Overview of the State

 

VT is a scenic and mountainous state bordered on the north by Quebec, Canada, on the east by NH, on the west by Lake Champlain and New York State and on the south by western Massachusetts. Vermont’s overall population is 647,064 (Census population estimate, 2022). VT is designated as a rural state, estimating that nearly two-thirds of its residents live in rural areas; there are no towns with more than 50,000 residents. Vermont’s land mass is small – 9,216 square miles – and averages 70 people per square mile. Composed of 14 counties with 255 municipalities (towns, cities, unincorporated areas and gores), Vermonters are governed at the state and local (but not county) level. More than one-quarter of all Vermonters live in Chittenden County. Washington County, where the state capital Montpelier is located, is the next most populous with less than one-tenth of the state’s population, and Rutland County is the third largest. The counties that make up the Northeast Kingdom – Caledonia, Essex, and Orleans – are the least populated and most rural.

 

These demographics strongly influence the way in which MCH services are delivered and how Title V planners address statewide policy and programming to improve health outcomes. Residents of rural areas tend to have lower incomes, fewer years of education, use public health insurance or have no insurance, and live farther from health care resources than their urban counterparts. Income is the most common measure of socioeconomic status, and a strong predictor of the health of an individual or community. The lower the income, the less likely it is that a person will have a healthy diet or regular physical activity, and the more likely they will smoke. This leads to a greater likelihood of adult conditions such as depression, obesity, asthma, diabetes, heart disease, stroke, and premature death and is also a risk for poor birth outcomes such as prematurity and infant mortality.

 

VT is aging faster than other states. In 2021, the median age of Vermonters was 42.7 years, compared to the national median of 38.4 years (ACS 2017-2021 5-year estimates). And the state/national age gap is widening, from about two years in 2000 to over four years in recent years.

 

Vermonters come from a wide range of racial, ethnic and cultural backgrounds, including African Americans and American Indians, many of whom are descendants of the original Abenakis. Many more recent residents come from Africa, the Middle East, Asia and Eastern Europe – and a Hispanic/Latino population from Mexico, Cuba and the Americas. While Vermont’s racial and ethnic minorities, at 8.1% of the total population (ACS 2017-2021 5-year estimates), are proportionately small compared to the rest of the U.S., the percentage of people of color has doubled over the past 15[KM1] years. This includes approximately 8,200 who identify as Black/African American, 1,500 as American Indian/ Alaskan Native, 10,800 as Asian/Pacific Islander, 13,400 as Hispanic, and 21,600 people of two or more racial groups.

 

Some of the growing diversity across the state is due to immigration from other countries, from a variety of regions around the world, including Africa, the Middle East, Asia, and Eastern Europe. Since the start of the state’s refugee resettlement program in 1980, between 7,500 and 8,000 refugees have arrived in the state, some of whom are people of color. Over the past year, Vermont has welcomed around 260 Afghan humanitarian parolees, many of whom have arrived as family units with multiple children. Vermont forecasts resettling as many as 500 refugees by October 2023[1]. A second refugee resettlement agency was established in Vermont last year, significantly expanding resettlement efforts and capacity in the state. The addition of a second agency now provides Vermont with access to resettlement services in both northern and southern Vermont. Other refugees currently arriving to Vermont are resettling from Democratic Republic of Congo, Egypt, Sudan, and Iraq. There are fewer than 5,000 undocumented individuals, mostly Mexican and Central American farm workers, according to the Pew Research Center.

 

In VT in 2021, the average per capita income was $37,020 and the median household income was $67,674 (2021 ACS 5-year estimates, adjusted to 2021 dollars), approximately the national average. 10.5% of Vermonters earned incomes below the Federal Poverty Level (2021 ACS 5-year estimates). Low-income Vermonters are more likely to be female, young (age 18 to 34), less educated, unemployed or unable to work, or a member of a racial or ethnic minority. The state’s workforce numbers just over 346,434 (April 2023), according to the U.S. Bureau of Labor Statistics. The state unemployment rate in April 2023 was 2.4% compared to 3.4% nationally. (During the COVID pandemic, as of July 2020 Vermont’s unemployment rate was 8.3%, compared to 10.2% nationally).

 

Education is closely linked with occupation and income. Assessed together, these can provide another measure of socioeconomic status. Vermonters tend to have more years of formal education than people in the rest of the U.S. 93.9% of adults age 25 and older had a high school education or more, compared to 88.9% for the U.S. (2021 ACS 5-year estimates), and 40.9% had earned a bachelor’s degree or higher, compared to 33.7% for the U.S. Educational attainment varies across the state: adults in Chittenden and Washington counties have higher levels of educational attainment, while those in the Canadian border counties have lower levels.

 

While the total population has grown, the population of children (0-17) has fallen since the 2000 Census count of 147,523 to an estimated 116,976 in 2021, which is a slight increase in recent years (114,005 in 2019). Vermont Medicaid covers pregnancy care up to 200% FPL and we have highest first trimester prenatal care rates in the country: in 2020, 84.4 percent of the babies were born to mothers who began prenatal care in the first three months of pregnancy. In general, the percentage of women receiving first trimester prenatal care has steadily increased since 1987. In 2020, 7.0% of Vermont resident births were low birth weight (less than 2,500 grams or 5 pounds, 8 ounces) and 0.8% were very low birth weight (less than 1,500 grams or 3 pounds 5 ounces). The U.S. low birth weight rate for 2019 was 8.2% (2020 Vital Statistics Bulletin). Vermont has very high rates of children enrolled in health insurance (98%--ACS 2021 5-year estimates).

 

Medical and Community Health Service Systems

 

VT is a rural state and relies on an extensive system of distinct center and home-based services throughout the state that are offered by a variety of community organizations. These organizations consist of agencies such as mental health agencies (“publicly funded Designated Agencies”), Parent Child Centers, home health agencies, and community action partnerships. The Department of Health ensures statewide coverage through 12 local health district offices. There are no county Health Departments in VT. For clinical services, there is comprehensive statewide coverage by private providers (the large majority of whom accept Medicaid patients) Federally Qualified Health Centers, and family planning services (Title X) offered by a network of Planned Parenthood clinics.

 

Vermont has a strong primary health care system for the pediatric population which makes us uniquely positioned to leverage high quality pediatric medical home efforts to support Title V efforts. Vermont families have high rates of health care access and a high level of trust in their health care providers. For decades, public health (Vermont FCH) has actively been integrating with clinical medicine as well as conducting dozens of CQI projects to improve evidence-based practice.

 

Vermont children have some of the best access to health care in the U.S., with 97% percent of children ages 0-17 having some type of health insurance, according to the National Survey of Children’s Health. 77% of families report that insurance for their children is adequate, with reasonable out-of-pocket costs, benefits that meet their children’s needs, and the ability to seek medical care when necessary. 92% of children under age six have seen a healthcare provider at least once during the last year for any kind of medical care (2020-21 NSCH). Vermont is a Medicaid-expansion state with generous Medicaid benefits and a global commitment waiver that allows a high degree of flexibility and innovation. Medicaid covers children up to 312% of FPL (birth to age 18); this includes children enrolled in CHIP. Nearly two-thirds (61%) of children 0-5 are enrolled in Dr. Dynasaur (Medicaid and CHIP, combined). All pediatricians accept Medicaid. Vermont’s rate of preventive visits by insurance type is consistent across payors: 89.9% of privately and 80.8% of publicly insured Vermont children had a preventive visit within the last 12 months (2020-21 NSCH).

 

Despite a high rate of Medicaid eligibility and access to pediatric health care for this population, Vermont has significant disparities in health, family and community indicators whereby publicly insured (Medicaid) children experience poorer outcomes than privately insured children, as demonstrated below.

Child Health Measures by Insurance Type (Source: 2020-21 NSCH)

 

	% Publicly	% Privately
Premature birth	8.7	7.6
Medical home	49.1	60.3
Ever breastfed	81.2	91.5
Behavior or conduct problems	18.0	4.3
Developmental delay	12.9	2.7
Child with a special health care need	29.8	16.9
Did not receive needed care coordination	17.9	15.4
Fair/poor mental/emotional health status of mother/primary caregiver	16.0	4.8
Two or more ACES	38.8	12.1
Does not live in a supportive neighborhood	42.0	26.2

 

Of note, a large majority of families with children under the age of 11 (69% of publicly insured and 65% of privately insured) in the NSCH noted that they did not receive care in a well-functioning system.

 

Existing qualitative data, and what can be deduced from quantitative data, suggest that equitable access to high quality care, services, resources, and support is variable, particularly for BIPOC families and children who experience adversities such as poverty, homelessness, or immigrant/ refugee status. The role of rurality in maternal and child health also creates challenges in equitable access to services and care.

 

According to the 2021 BRFSS, more than nine in ten (94%) Vermont adults under the age of 65 said they have a health plan. This is higher than the 87% reported for the U.S. Health care coverage rates among Vermont adults 18-64 were similar in 2019 and 2020 but have slightly increased since 2011 (89% to 93%). Ninety percent of Vermont adults reported having a personal health care provider in 2021, significantly higher than the 84% reported by U.S. adults. Less than one in ten (6%) of Vermont adults said there was a time in the last year they did not go to the doctor because of cost. This is significantly lower than the 9% among U.S. adults.

 

Vermont’s 14 counties are served by eight Critical Access Hospitals (CAHs), one additional Small Hospital Improvement Program (SHIP)-eligible hospital, four regional PPS hospitals (three in rural counties), one VA hospital, and two academic medical centers. These two large hospitals are both Level 1 Trauma facilities, serving most of Vermont, much of western New Hampshire and part of northeastern New York. VT is also well-served by a network of 11 FQHC organizations, operating ~60 primary and ~17 dental care sites in all 14 counties. Mental and behavioral health care is also available on site or through local partners. VT also has 10 Rural Health Clinics (9 attached to CAHs), 7 Planned Parenthood of Northern New England health centers, and a network of 11 free clinics through Vermont’s Free & Referral Clinics (VFRC). Population to provider ratios can be found on the Health Department website at: http://www.healthvermont.gov/systems/health-professionals/shortages-and-designations. Most Vermont hospitals, FQHCs, RHCs, MH designated agencies and many long-term care facilities and other providers are participating in OneCare Vermont, the single statewide Accountable Care Organization (ACO) and Vermont’s All-Payer Model (APM) health care reform agreement with the Centers for Medicare and Medicaid Services (CMS).

 

In 2020, there were 5,127 babies born to Vermont residents. The crude birth rate in 2020 was 8.2 per 1,000 residents, a slight decrease from the 2019 rate. The teen pregnancy rate for ages 15-19 was 10.6 per 1,000, lower than the 2019 rate of 11.7 and the 2018 rate of 12.8. In general, the teen pregnancy rate has been decreasing since 1991. (2020 Vital Statistics Bulletin) Teen pregnancies vary significantly among communities. The 2020 rates show that while Burlington/Chittenden County (Vermont’s only MSA) has a teen pregnancy rate of 6.4 per 1,000 female 15-19 population, rural communities such as Newport (22.4) and Springfield (19.1) have significantly higher rates. New families at risk, defined as first births to single mothers aged less than 20 years with less than a high school education, accounted for 2.6% of first births for 2020 (Vermont Maternal and Child Health Annual Surveillance Report – 2020).

 

Social Determinants of Health (SDOH)

 

Despite high rates of coverage and health care utilization, Vermont children experience concerns related to SDOH that impact their growth and development. Chronic poverty can lead to a wide range of challenges, which negatively affects physical and social emotional health and development and the ability to learn and be successful in school and beyond. More than one in eight Vermont children birth to 5 live in poverty (13.1%). This is further exacerbated by race, whereby 24.2% of Vermonters who identify as black live in poverty compared to 10.3% of white Vermonters.

 

In 2019 in Vermont, 14%, or approximately 15,730 children under age 18, live in households that are food insecure. Of the 14% of children living in food insecure households, 42% are likely ineligible for federal nutrition programs compared to 23% for the nation. The cost and availability of housing is another significant challenge: 54.5% of Vermont households who rent and 26% of households who own report paying more than 30% of their income toward rent or a mortgage. The average Vermont renter makes $13.83 an hour and can afford to spend $719 per month on rent, but the average two-bedroom apartment costs $1,231 per month.

 

Exacerbating the challenges related to food and housing, 70% of Vermont’s children live in rural areas, making access to reliable transportation a necessity. However, low-income families often rely on older vehicles and spend a higher proportion of income on transportation fuels (which is only increasing); 10% for drivers making less than $25,000 per year compared to 5% for drivers making more than $75,000 per year. For those who need or want to get around without a car, existing fixed-route public transit does not exist in many rural areas of the state or when available, it is not flexible enough to consistently get rural residents to work, childcare, and other services.

 

Children and families are grappling with unemployment, access to adequate food, housing, affordable childcare (particularly for infants), and other necessities, all of which have been exacerbated during the COVID-19 pandemic, indicating a need to address SDOH. For example, a 600% increase was noted in 2020 [KM2]in calls to Vermont’s 2-1-1 for families reaching out for support, largely in the areas of food resources, basic needs, and need for problem solving/listening support.

 

Toxic Stress, Child Safety, and Resilience and Early Childhood and Family Mental Health

 

Living in strong families within supportive communities provides the foundation for long-term child health and well-being and the ability to overcome adversity. In Vermont, 22.8% of children under ages 0-17 have had two or more adverse childhood experiences (NSCH 2020-2021). The four most common ACEs in Vermont are: experiencing the divorce of a parent or guardian (16%), living in a home where it is hard to cover basic needs (14%), living with someone with substance use disorder (9%), and living with someone who has a serious mental health challenge (7%). Another indicator of child safety is the number of Vermont children exposed to domestic violence. According to the Vermont Network Against Domestic and Sexual Violence, in 2022 there were 1,160 children and youth connected with an advocate for help related to abuse toward a family member or toward themselves.

 

Vermont’s child protection system has struggled in the past few years—with rising caseloads and increasingly complex cases, including substance use. In 2022, there were 17,725 reports were made to the Child Protection Line—1,218 more than in 2021. Of these reports, DCF conducted over 2,000 investigations and substantiated 593 reports, representing 713 unique child victims. During the last quarter of 2022, there were: 1,067 children in DCF custody, 487 children in the conditional custody of a parent, relative or other person known to the child and family, and 197 families getting ongoing services after an investigation or assessment determined there was a high to very high-risk of future maltreatment (https://outside.vermont.gov/dept/DCF/Shared%20Documents/FSD/Reports/2022-CP-Report.pdf).

 

There has been an increasing trend over time in the percent of behavioral, emotional, mental health, and developmental conditions for Vermont’s young children. For example, the percentage of children ages three to five with a behavioral, emotional, mental health, or developmental condition has increased from 8.3% in 2016-2018 to 16.1% in 2020-2021 (NSCH 2020-2021). However, the availability of early childhood and family mental health services, publicly and privately cannot keep pace. There has been a substantial and growing number of vacancies in the community mental health system from 500 vacancies in June 2020 to 862 in August of 2021. This sector of the workforce makes possible the critical mental health resources, services, and supports for Vermont’s young children and their families.

 

Substance Use

 

Supporting the reduction of women’s use of harmful substances during pregnancy has been one of Vermont’s key public health initiatives in recent years due to some of the highest rates of substance use in pregnancy across the nation. This includes tobacco, alcohol, marijuana, and other substances. One fifth (19.3%) of women smoked cigarettes in the three months prior to pregnancy; yet a significant number (15%) received no guidance from their health care provider to quit smoking. 11.5% of women drank alcohol during pregnancy—with much higher rates of alcohol use in the three months prior to pregnancy (71%). More than one in 10 (11.4%) women report using marijuana during pregnancy (PRAMS 2020).

 

In 2014, Vermont’s rate of infants born with a diagnosis of drug withdrawal syndrome hit a peak rate of 35.0 per 1,000 live births but has since dropped down below the 2009 rates to 18.9 per 1,000 live births, one of the highest rates in the nation (2020 State Inpatient Data). Vermont has built a strong system for pregnant and parenting families with SUD, and specifically Opioid Use Disorder, however, we are concerned with trends we are seeing in data such as Plan of Safe Care notifications which indicate that many families are being missed.

 

Youth Risk Factors

 

Data from the 2021 YRBS demonstrates concerning risk factors for Vermont’s high school students.

 

13%	students drank alcohol before age 13; 12% reported binge drinking in the past 30 days
5%	students smoked tobacco in the past 30 days; during the last 30 days, 16% of student reported using electronic vapor products (EVP)
31%	students have ever used marijuana (20% used it in the past 30 days)
10%	Students ever used a prescription stimulant or pain reliever that was not prescribed to them or used one in a manner different from how it was prescribed
21%	students have ever had unwanted sexual contact; 1 in 13 of those who dated experienced physical dating violence
14%	students made a suicide plan; 7% of students attempted suicide
24%	students reported having sex in the past 3 months; 7% reported 4+ sexual partners in their lifetime and 3% had sex by age 13; among sexually active students: 53% used most or moderately effective contraception; 21% used drugs or alcohol at last sex

 

State health agency current priorities/initiatives

 

VT is a small state, with a culture of collaboration among state government, community agencies, coalitions, hospitals, health centers and health care providers. The Health Department is the single public health agency that serves all Vermonters, with its central offices and lab in Burlington, and 12 district offices located around the state. State health reform efforts have included a focus on promoting health and preventing chronic illness. Public Health is written into the state’s health reform law.

 

Vermont finalized our State Health Assessment and State Health Improvement Plan, which helps us prioritize goals and objectives for health, monitor trends, identify gaps and track progress. The SHA/SHIP use a health equity framework, evaluating FCH (and other health) data by key populations that have experienced historical injustice. The Department of Health used a collaborative process to develop the SHA/SHIP; key department and external stakeholders reviewed health status indicators of Vermonters with the goal of identifying three to five statewide strategic health priorities. The SHIP presents the priorities and improvement strategies agreed upon by multiple public health partners and provides the framework for creating healthier communities over the next five years. Several the outcomes identified for the five-year SHIP are FCH focused, including Optimal Child Development and Resilience. Title V/MCH is perfectly positioned to take a leadership role in the development and implementation of strategies to achieve this outcome.

 

VT public health planning relies on the framework of the Prevention Model, as based on a five-level Social-Ecological Model. This model recognizes that, although individuals are ultimately responsible for making healthy choices, behavior change is more likely and more sustainable when the environment supports individual efforts. Comprehensive prevention and health promotion programs, to be most effective for the long term, and to reach the largest number of people, should address multiple levels of the model. VT public health assessment and actions are also rooted in the concepts of the social determinants of health. The Health Department leadership recognizes that public health efforts need to influence not only health care and health systems, but also areas such as education, early care and education, housing, law, economic opportunity, community planning, transportation, and agriculture.

 

The Health Department emphasizes that public health actions are based in researched strategies and in measurement and accountability. Use of resources from national agencies, such as the Centers for Disease Control & Prevention, Substance Abuse and Mental Health Services Administration, and the Maternal and Child Health Bureau (MCHB) offer resources to programs and policymakers that guide the selection of successful evidence-based interventions. For example, VT Title V has benefited from the technical assistance available from the MCHB Collaborative Improvement & Innovation Network, the AMCHP resource center, and the MIECHV evaluation resources.

 

The Department of Health has a comprehensive performance management framework in place to improve the health status of Vermonters by ensuring the efficacy and evidence base of services delivered. Performance management establishes and manages systems at the Health Department to identify and regularly report on population objectives and performance measures, perform quality improvement activities, and assess and emphasize the need to fund and implement evidence-based practices to change population outcomes. These measures are designed to be evidence-based and describe how the department holds itself accountable to making population-level change. Performance measures are displayed on the Performance Dashboard at: How Are We Doing? Performance Scorecards | Vermont Department of Health (healthvermont.gov). Note that this dashboard is being updated to align measures with Healthy Vermonters 2030.

 

The Public Health Accreditation Board (PHAB) Accreditation Committee awarded five-year accreditation status to the VT Department of Health in June 2014 and reaccredited us in March 2022. With accreditation, the Health Department is demonstrating its commitment to improving and protecting the health of Vermonters and advancing the quality of public health services nationally. The process has allowed our department to assess our strengths and identify areas for improvement to continue to improve the quality of our services and performance. We are in the final phases of submitting our application for reaccreditation. 

 

Vermont’s Department of Health, and especially MCH, has an ongoing commitment to health equity and family engagement. CDC Health Disparities funding, has enabled us to start an Office of Health Equity Integration which is comprised of a Director and community engagement liaisons who play integral roles in addressing systemic barriers both within and outside of state government and building sustaining relationships with community partners based on new models of power sharing. Additionally, many of the divisions, including MCH, were able to hire Health Equity Team Leads to ensure health equity integration throughout our programming and systems improvement. MCH’s longstanding commitment to family engagement is described throughout this application.

 

As Vermont continues to work through and emerge from the COVID pandemic, there is a mountain of work to do. MCH will continue to work in partnership with the Health Department’s COVID leadership, as well as the Agency of Education, Child Development Division, and other partners to provide policy recommendations, guidance, and supports to Vermont’s families and children.

 

State Statutes and Legislation

 

Bill #	Title	Summary
H.222	An act relating to reducing overdoses	The bill increases funding for Narcan to become more available an eliminates potential barriers to the administration of Narcan, facilitates access to SUD medications, ensures access to telehealth options for treatment, codified the decriminalization of personal amounts of un-prescribed buprenorphine and expands the unused prescription drug disposal program, including unused needles and syringes.
H.481	An act relating addressing children and adolescent deaths by suicide	The bill requires schools to provide education and training for school staff regarding identifying and preventing mental health challenges, specifically eating disorders.
H. 230	An act relating to safe gun storage and access to firearms for children	This bill states that an individual can face criminal charges for negligent storage of a weapon if a child or prohibited person gains access to a weapon.
H.89	An act relating to protection of Vermont providers, providing reproductive and gender affirming health care to out of state residents.	The bill states Vermont providers do not have to cooperate with out of state investigations regarding the reproductive or gender affirming care they provide to out of state patients who traveled to Vermont to receive care.
S.37	An act relating to the protection of Vermont providers providing reproductive and gender affirming care.	This bill adds professional protections for Vermont providers providing reproductive and gender-affirming care from medical malpractice insurance rate hikes and from having their medical license revoked for providing these services.
Article 22 of the State of Vermont Constitution	An amendment relating to personal reproductive liberty.	The amendment guarantees an individual’s right to personal reproductive autonomy, to determine one’s own life course and shall not be denied or infringed upon unless justified by a compelling State interest achieved by the least restrictive means.

 

[1] Tan, Tiffany. 2022. “Hundreds of Afghan Refugees Have Been Relocated to Vermont.” VTDigger. September 6, 2022. https://vtdigger.org/2022/09/06/hundreds-of-afghan-refugees-have-been-relocated-to-vermont/.

[KM1]Update?

[KM2]Update?