Senate Health & Welfare receives primer on Vermont health care system, Medicaid and workforce pressures

Nolan Langwell of the Joint Fiscal Office told the Senate Health & Welfare committee that his “health care systems 101” briefing is “meant to lay out the landscape and also help level set” as lawmakers prepare for policy work this session.

The presentation walked committee members through Vermont’s providers, payers and regulators, with repeated cautions about outdated public data and several policy points the committee may revisit during Medicaid and budget deliberations.

Langwell said the state’s population increased from about 623,000 in 2019 to about 647,000 in 2023, and that an aging population is driving higher per‑person health costs. He described Vermont’s hospital system, federally qualified health centers, mental‑health providers and long‑term‑care capacity, then turned to payers and public programs.

Hospitals and providers

Langwell told the committee Vermont has 14 hospitals, including the University of Vermont Medical Center (UVMMC), the state’s only level‑1 trauma center. He said UVMMC accounted for the largest share of hospital patient revenue and for a notable share of emergency visits and inpatient days. Langwell said hospitals’ combined operating expenses reported in the most recent publicly available dataset were about $3.5 billion and cited roughly 238,919 emergency department visits in the referenced year.

Langwell said federally qualified health centers (FQHCs) play a major role in primary care: there are 11 FQHC organizations operating about 92 sites statewide and serving roughly 198,000 Vermonters, according to the materials he used.

On behavioral health, Langwell noted designated agencies and specialized service agencies (DAs and SSAs) administer community mental‑health services under state statute and that the Vermont Psychiatric Care Hospital in Berlin is the state’s primary involuntary psychiatric facility (about 25 beds, Department of Mental Health operated). He also named other designated psychiatric inpatient units operated by hospitals in the state’s system.

Workforce pressures

Langwell described workforce constraints across professions. He cited approximately 1,400 physician full‑time equivalents (FTEs), with a disproportionate share of new physician growth occurring in specialty care rather than in primary care. He said many licensed clinicians are near retirement age: about 65% of physicians are 45 or older and 26% are 60 or older. He gave similar age and supply details for physician assistants, advanced practice registered nurses (about 868 licensed APRNs, with roughly 84% actively practicing) and dentists, and flagged that Vermont has no in‑state physician assistant training program.

Payers, market structure and coverage trends

Langwell summarized Vermont’s payer mix: commercial insurance covers a large share of working‑age Vermonters, but government payers (Medicare and Medicaid combined) have grown as a share of total coverage over time. He said roughly half of children are enrolled in Medicaid programs because Vermont’s eligibility for children is more generous than for adults.

On the private market, Langwell said Blue Cross Blue Shield of Vermont and MVP Health are the largest carriers in state; he noted Blue Cross Blue Shield is Vermont‑based and MVP is based in New York. He said about 74% of the commercial market is self‑insured (typically large employers that bear claims risk and often purchase third‑party administration), a segment the state cannot regulate because federal law governs employer self‑insurance.

Langwell gave enrollment snapshots: about 37,000 people covered by small‑group plans and about 34,000 in individual plans, and said roughly 82% of people in the individual market receive some form of federal or state premium assistance. Using the most recent survey data he cited (2021), he said the uninsured rate was about 3.1 (about 19,400 people) and that among uninsured Vermonters, many were eligible for Medicaid, eligible for a subsidy through Vermont Health Connect, or had access to employer coverage; cost was the most common reason cited for remaining uninsured.

Medicare, Medicaid and Vermont’s waiver

Langwell emphasized that Medicare is a federal program and “we have no control over it,” and contrasted that with Medicaid, which is a joint state‑federal program over which Vermont has substantial policy and budgetary authority.

He described Vermont’s use of a Section 1115 demonstration — Global Commitment to Health — which the state uses to administer many Medicaid functions and to obtain federal matching dollars for programs the state prioritizes. Langwell said Vermont is among the states that have used waivers to expand covered services and to finance investments such as community and behavioral‑health supports that might otherwise be paid for solely with state dollars.

Langwell also noted the state’s population of “dual eligibles” (people covered by both Medicare and Medicaid), which he said totals roughly 22,500 (2024 figure). He told the committee the Agency of Human Services spends in excess of $600 million a year on services and supports for that group (a mix of state and federal funds and other appropriations).

Budget context and data caveats

Langwell repeatedly cautioned that much public health data lags, noting key datasets used in his slides were several years old and that the Green Mountain Care Board’s expenditure analysis had vendor and staffing delays that left the most recent complete public dataset behind schedule. He asked committee members to expect updated survey and expenditure releases later this year if pending budget adjustments are approved.

He also highlighted the magnitude of Medicaid in the state budget: in the fiscal figures he cited, Medicaid accounted for about $2.3 billion of roughly $8.56 billion in total gross appropriations (all funds) referenced in the slides used for the briefing.

Why it matters

Langwell told senators the briefing was intended as a reference so legislators have a common baseline before debating bills that affect hospitals, insurers, Medicaid eligibility or provider workforce. He repeatedly said the presentation should be used as an “encyclopedia” to revisit specific figures and to inform follow‑up requests for more granular data.

Committee members asked follow‑up questions about emergency‑department utilization, non‑emergent ED visits, availability of more recent survey data, reporting for health‑care‑sharing ministries and the state’s ability to influence self‑insured employer markets. Langwell advised that some of those data requests would require extra staff or vendor work at the Green Mountain Care Board or the Department of Financial Regulation and could be produced on request.

Ending

The briefing closed with Langwell offering to return for a deeper dive on Medicaid and financial details during the committee’s next meeting; the committee took a short recess to move to later agenda items.