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 623,657 (Census population estimate, 2017). 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 68 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. Rutland County, the next most populous, has less than one-tenth of the state’s population, and Washington County, where the state capital Montpelier is located, 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 he or she 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 2017, the median age of Vermonters was 42.8 years, compared to the national median of 37.8 years. And the state/national age gap is widening, from about two years in 2000 to five years in 2017.

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 7.5% of the total population (2018 Census population estimates), are proportionately small compared to the rest of the U.S., the percentage of people of color has nearly doubled over the past 15 years.  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. This includes approximately 8,200 who identify as Black/African American, 2,100 as American Indian/ Alaskan Native, 12,600 as Asian/Pacific Islander, 12,500 as Hispanic, and 11,300 people of two or more racial groups. 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. There are fewer than 5,000 undocumented individuals, mostly Mexican and Central American farm workers, according to the Pew Research Center.

In VT in 2017, the average per capita income was $31,917 (ACS) and the median household income was $57,808, approximately the national average. Eleven percent of Vermonters earned incomes below the Federal Poverty Level. 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 346,349 (April 2019), according to the U.S. Bureau of Labor Statistics. The state unemployment rate in April 2019 of 2.2% is lower than the national average of 3.6%.  

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. In 2017, 92.6% of adults age 25 and older had a high school education or more, compared to 88.0% for the U.S., and 38.3% had earned a bachelor’s degree or higher, compared to 32.0% 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 116,825 in 2017. Vermont Medicaid covers pregnancy care up to 200% FPL and we have highest first trimester prenatal care rates in the country: in 2017, 87.1 percent of the babies were born to mothers who began prenatal care in the first three months of pregnancy, an increase from 86.9 percent in 2016. In 2017, 6.7 percent of Vermont resident births were low birth weight (less than 2,500 grams or 5 pounds, 8 ounces) and 1,1 percent were very low birth weight (less than 1,500 grams or 3 pounds 5 ounces). The U.S. low birth weight rate for 2017 was 8.3 percent. Vermont has very high rates of children enrolled in health insurance (98%). All pediatric providers in Vermont accept Medicaid. The 2019 Annie E. Casey Kids Count ranks Vermont 6th in overall child well-being and 9th in the health domain for children and 3rd in family and community rank. The 2019 Kids Count reports that Vermont is ranked 17th in economic well-being. Data from the 2019 Kids Count report shows troubling economic indicators for Vermont:

According to the 2017 Kids Count report (based on 2015-2017 ACS data), 45% of 3- and 4-year-olds were not enrolled in school, including prekindergarten education or kindergarten. Nationally, Vermont has the highest per pupil spending and the lowest student-to-staff ratio. The student population has dropped by 21,000 since 1997 and projections show continuing declines through at least 2030. These projections also indicate that the number of working age adults and taxpayers will decline through at least 2030. These demographics are prompting critical community and state discussions on public school funding and the make-up of Vermont’s rural school districts. According to the Annie E. Casey Foundation, VT has among the lowest percentage of high school students that do not graduate in four years ranged (11% for 2016-2017).

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 statewide system of Planned Parenthood clinics.

According to the 2017 BRFSS, more than nine in ten (93%) Vermont adults under the age of 65 said they have a health plan, in 2017. This is significantly higher than the 85% reported for the U.S. Health care coverage rates among Vermont adults 18-64 were similar in 2015 and 2016 but have increased significantly since 2011 (89% to 93%). Eighty-seven percent of Vermont adults reported having a personal health care provider in 2017, significantly higher than the 78% reported by U.S. adults. Less than one in ten (9%) 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 13% among U.S. adults. Vermont is a Medicaid-expansion state with generous Medicaid benefits and a global commitment waiver that allows Vermont a high degree of flexibility and innovation.

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 12 FQHC organizations, operating ~50 primary and ~12 dental care sites in all 14 counties. Mental and behavioral health care is also available on site or through local partners. VT also has 9 Rural Health Clinics (attached to CAHs), 12 Planned Parenthood of Northern New England health centers, and a network of 9 free clinics through the VT Coalition of Clinics for the Uninsured. Population to provider ratios can be found on the Health Department website at: http://www.healthvermont.gov/systems/health-professionals/shortages-and-designations.

In 2017, there were 5,655 babies born to Vermont residents. The crude birth rate in 2017 was 9.1 per 1,000 residents, a slight decrease from the 2016 rate. The teen pregnancy rate for ages 15-19 was 14.4 per 1,000, lower than the 2016 rate of 16.7 and the 2015 rate of 16.9. In general, the teen pregnancy rate has been decreasing since 1991. Teen pregnancies vary significantly among communities. While Burlington/Chittenden County (Vermont’s only MSA) has a teen pregnancy rate of 7.1 per 1,000 female 15-19 population, rural communities such as Morrisville (29.9), Brattleboro (23.2), Bennington (21.5), and Newport (20.5) 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 3.1% of first births for 2017, slighter lower than the 2016 rate of 3.4%.

Although Vermont has low rates of teen births, high rates of health insurance and access, Vermont is faced with ongoing and emerging economic, social, and health issues that impact the maternal and child health population in significant and troubling ways. Vermonters have among the highest rates of alcohol, tobacco use, and substance use during pregnancy, placing the health of mothers and children at risk. According to the most recent data from Vermont’s 2017 PRAMS: 

Opioid and other substance abuse and dependence during pregnancy is a significant problem in Vermont. The rate of infants born exposed to opioids is increasing in Vermont: 50.6 per 1,000 live births in 2015 compared to a rate of 18.0 per 1,000 live births in 2008, although there has been little change since 2013. The increase may be partially explained by an increase in provider awareness and increased access to treatment. The U.S. rate is calculated slightly differently from the VT rate. When using the same diagnosis code, the VT rate is four times higher than the national average in 2016 (28.2 compared to 15.0 in the New England states and 6.8, nationally) (birth hospitalization data, HRSA). Quality improvement data have shown that the clear majority of women delivering an infant with neonatal abstinence syndrome (NAS) are on Medication-Assisted Treatment (MAT). Eighty one percent of women delivering an NAS infant were on Medicaid.

Vermont’s child protection system has struggled in the past few years—with rising caseloads and increasingly complex cases, including substance use. In 2017, there were:

• 25% more children in DCF custody than in 2013.
• 44% more families getting ongoing services after an investigation or assessment determined there was a high to very high‐risk of future maltreatment.
• 100% more children in the conditional custody of a parent, relative or other person known to the child and family, while DCF remained involved to supervise, provide services and ensure children’s safety
• 56.4% of children ages 0 to 5 are in custody due to a substance use issue (as of November 2018)
• 41.3% of children ages 0 to 5 are in custody due to an opioid use issue, specifically (as of November 2018); this is down from 49.8% in 2017 and 53.2% in 2016

The impact of trauma and adverse family experiences are felt in Vermont, as they are throughout the country. According to the National Survey of Children’s Health 2017, approximately 23% of children and youth in Vermont has experienced two or more adverse family experiences (AFE), compared to 19.3% nationally. While most children fair well, a sizeable number of Vermont children live in families that are experiencing challenges. These challenges have the possibility of directly and indirectly impacting the social-emotional development of children.

Data from the 2017 YRBS demonstrates concerning risk factors for Vermont’s high school students.

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 recently finalized our State Health Assessment and State Health Improvement Plan, which will help us prioritize goals and objectives for health, monitor trends, identify gaps and track progress. The SHA/SHIP use a health equity framework, evaluating MCH (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 MCH 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: http://www.healthvermont.gov/hv2020.

The Public Health Accreditation Board (PHAB) Accreditation Committee awarded five-year accreditation status to the VT Department of Health on June 18, 2014. 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 in order to continue to improve the quality of our services and performance. We are in the final phases of submitting our application for reaccreditation. 

State Statutes and Legislation

Our legislative sessions ended with notable new laws to protect maternal and child health:

• S.86 An act relating to increasing the legal age for buying and using cigarettes, electronic cigarettes, and other tobacco products from 18 to 21 years of age

H.47 An act relating to the taxation of electronic cigarettes

H.26 An act relating to restricting retail and Internet sales of electronic cigarettes, liquid nicotine, and tobacco paraphernalia in Vermont

Taken together these new laws strengthen Vermont’s regulation of tobacco products. Vermont’s new legal age for purchase is 21, electronic cigarettes are now dually taxed, and new restrictions placed on internet sales for e-cigarettes and other paraphernalia

• S.40 An act relating to testing and remediation of lead in the drinking water of schools and child care facilities

Requires lead testing in all schools and child care facilities.

• H.57 An act relating to preserving the right to abortion

This act establishes as a fundamental right the right to choose or refuse contraception or sterilization and the right to carry a pregnancy to term, to give birth to a child, or to have an abortion. 

The legislature and Governor did not come to agreement on bills including paid parental leave, minimum wage, and marijuana regulation (marijuana was legalized in Vermont as of July 1, 2018). These legislative topics will be reintroduced in the second year of the biennium beginning January 2020.