This spring, the Vermont General Assembly rejected an ambitious bid to expand and improve peer-based mental health services throughout the state. Neither of the two complementary bills drafted by Vermont’s five peer-led mental health organizations – Alyssum, Another Way, MadFreedom, Pathways Vermont, and Vermont Psychiatric Survivors – passed in any form during the legislative session.

Introduced by Sen. Cheryl Hooker of Rutland, S. 194 and S. 195 aimed to establish, respectively, a new network of seven peer respite centers and a statewide certification program for peer support specialists. The respites would have replicated the model developed by 11-year-old, Rochester-based Alyssum, a peer-operated overnight program in a homelike environment, to provide “person-centered crisis support,” as the legislation put it, in locations stretching from Bennington to the Northeast Kingdom. At the same time, the Vermont Department of Mental Health (DMH) would have contracted peer-led organizations to set official standards for peer support and to train, test, and roster peers.

Journeying between four committees in the Senate and House, the legislation drew support from peers, psychiatric survivors, mental health consumers, executive branch officials, and legislators themselves, in addition to facing various doubts and criticisms. Ultimately, a group of senators balked at the price tag: $2.525 million in total, reduced from $4.275 million originally.

The Senate Committee on Health and Welfare received the first testimony in late January, with advocates joining Commissioner of Mental Health Emily Dawes to endorse the bills. Stumbling blocks began to appear soon thereafter.

In February, the Office of Professional Regulation (OPR), which licenses Vermont’s psychoanalysts and psychologists, declared its availability to “assist with credentialing peer support specialists.” OPR’s process begins with a “Sunrise Review,” which, in the words of Director Lauren Hibbert, assesses “whether it’s necessary for the government to intrude into the marketplace.” Staff Attorney Lauren Layman told senators that OPR could submit a report by Dec. 15, putting the legislature in a position to craft a peer certification law in 2023, rather than in the current legislative session.

“This is a new concept to us,” Layman said. “When reading this bill, initially it was unclear to us whether there would be some form of psychotherapy being used by peers in support of other peers.”

MadFreedom founder Wilda White argued against giving OPR a primary role in the certification process: “This is something that is happening in 48 states, plus the District of Columbia. Most of the states do not have their office of professional regulation involved in this, for the very reason that, for peer support to work, it needs to look very different – because it is – from the medical profession.”

On the other hand, Agency of Human Services (AHS) Policy Advisor Shayla Livingston advocated for OPR’s participation in the development of the certification, and for “considering a framework for respite beds” after the establishment of the certification program. She also floated a potential alternative route that would, instead, look at a set of six programming proposals for “unlocked community residences” received last year by DMH and conceived largely by the Designated Agencies.

Finally, Livingston suggested that funding, even for the certification program alone, could present a problem. “I do just need to say it’s not in the governor’s budget right now, so I’m not clear where that money would come from. At least in the department’s budget, there is not room for that,” she warned.

Sen. Ginny Lyons, chair of the Committee on Health and Welfare, encouraged OPR’s involvement but expressed a desire to move forward on both the certification and the peer respites without delay. “Every time we take a step forward, we somehow take two steps back with a working group or a report or something,” she complained.

In March, Hooker presented the committee with a new draft that combined S. 194 and S. 195 into a single bill. The updated version of S. 195 codified a collaborative role for OPR in the development of the peer certification, but its timeline did not leave room for a Sunrise Review. It also reduced the immediate cost of the legislation by lowering the number of new respites to four in the near term. The other three would appear in 2025 and wouldn’t require an appropriation until then.

Unanimously, the committee approved the legislation and passed it on to the Senate Committee on Finance, which forwarded it without complaint to the Senate Committee on Appropriations. Here the bill – or the substance of it – ran into a wall.

Unlike the Committee on Health and Welfare, the Committee on Appropriations took no testimony from advocates. Instead, it used a single 30-minute hearing almost exclusively to articulate its resistance. One member of the committee, the powerful Senate President Pro Tempore Becca Balint, who gave the keynote address at Mental Health Advocacy Day this year, was not in attendance.

Sen. Philip Baruth wondered what would happen “if somebody has a break and becomes violent” at a peer respite. “What does the security look like?” he asked.

Hooker, the bill’s lone representative, explained that peer respites operate as voluntary programs. Sen. Jane Kirchel, the committee chair, indicated a preference for prioritizing funding for locked capacity in the mental health system, bringing up the 1980 and 1991 murders allegedly committed by Vermonters Louis Hines and Elizabeth Teague prior to their involuntary commitments.

Sen. Dick Sears shared similar sentiments, lamenting the loss of the Vermont State Hospital in 2011. “We haven’t solved our bed situation for the mentally ill since the Irene closure, and even before that it was a crisis,” he said.

“I understand the value of peer support,” Kirchel professed. “We just haven’t figured out how much money we have. And we might have less, depending on what the committee next door decides relative to some of their tax reduction proposals, because the House actually reduced revenues by about $50 million.”

Hooker sought to persuade the committee that a peer respite “pays for itself” by diverting patients from expensive emergency rooms, and that it is likelier than inpatient care to help its guests avoid costly hospitalizations in the future. But the question of money persisted.

Part of the rationale for S. 195 had emerged from the Centers for Medicare and Medicaid Services (CMS) policy to permit states access to federal dollars for peer support as long as they’ve implemented certification programs for practitioners. This benefit – which, following an agreement between CMS and AHS, would allow peer supporters in Vermont to bill Medicaid insurance for services provided to their clients – represented a potential problem in Kirchel’s eyes.

The “Global Commitment waiver” that structures Vermont’s Medicaid program also imposes a financial cap on federal contributions. “It’s very close to being hit,” Kirchel cautioned.

Amid the perceived squeeze, Sears pointed to what he saw as a competing imperative to raise Medicaid reimbursement rates for cash-strapped Designated Agencies. “I certainly agree with Senator Hooker that we have a crisis in mental health, but that is partly exasperated by the fact that we can’t hire workers in our Designated Agencies,” he opined.

At a subsequent hearing, the Committee on Appropriations – again, without Sen. Balint – recommended a version of S. 195 that eliminated the new peer respites completely and stripped all of the funding for peer certification. Even so, the text of bill still mandated the certification program.

Upon receiving this S. 195, the House Committee on Health Care discovered that, thanks to the previous change, DMH had no means to pay for the three contracts with peer-led organizations that the legislation would compel it to enter for curriculum development, peer training, and the issuance of certifications. On April 21, the committee proposed a strike-all amendment.

In the annual budget adjustment, DMH had secured funding for a $30,000 grant that would convene stakeholders to “draft a recommended work plan” for the future implementation of a peer certification program. Out of a concern that dropping the defunded legislation altogether would send an unintended message of opposition to the notion of peer certification, the Committee on Health Care instead crafted a largely symbolic bill endorsing DMH’s preexisting intention to issue the grant.

On April 5, Vermont’s five peer-led mental health organizations had written a letter to the committee, urging it to restore S. 195 to the Senate Committee on Health and Welfare’s version. Once it had become clear that the funding in that draft would not return, however, they sent another letter asking the legislature to abandon the bill and to allow them to “work cooperatively with DMH to develop and implement a statewide peer certification program outside of the legislative process.”

When S. 195 circled back to the Senate Committee on Health and Welfare, its members heeded this request. The bill died in May.

DMH’s interest in implementing a peer certification program had preceded S. 195. Before the House Committee on Health Care on March 31, Deputy Commission Alison Krompf mentioned that DMH and AHS had previously discussed a shared aim of petitioning CMS for a Medicaid state plan amendment to add peer support among Vermont’s covered services.

“That’s something we were planning on working towards anyway,” she said.

Pin It on Pinterest