increase in the substance, you know, the residential treatment and you have no increase for the recovery or substance abuse recovery centers. Maywood, isn't that the same group or are we talking different populations? So let's talk, there's a continuum of care. Person with substance use disorder entering the system, we have the well-known hub and spoke system, which is really patient focused and intensity driven by more intense in the hubs, less intense in the spokes. If at that point in a person's course of illness, it's deemed essential they be in a more inpatient setting in a hospital, that would be a residential facility of which we have free in Vermont. People stay generally the range of 21 days at that facility and kind of removes them from the environment they were in. But then they have to go to another environment. And whether you're in the hub and spoke or whether you just came out of a residential and now are in a hub or spoke, you need to be engaged in your recovery. That's the role of the recovery centers. So trying to maintain people in a state of remission for the condition and return them to a productive life with supports of employment, supports of housing, supports of counseling, peer support, et cetera. So the focus on this is really on the fact that all parts of the treatment system during the pandemic, the one that seemed to have the least resilience was the residential facilities. They had to have their number of beds severely curtailed because of outbreaks and illness and staffing issues. They also, in addition to that, really just had difficulty maintaining the beds that they had with the available staff even when they didn't have staff out sick because of COVID. So they just had a tremendous struggle and they need further support. So what we've done is sort of rearranged the same pot of money to support a little more of their needs, leverage some general fund money now through Medicaid to give us an additional 27% through the Medicaid formula and still focus on these other aspects of the treatment system, not the recovery. That's a separate bucket, if you will. This is really substance use disorder treatment focused. I'm hoping- I'm going to declare. So I mean, treatment is treatment. I think- So basically treatment is treatment of medication for opioid use disorder and it's counseling, et cetera. All of which continues as you're into recovery but the recovery centers are very much focused on you as an entire holistic person and all of the needs you have in addition to maintaining your sobriety for what substances you thought that. Hope I've been correct. Yeah, no, no, you're fine. I'm just trying to understand why we increased one area. Obviously you saw it increase costs. We've really got crisis. They have price pressures too. I'm not looking for increases whether that needed but it does beg the question. And they all had the same travel issues that hospitals have too. So I mean, they had substantial increase of costs and stresses support for us. Go ahead. Thank you, ma'am. Can you tell me if there's residential treatment centers? Are they at running at full capacity now? Right now, I can't tell you. I know that often they have waiting lists. A real question you're asking is do they have the same number of beds that have pre-pandemic opposed to their full capacity with a reduced number of beds? You know, I get increasing that. I think what I'm really getting at is when this says expanding capacity, what does that mean? So having them have the number of beds that they thought they had originally but couldn't maintain due to the pandemic. All right. We're getting it easy for a model who's identified to get into one. So this isn't actually expanding the service or number of beds. It is enabling those treatment centers to run at capacity with the staff that they need. Which may need expanding beds, but not beyond what they originally started with just back to where they started. And I'm assuming that just the line above expansion of substance use disorder treatment and that expansion looks like what? Yeah, so. What do you mean the 954th? I'm in the crosswalk. It's number two. So that's really, we have two types of beds in Vermont. We have the public inebriate program which is sort of a 24-hour stay kind of thing for people who might otherwise end up in a correctional facility, but don't need to be there. And then we have what's called sobering beds which are really people who may be in treatment, who may have relapsed and may be back to square one, but be supported in getting back on track again and can stay days or even weeks in a different type of bed. So sobering beds, residential beds, those are all included in that aspect of the treatment, if you will. There's also, I think a hope in there that there would be more capacity in residential facilities, which you were talking about earlier. But that's out of this bucket as opposed to the previous bucket, which is just getting the residential facilities back to operating the way they need to operate for what they have at the time. Okay, thanks. I can follow up later. Yeah. It's more specific question. Thanks. Thanks. Good. Yeah. Okay. So next up is an increase in general fund for services and services prevention. This is related to the cannabis excise tax revenue. This amount, the $1.41 million reflects about 30% of the projected cannabis excise tax revenue for fiscal year 23. And during the 2022 legislative session the assembly established legislative intent that the minimum of $3 million would be available annually for substance misuse prevention. So you'll see on the next slide, this phase of preparation is paired with the one-time appropriation to collectively have the full $3 million available in 24. For FY25, yes, sir. Go ahead. So as the tax receipts increase in cannabis will be the extra general fund to get to the $3 million, is that what I'm reading? That's right. Okay. Choose us out back to Congress. Okay. Thank you. It's just that breach. Right. I don't see it. I guess I would use the word not as, but if the tax receipts. Okay. That's fine. It's totally worth it. I'm not hoping it does. So we need this. So, that's me. If I may, another question I had coming back to opiate use treatment. I had a situation in particular raised this issue where they've implied offered employment who have substance use disorder. And occasionally they, those employees need to be able to take advantage of that habit spoke model. And I don't mean if it's hard to predict when those crises occur or those needs occur. And the businesses want to be supported and yet are feeling the crunch in terms of being able to support that type of employee. What kind of services or support do we provide here? Maybe it's not in this budget, but to provide the actual businesses that doing their part, it's been fabulous, doing their part to support our workforce and including people with substance use disorder. So that we are not creating, we're creating the right incentive for businesses to help in terms of providing that part of solution. That's where we've dedicated monies that go to the recovery centers to actually work on employment for the people attending those centers. There's been a lot of programming for employers in general about reducing stigma so that they fight this workforce as opposed to push away, create barriers. And there's a lot of anti-stigma campaigns that the health department actually talks. With this in mind, but also with people just getting into treatment and with youth and stigma that might be associated with them for some of their habits. So I think across that continuum is really where we're at. But one narrow dimension to what you said is really crisis management. Someone has a stable employee who's been faithfully attending what needs to attend and then they have a crisis of relapse and how does that get managed? Not sure we have a specific intervention for that. It would be similar to someone who gets sick at work for whatever illness and needs to be replaced on a temporary basis. So I don't know if we have a special program, but we can find out. Yes, that would be helpful because you could see how it could play out where, and it may not be a crisis which requires residential, having a residential, period of stable vision. But it may be just being able to go to a spoke area for the day or for treatment. The problem is that the business is relying on that employee for a certain output and it makes it very difficult for that business itself to... I hear you. So anything you can provide in terms of better understanding. Okay. And the slide that's in front of you is purely prevention focused. So that's really these regional coalitions that we're providing more of with the money that we've had for this fiscal year and further plans for the following fiscal year. I want to make sure that you've got time. But then last slide is really... It's the money I'm revealing by newness. The cannabis money goes into the general fund. It's not a special fund. Yes, it comes out of the general fund. Okay, thanks. And that's true of all the cannabis money. It's generally goes into the general fund. We can talk with... That's a whole different conversation. This is the education prevention. Okay, great. All right. Thank you. So on this last slide, we have the previously mentioned substance use prevention money. But then more importantly, because it's the newest item on the slide, the hub expansion pilot, which is part of a broader vision, if you will, that you're going to hear about across, you may have heard about it even yesterday from the agency secretary, a vision that really tries to manage co-occurring disorders, which we consider substance use and mental health co-occurring at the same time, which is a very high percentage actually, as well as co-occurring substance use disorders. So by definition, and this is federal regulation, if you are attending a hub, you have an opioid use disorder that requires the hub, maybe on methadone, maybe on buprenorphine. Doesn't mean that you should have any other substance use disorders you have and ignore it because you're going to have the opioid use disorder managed. But in fact, often other co-occurring, whether it's stimulants, whether it's alcohol, are not being managed at the same level. Same for the mental health issues. So the goal of this hub expansion pilot is actually as part of that effort to make sure the hubs are equipped to handle all of the things I just said. The bigger vision has to do with also Mayford yesterday to deal with expansion of the blueprint for the primary care setting and its focus on these co-occurring disorders, focus on Dulce program, which is the pediatric office with an abetted family specialist in it, which is a very preventive kind of focus. That's a real package looking at the crisis of mental health and substance use and trying to address it in a much more expansive way than current funding streams and current practice have a lot. I'm going to assume that this is in the B1100 section of the bill. This is in the language. Yes. Our time is up on that last slide. Thank you. Thank you for your detailed willingness to entertain all of our questions. We're going to excuse you. And as we said, the B1100 department of health and public health is through representative Dickinson and substance use is through representative Brumlin and we'll filter our questions through them so you don't get all of us in a moment. What you had to answer in one slide. Yeah, exactly. Yeah. Three minutes to switch over. All right. Welcome back to the Vermont House Appropriations Committee. It is still Tuesday, January 7th, 2023. A little bit after 1130, we're going to hear from the department of corrections right now, their budget and we'll try to be as efficient as we can. We've got people that are coming in and out because there's a couple of other meetings going on. So it is no reflection on you at all. Just the multitude of activities. You were here. I can't remember if you were in before BAA. Yes. So we've had introductions. But I think representative Squirrel, you have invited members from the other committees if you'd like to introduce them. Yeah, there are two members from corrections and institutions Eric, Wyatt, and Kristin Roberts. May I have a chair? You're welcome to ask questions if you'd like to. You're welcome. Okay. I think you know us and we'll dig right in. Okay, sounds good. Thank you. For the record, I'm Nick Demmel, I'm the commissioner of the Vermont Department of Corrections and I'll let Kristin introduce yourself. Kristin Calvert, financial director of the Department of Corrections. And certainly I think you want to hear from her more than me. And so I'll let her walk you through the lines and happy to answer any questions as they come up. So in the interest of efficiency, we can skip to page nine, which is where the ups and downs begin. That's good because if we spend so long, we don't get to meet the... Thank you. Okay, so starting with the Corrections Administration appropriation, the four lines here reflect the annualization of salary and benefits, as well as the internal service fund increases. And that's it for administration. Next section down, the 336, the Pearl Board appropriation is the same, annualization of salary and benefits and internal service fund increases. On page 10, Corrections Education, it's also included annualization of salary and benefits, as well as internal service funds. But also included here is a proposal to move the Community High School of Vermont to the Education Fund from this year. So you're referencing the special fund as an ed fund here. Correct. Is it the same on these other special funds? No, there's a few different funds in that special fund category, but in this appropriation. That line is ed fund. Okay. I love chair. Yes, sir. What's the thinking behind that? Well, that's a great question. I think it kind of differs from committee to committee as far as if the Community High School belongs to the Education Fund. You do it as an exercise every year to put it on the table. The past couple of years, it's been moved back to general funds, but we're proposing it again for a discussion. Representative School. Yeah, but it's a little bit like Groundhog. Yes. It's gonna come in last. As long as I sit here and talk to you about the state of the general fund, I think there was a time in the past when we didn't fund it. I think part of that debate is about whether that's a traditional high school kind of setup and whether it has to be or should it be funded through the ed fund. So this will be a debate that'll go through other committees. I think there's more of a position here, but I think about this. I look at it in a different way, I'm sure. Yeah. Representative, please. I don't know whether it's this one or the next section, but I know there's been talk about, besides like getting the high school card, which is where you're getting a degree, is what other sort of vocational training, is that in a different section? It's a lower section. Okay, so when you get to that, I would like to hear about how you're changing for that because I know it hasn't been a trail, but this is as well. I was on corrections and institutions my first term, and the folks who are incarcerated get moved around and they serve the program here and they're there and all that, so I'd be interested. I know that's more of a policy thing, but we'd be happy to talk about that. Absolutely. Next section, B338, is our Correctional Services Appropriation. This is where the bulk of our budget exists. The first two lines are, again, annualization of salary benefits. The next one down reflects a transfer of a position from DOC to the AHS Central Office. Just one, right? That's housing. It is now, that's correct. And a point of clarity. In BAA, it had a different position number attached, which was the DOC positions. In this document, it's the AHS position. It is still referencing the same. Sure. Yes, you're glad. And since we did it in the BAA, and if it stays in the BAA, it'll come out of this. Right. Sometimes you've indicated on your crosswalk, like in BAA or not. Okay, so it's in the BAA. The next line down is the Health Care Services Contract increase. We are transitioning or will be to a new vendor and that is still a negotiation, but this is our, go ahead. Yes, sir. So what do we pay now for the Health Care Services Contract? It's just under 20 million annually right now. So this is, you're projecting it to go up by 50%? Yes. Wow. Yeah. We were getting a real good deal, or we were unrealistically low. I mean, I don't know. Yeah, I think it's a, No, go ahead. I think it's a little bit of that. I think we had a very low price point for our previous contract. And the change in the cost of health care staff post pandemic is, I think the major driver of this increase is it is much more expensive today to hire a qualified health professional than it was five years ago when we negotiated the last time. Okay. No, I, you know, that's the new reality, I guess. It's just, this is vague. So this is, you know, next year we're starting at, is that a fixed five year contract or does it go on each year? No, it's fixed with some built in. With some optional exceptions. Okay. Yup. Thank you. So the current one is five years old So yeah, that's part of it. I'm sure. Great, but we opted to go back out to bed. Okay. Representative Shaw, are people who are incarcerated are going to get more and better benefits as a result of this? That's the goal. I mean, one of the things we recognized in the pandemic but certainly kind of in the last year is the toll that the pandemic had. And it's not just in physical health, although that is a big part of it. We have a sicker population that we ever have before but it's also the mental and emotional toll the pandemic took. Some of that's our own doing. The mitigations that we put in place to protect folks cause people to be in isolation for long periods of time. Recreation was truncated. Visitation was truncated. Those have a mental and emotional health toll on the population. And so one of the primary reasons that we did the contract this year, the first available opportunity was to redesign the contract to be more responsive to the needs of the population we're serving. Okay. Great. Next line down is the electronic health care record. We have removed this from the health care service contract. It made its own agreement. So it aligned with our offender management system and to have better maintenance of our own data. You work with ADS with that, right? Correct. The next line down offender management system this represents an annual increase for the maintenance of that service. Next is the Prison Rape Elimination Act and that's over in the federal fund column. This is for the second year of expenditures for that federal grant that we have currently. And it's being eliminated? Like the grant? No, we're hoping to, Prison Rape Elimination Act. Elimination. Yes. We're not eliminating the grant. Oh, correct. And then below that is internal service fund workers compensation increase. The next three lines reflect facility inflationary pressures and a little bit of savings, mostly attributed to the decrease in the incarcerated population over the last several years. And then there's no questions. The next several lines, again our internal service fund increases and a small decrease in one. Thank you. Sure. Moving to page 11, section D338.1. This is the Justice Reinvestment II appropriation. This is made for the fiscal year. There are no payroll costs in this appropriation so no corresponding increases. I think Representative Squirrel had a lot to do with creating this number in the space. Yes. Yeah, if I may remember in the PAA, we actually moved $2.7 million into this round from correctional services and from the other state. They were in tune with us, depending on the year. Great. Yes. And part of the goal here is really, I think to recognize what money is being spent on justice reinvestment versus other parts of the DFC budget. This gives us a cleaner look at that budget item. There's a question. Representative Harrison? Can I go back to the previous section? Sure. I think we need to do a three-year phase. I'm meeting with you guys tomorrow. So this is for me. What kind of percent increase is that? I assume your footprint. It has not changed. I don't know the exact percentage. I have to figure that out in follow-up. I mean, I can ask tomorrow. I just didn't know if that was unique. Not on the top of the page. The percentage was unique to you because you had extra work needed to be done or? No, I think it's just reflective of their operating increases. Okay. I'm sorry, I missed your question, Representative. I would just ask you whatever it was, yeah. Oh, our overall fee for states. Oh boy, we just paid them. So it should be around top of my head, but I don't have the figures. It's around two million, I believe, for all of our locations, but I would like to clarify here. So this is two percent. We can follow up with the exact specifics. Yeah. So they have those, you know. Well, Representative Harrison, when he meets with BGS, that's why he's gonna feel asked. Okay. Yeah, great. Okay, so I believe we left off at B339, our out-of-state bed. No increase or decrease here. The salary associated with this appropriation. That's not an increase. No. Four million is just fine. Correct. How many, how many members do we have out-of-state? 100, go ahead. Sorry, 124 incarcerated individuals out-of-state this morning. And the last time, they were in Michigan? They're currently in Mississippi, and they've been there for five years, I think. Yes. A private facility in Tell Hatch County, Mississippi. We were in like Pennsylvania, we were in a very short period of time. Yeah, we'd been in Pennsylvania, Kentucky. Michigan, Michigan. And then kind of a spattering of other places over time. That's the lowest I've seen. So that's, I mean, that's great, but there it is. Do you have a question? It's just such a basic question. Sorry, I'm sorry to take you back. I don't know, I don't know. All of that markings, the titles are talking about budgets as passed for fiscal year 24, but it hasn't passed yet. And I'm not seeing adjustments. Is there any, would you include FY23 in here, anyway? The top, are you, in the dark green, on the dark green, should be as good? I'm assuming it should be 23 all the way through, not 24 all the way through. Oh, okay, yes. It's a problem through all of the, yes. Right, no, no, no, it's, no, it's not. No, that's why it's not. I was in a VDH, just checking. So the dark greens are fiscal year 23. Current year, and then the bottom underneath, but I guess there wasn't adjustment. And this does not account for budget adjustments. Correct. Okay. Just making sure we're on the same page. Okay. Left off at B340, the Correctional Facilities Recreation Fund. The only change reflected here, salary, grants, retirement. Page 12, 341 is where our offender work program lives. I have a question. Go ahead. Yeah. So if I am looking at this, it looks as if it's in the internal service line, then it's paid for through the sale of whatever it is. Are you in the BWP? Yeah. Correction? Yes. I mean, can you tell us what the offender work programs currently are that are active? So this whole program is going through a redesign and a re-imagination. Historically, the way the department has run its industries programs is we have dedicated industries at certain facilities. We have a wood shop, print shop, which does letterhead envelopes, things like that. Sign shop that makes highway signs and things of that nature and a plate shop. We historically have had a small engine repair shop and a couple of other things here and there. Those are static industries at certain facilities, predominantly Northern state in Newport and at Northwest in St. Albans, Swanton area. That model was designed to be self-sustaining that we would sell product, it would pay for itself and in the process, hopefully teach skills that would be valuable to the incarcerated populations that are pursuing that. They do get skills to be clear, but I think we began to believe the skills they were getting were not in alignment with skills that were in high demand in the community and it was limited where we could provide access to those programs. Separately, the system was not self-sustaining and actually running a fairly large deficit year over year and then it has for many years. And so we used two separate federal grants over the last few years to review and study. Sorry, that's okay, no, no, no. I'm so apologize, that's my fault. Yeah, I'm sorry, I'm sorry, hold on. Can we get back to that question? She had two phones and one was somebody else's. No, look, I didn't call the same case. There was, we were leaving a place together and I went, oh, represent Blumlee. You left her phone and I handed it to her. So in other words, I'm stolen. Take it to Sergeant and Arms Office. They will find us. Oh, good. Sorry about that. Did you answer it? I'm sorry. Oh, that's quite all right. Well, we, I bet it was adrenaline rush. So, yes, so good. So you said it. I think the direction says something. Okay. I will definitely. I can try it, Mark. My day, don't. So thank you for the offering. For housing. So the system is not self-sustaining, that's right. And it was costing more than we were bringing in. And there's a variety of reasons. And we're happy to brief on that if it's helpful to you. But we use two federal grants to study and redesign the program over the last several years with an eye towards really creating a vocational training system that provides high demand skills to incarcerated individuals that we can then connect them with high demand jobs or jobs that are, there's a major gap in our workforce in the communities because we know that the predicate to success in the community is largely based on housing and employment. And then substance use and other things with certain individuals, but by and large, everybody needs housing and everybody needs money to survive and get those basic needs satisfied. And so we wanted to make sure that we were designing a system that delivered that. The other part of that though, and somebody alluded to this, the industries are limited in where we can provide them. And so some individuals get access to them, then they get moved to another facility. Some individuals never go to those facilities in the first place and won't gain access. And so we wanted to flatten that across our system to make sure that we were getting every incarcerated individual access to those programs no matter what facility they were serving in. That work is underway and it'll be based, I think for this committee, maybe most familiar with the career technical education model that's used in the communities, very similar. We're bringing that type of model into the correctional system. So we'll have mobile labs that we can move from facility to facility. We'll have certain instruction provided and move that around. We've had a lot of outreach from private industry and from other state government agencies interested in coming in and training because they know they need that workforce. And so it really helps both sides of the equation. It helps the incarcerated individual with their rehabilitation and positive re-entry in the community. And it helps our economy by filling gaps in our workforce which we know is challenging in the state. Representative Dickinson, and then we'll be back. Yeah, regarding those CTE programs or the correctional industries. When I started at institutions, at another point in time, one of the things that was when they tried to eliminate the high school of Vermont. And so we did a visit up at Northwest to look and see what they had. Saw a lot of these things that they had. One of the problems that came up that was discussed in professions and institutions was that the guy who was teaching the auto shop basically said he was the school bus that day to go to round people up to go to school. There was a discussion about the fact that the inmates would often step all night and sleep till three in the afternoon. You offer the programs, you have these programs. Apparently the auto shop was a highly successful one because it's a huge demand. The pay high salaries, if you can come out with that you're really doing it. You've got real potential to make that money and do all the things you need to do to have a stable life. But if they don't go, what do you do about that? Well, it's voluntary. We can't force people, and nor should we be forcing people to participate. But we weren't even offering it uniformly across the system. So we need to meet people where they are and give the opportunity. And if people want to take advantage of it, we hope that they will because we think that'll be really successful. But we've seen in survey after survey and most acutely in the Prison Research Innovation Network surveys down at Springfield that one of the principal complaints among the incarcerated population is they don't have enough to do. And so if we can provide them productive offerings like vocational training or like greater access to education, another area we're working on, we hope to fill in some of that time with something that's interesting, useful, gets them connected with skills they need and hopefully can use when they get to the community. Representative Bowen. Me again. Seems quieter in this study. I know there's a discussion about, so my history is I used to head up for Montmorets for Women. Oh, and we used to build modular homes at the renewal facility and then at the St. Albans facility. And then everything changed. Positive things about the home building. Yeah, it was a great program. I think that one of the questions I have is how much of the service delivery will rely on DOC staff? And I ask this question because I think that community providers are really important because they help provide a link to community resources and to employers. And what I would hate to see is a system that is reliant on DOC workers and try to develop that internal capacity when there is capacity outside. And the reason I bring up community-based organizations and not just employers is that oftentimes community-based organizations are better able to meet people where they are, help problem-solve if there's a problem that comes up in the midst of the training, and to connect them, those folks, to resources once they leave prison. And so I'm just, I'm really making a statement, I guess, but I did, I was curious about whether your vision includes that kind of collaboration. Yeah, it's a really important question. I think our goal is to increase our reliance or partnership with community-based providers and outside private or public employers. I think you probably know this well. At the Women's Facility in South Burlington, there is a robust support network in place of community providers, Vermont Works Women, but also several others who provide that kind of fabric of support to the population there. That's not replicated in the men's facilities around the state. And so one way that we can build some of that fabric in is through our vocational training programs. And you're right. I mean, I think one, we have a staffing crisis. So we don't have a lot of available staff to dedicate anyway. We do have vocational staff currently that we plan to keep to help provide kind of the foundational elements here, but it will be a reliance on community partners to come in and support this work, absolutely. And I think there's force multiplying value there that's good for us because we don't have a ton of staff, but also there's intrinsic value in bringing those partners in to help work on these programs. Thanks. I think that concludes your walk sheets, which we've got the big stuff out of the way first. If you want to, but only if you want to, and I think I'm seeing Representative Harrison, is that your hand? Oh, that's good. You're just in? How far? May I ask? Yes, please. Okay, so we sort of, I think talked about it, but maybe it didn't register with me. Your current year budget, we included money in the BAA for the site agreement to take care of the contract changes with your staffing issue. Did you say that that is built into this budget for fiscal year 24? The side letter is captured in BAA. Okay, but how far does that take us? The current side letter goes through the end of March. This March? Right. So there's no assumption of going forward in fiscal year 24. That's not reflected in the budget, no. So if you do negotiate something with the union, that would have to be addressed either. Probably through what we finished this before and next year's BAA, right? All right, I just. Wanted to be clear. Yeah. No, that's exactly right. All right, thank you. All right, we'll do a little on that. Do you want to go back to the first page, just a little bit of your highlight? Sure. Yeah, happy to talk about this. It'll be a little abstract, but if there's specific areas you want to talk about. So the department, you know, we conducted robust staff surveys last year to understand what are the things that motivate the staff? What is the mission they're attached to? And we use that work to start to frame out what our priorities will be for the year ahead. We centered on four key areas that I think we need to absolutely get right. And if we don't, we're not gonna be able to achieve our mission. Those areas are outlined here on the summary and highlights section. They're staff and staffing. And we think about those as two different problems that are related. The staff are human beings that we need to take care of and we're responsible for and need to make sure that they have productive, happy experience while they're staff members in DOC that we're giving them new skills that we're investing in the whole person that they're well, healthy. And the staffing situation is resolving what is a systemic understaffing crisis within the Department of Corrections. And those things are related, but they're also separate because I think too often we worry about the staffing problem and forget to take care of the people. The second priority that we have listed here is health and wellness and that's related. It's, but it's both sides of our equation. It's our staff, but also our incarcerated population. Making sure we're providing community standard of care that we are taking care of people's emotional needs, physical needs, that the environments that our staff work in are healthy and conducive to their work. And it's really that whole package of wellness and health issues. The third topic is diversity, equity, and inclusion. And then we add in this idea of ensuring that DOC is a just system. And that's really important to us, making sure that we don't have disparity in adjudicating disciplinary reports with incarcerated individuals, things of that nature and really focusing in on that work. We know nationally that BIPOC community members are disproportionately incarcerated at a higher rate than their white counterparts. All of this work I think is captured here and an area that we really want to spend time focusing on. And also funding with our community partners as we did last year through the community justice centers and put money aside specifically for diversity, equity, and inclusion work there. And the last part is modernizing the system. And that's modernizing our technology. I think that's the first place people turn, but it's also modernizing our practice and making sure that we are the cutting edge, corrections agency in the United States because we have the opportunity to do that here in Vermont. We have the political will, we have the policy interest. So it's making sure our training is the best training that we can provide our staff. It's making sure that the models, transitional housing is a good example of this. We have, I think the nation leading transitional housing model for getting people transitional housing as they reenter the communities. Making sure that those practices are up to date and getting us ready for our future. Those four. I'll be right there for a second representative. I'm happy to wait. I just, I have some questions around some of the data. And I'll just signal when you're talking about the modernization of being sort of the best in class, if you will, it's tied to that. But let me know when it's the right time to jump in there. I was simply gonna say these four areas kind of encapsulate the direction that we want to funnel all of our work in the year ahead. Because I think if we can hit on these points and succeed in these areas, we'll be in pretty good shape or at least we'll be on the right path. But I think maybe now is a great time for your question. So this is a, I'm gonna start by not a question but and not intended to be a lecture at you, but a comment about data. And I think it was in our committee letter or chair letter to the administration that it's a challenge that we have around how we tell the stories with the data that we provide. So you have some nice data charts here and there's something missing. I think it speaks to what you just said, which is why my hand went up when you were saying it, which is that there's no external context to your data. Okay. So for instance, you had a 4% increase in the monthly percent of incarcerated individuals placed in segregation over the time period from 9% to 13% was that expecting? Is that a pattern that's happening across corrections nationally and you're just part of that this is something tied to where we are culturally, the pandemic, something, right? Or did we change our policies or were we expecting to go down and we went up? So without that context, that number is relatively useless for us as evaluating whether you're meeting the goal that you just stated and one other example, 45% of returns to incarceration from technical violations. So to me, that feels like, I'm gonna figure this out. I was on corrections eight years ago, we were talking about technical violations and returns and I don't remember what the number is there, but I don't know what your goal is. I don't know what you think is reasonable to attain. I don't know what the obstacles are that are preventing you from achieving that goal. To me, technical violations on the face of it should be near zero, given all of the overarching approach. I don't mean that it has to be zero, but like it should be in that direction, not half. But I don't know and I don't know what's reasonable to how to evaluate from a budgetary perspective, but also then for our policy committees from a sort of strategic policy perspective, how to make sense of any of these numbers. Yeah, your point's well taken. I think some of that could be the feature of this document itself because we do have, especially when we talk about violations up for a low, we do have decks totally dedicated to measuring and showing comparables over time, showing what violations were for if it was one or multiple. And that's a lot of the work that we've done with the Centers for State Government through the justice reinvestment initiatives. But your point's well taken and providing some additional context here. That would help guide you. We would be happy to do that. Yeah, no, eight years ago it was a 200 page presentation for you that, but many of those data slides at the time were mashed together. And the gold standard in data visualization is that the representation of the data should allow you to understand what's going on simply. So it's not actually that you need necessarily more detail is that you need more context. And so for that 45%, if that was its own slide, trend line, external benchmark, department goal, and what do we think is going on causally relative to where that curve is going up or down relative to our goal, that would tell us a tremendous amount of information. And it doesn't have to be all that complicated, right? And so thank you for doing this. And also, I don't have an extensive it. So now it's literally. I appreciate your comments because one of the things I noticed when I came into this role is we did not have a robust data and research team in place to be able to do the type of work you're talking about. And it's so critical in the criminal justice space. So one of the investments we made was building out our data and research team. When I started, we had one and a half people dedicated to data. Now it's a team of four. They're aligned to the commissioner's office. They report directly to us so that we can really do the type of data work you're talking about. But they're in their nascent stage. So it's going to take us a minute to get this all right. But I appreciate your comments and they help us to kind of guide us down that path, which I think is where we need to be. And that's part of our modernization. And I would submit, thank you for that. And I would suggest actually that you take your three most important better off measures and send them back to us with some of this information. Whatever you think the three most important are for us as appropriators and as legislators to understand where you're going and why. And that's a good message. We absolutely can do that. And hold them out as individual slides and do that. Thank you. I'm done, sorry. I'm just kidding. Definitely our data guy. I know, because I know personally too, is very concerned about your workforce in your world right now. Because you can't close your doors. That's right. I substitute teach at the elementary school. I said, but there's a couple of places like that. The hospital corrections and the schools that just can't close. The two of them I'm not going to work at right now. But schools and hospitals get a lot of attention and corrections that's left behind and people forget that our staff is toiling every day and night, every day of the year to get this right. And they do just a remarkable job. Extremely worried about the, I think there was a rate of suicide prevention that was just as high with the staff as it was. I've got representative Blumley and then representative Harrison. I will stop talking. This is just a point of clarification. So in one of the initial pages in the report do you go to 37% in the imprisonment rate from 2013 to 2002. And then so I'm looking at this 1354 number that's, I can't see a page number, but it's where you have the population report as of April 31. Yeah. So I am assuming that this 1354 represents it is 37% less than our high in 2013. Yeah. And does that translate into open beds in the system? Not necessarily. I mean, to an extent, yes, of course, right? We have 400 or whatever, I don't know, I'm a lawyer by education. So math in public is a scary thing for me to do. But a few hundred folks are not in the system, necessarily that equates to we have more beds. I think what the story doesn't tell there to our data experts point is we were oversubscribed today on our beds in Vermont. We were way oversubscribed in 2013. And to the tune of, and I don't know what the out-of-state number in 2013 was, but there were periods where we had 700 people out-of-state and today we have 125. Yep. And we're still tight in every facility. There's no wiggle room. So there are more beds available than there were in 2013, but those beds are already taken up. And the number of people who are there for technical violations, what does that number? We could probably post that out. Anyway, it's okay. We can, I can. This is. I mean, I think the overarching story there is justice reinvestment majorly changed the way we think about technical violations and the way we think about any type of furlough violation. We created an objective table of a penalty so that we could try to eliminate disparity and it goes up, the more technical violations or the more serious, the higher the sanction, but low infrequent technical violations don't result in incarceration by and large in the system any longer. And I think that is some of the best work that came out of the justice reinvestment initiative. Okay. Thank you. Representative Harrison, I'm going to represent you, Joel. So following up on representative Lino and having some context of, you know, data, what have you, if we compare how we, you know, what our costs are all in costs for inmate versus, you know, other rural states, you know, we talked about Montana earlier. I mean, it wouldn't be fair to compare us within New York, which they probably have mega prisons. Sure. I'm just, you know, I'm just curious, are we being efficient? Are we too low, too high? I've just, do we ever look at that? That's a good question. So we do have a rough kind of number for what it costs to incarcerate an individual in Vermont over the course of a year. I'm a little reticent to use those numbers for it, frankly, because I think there's a lot more to that story, but to answer your core question, it's also extremely difficult to compare us to other systems because Vermont has some unique features. It's a unified system. So we have every detainee in the state as well as every sentenced individual. There's only five other states that have that across the country, Delaware, Connecticut, Alaska, Hawaii and Vermont, those are the ones. So those are maybe the closest we could compare to, but they also have very different populations. I'd say Delaware is probably the closest to Vermont is in terms of size and scope of responsibility. And we can ask them if they have a similar number or what their methodology is to reach the cost per incarcerated individual and compare those and share that with you. But those are pretty challenging comparisons to make as far as the data goes. Again, the level of service, I guess, is certainly different. I understand a lot of qualitative changes. It's just like to know we're in the ballpark or other states are a lot more efficient or less efficient. And I understand it's not easy to compare to a qualitative. But no, it's a valid question, certainly. Thank you. Representative Jones. Good morning or afternoon? Thank you for coming in. I have two questions. One as a follow-up on the work program. And I appreciate the opportunity that you're providing is based on an application process, as I understand. And the person who will be applying is under their own direction to apply for them. Do we offer a minimum wage for that work? And if so, I can envision that, especially when you look at recidivism rates and how housing and employment are critical components to ensure a reduction in the chance of recidivism. How important that work experience is in developing their skills as you described. And I can only imagine a minimum wage that could be set aside to provide that kind of support after incarceration will be helpful for that person. Can you describe how we provide a wage? Yeah, it's a very good question. So there's the industries program and folks who participate in that program do get an hourly wage. And I don't know the number off the top of my head, but we can certainly provide that to you. It's lower than a public income community. There's also jobs within the facilities. For example, people work in the kitchen, help prepare food, they get paid an hourly rate as well. So those are separate, but I wanted to capture, we captured the different ways that folks can recruit from on the inside. Those wages are significantly lower than they would, if you were a prep cook in a private business in Brunton, you'd be making a totally different wage than somebody working in one of our correctional facilities. But I think as we look to the vocational training conversion that we're going through, how we compensate folks who participate in those programs is still up for consideration and up for conversation. I think that's an important area that we have yet to kind of flesh out as we design these programs. Cause I think it's an important thing. You're right that it's nice if you leave the facility with some cash, certainly to help you get on your feet. But also we want to make sure that we're providing what's appropriate to them. Okay, yeah, more information would be helpful. Absolutely. And then a follow-up question. Yesterday we had the executive director for the commission on women. And she mentioned one of obviously the additional challenges that face women who are incarcerated. I know you're dealing with a breadth of challenges, but obviously one of them is in particular for those inmates that have families, children. And there's been research and studies looking at campus-based solutions for housing inmates may be more suitable and that's in terms of best practices, having the right kind of institution to be able to support those needs. And I know we've been talking about this idea for quite some time now. Where are you in that thinking in terms of moving the state towards a facility that could provide more of a standard-type of facility for women in those challenges? Yeah, that's a great question. So we are in the process of not putting a shovel in the ground right now, but designing and preparing to build a new women's facility. Actually the two facilities, detention side, the more secure setting and a reentry side that is much less secure and much more designed to support folks as they are reentering the community, connect them with jobs. One of the models we're using for that is the state of Maine who does this very well and has for a number of years now, they have a secure facility and they have a reentry facility. The reentry facility has no locks, there's no fence around it. The women leave during the day to go to jobs, they come back in the evening. It resembles when you walk through it or resembles like a college dormitory essentially. And so a totally different feel than if you were to walk through our women's facility in South Burlington right now. So that is the direction we are going. I think there is a lot to be said about the environment that people are incarcerated in and what impact it has. And so as we design for the future, knowing that when we build a prison in Vermont, we keep it for 50 years, we need to be really thoughtful about building a facility that's trauma-informed that's responsive to the gender needs of women that it's light and more therapeutic as much as we can make it therapeutic. And so all of that is being considered, we have a stakeholder group of outside providers and volunteers who are weighing in on that process and helping to inform decision-making. And I think that process is going well. We still have a ways to go. I think we have one more major design phase after our current phase that we're in where they'll actually start mapping out the building and then we'll start down the road of actually placing it and constructing it. Well, thank you because I for one in this committee very much appreciate planning. Yes. And I've learned that through, you know, through the osmosis here. Yeah, it can be a bit daunting at times when you have three or four design phases, but yes, you're right, it's important. And we've just uncovered interesting things in that process where the architect will tell us, well, we think it should look like this and our security staff will say, well, that doesn't make any sense. And then the outside groups say, you know, here's how you would put provider space in there or recreation space or any other case, maybe. So that's been very helpful. Thank you. I look forward to hearing more of that. Yeah, absolutely. Thank you. So I'll just wrap it up and thank you for your data. I'm looking at it too, no one stands up to me, but it's not really a surprise, but I mean, the total with the grand total is the age cohorts that I actually expected to see the population older. And it's surprised me a little bit at the range. And then when I look at here, the data that you've provided around people that are in correction facilities, by correction facility and by crime, very interesting. Yeah, very interesting. And that has all changed in the last couple of years. So I mean, we've had major shifts in the population that we're serving, which I think is quite interesting as well. Yeah, because I know that some of the memory care pieces for some of the elderly was problematic. Well, anyway, let me wrap up with this by just asking you what is that you're the most proud of in the last year, and then what is your biggest challenge? Those are tough questions. The biggest challenge is far and away our staff and staffing issue, trying to really commit and invest in our people and then similarly doing the recruitment and retention work that's necessary to fix our staffing crisis, which we have. That is also probably the area that I'm most proud of. I mean, I think we sat down and launched, designed and then launched a plan last year and in the fall, we call the stability and sustainability plan. And it really took a new approach to tackling this problem. And we saw a 5% decrease in our vacancy rate amongst our security staff positions since launching that plan. That's a big deal to us. And we are available. We're not perfect. I'll be the first to admit and we have not gotten everything right, but we're trying to learn from our mistakes and keep improving it and keep adding to it. And we hope to see those trend lines. Well, thank you. Yeah. Budget is represented in schools and so we'll filter our questions so that you don't have to hear from all of us for representative school. Great. Thank you. Thank you very much.