Transcripts For CSPAN3 Mental Health Care 20171214

The Senate Committee on Health Education labor and pensions will come to order. Were holding a hear nothing titled respondinging to Mental Health needs. Senators cassdy and murphy were the leaders in the senate and Mental Health reform and toes reforms were included in our 21st century cures act. Senator murray is not here today and so shes asked senator murphy to fill in for her. And ive asked senator cassdy to chair most of this hearing or at least until 11 45. Ill come back to attend it but think its important they chair the hearings, especially given their leadership in enacting the legislation last year. After our witness testified, senators will have five minutes of questions. Sean lest hadder is by all akounlts a typical busy nashville young adult with a fulltime job who also attends college. Two days before his 24th birthday experienced his first schizophrenic experience and since then admitted five times, spending three weeks receiving psychiatric treatment. He recently rote me saying this may seem slightly depressing but my story does not end there. The doctors and staff i encountered there taught me to live productively again in society. Ive been free in the hospital for a whole year now. Ive returned to work and even paid off car. Im currently enrolled as a junior pursuing a degree in psychology. Sean is one out of nearly 10 million in the United States with a serious Mental Health condition. Without this treatment his story could have had a very different outcome. About one in five adults have a Mental Illness according to the department of Mental Health and Substance Abuse. Thats more than 1 million and over 230,000 have whats considered a serious Mental Illness. Over the past few years this committee has worked in a bipartisan way to update parts, including programs at the Mental Health Services Administration we call samsa for the first time in over a decade. This effort was championed by senators cassidy and murphy as well as collins and other members of this committee they were part of the Mental Health reform act and majority leader mcconnell called the most important Legislation Congress passed last year. Today marked the third hearing on the implementation of of the cures legislation. We hope it updates will help more americans access quality based education and health care. As i said when we begin hearings on the every Student Succeeds act, its not worth the paper prinlted on unless its implemented properly and i intend to make sure it cures act is properly implemented as well. Our focus is to hear how samsa is implementing the Mental Health provisions in cures. Of the 10 million americans with a serious Mental Health iliniln and that includes bipolar disorder, major depression. Millions go without treatment as families strug tool find care for loved ones. Most are provided by the private sector or through programs run by the states. The largest role in the federal government is the amount spent through medicaid and partnership with the states. The federal government also plays a role through samsa, which while relatively small compared to medicate and responsibility of states is quality prevention screenings and recovery services. Tennessee received over 80 million in samsa grants last year. Prior to our wurk federal Mental Health programs had not been updated in a decade and the cord nations was not as effective as it could have been. I hope well learn more about how implementations is going. How has it improved on the best way to assist those with Mental Illness. For example we hope Promising Research and earlyfort vention programs at the National Institutes of health would translate to Clinical Applications and the samsa blocks to states to insure its best meeting the needs of those suffering from Mental Illness. In addition we encourage the adoption of proven scientific treatments. And id like to hear how the agency started incorporate more evidencebased approaches in Mental Health and inhad crease integration between primary care and Mental Health care and insure its comparable for other medical conditions and strengthen Suicide Prevention efforts. Dr. Mccants cats serves as the First Assistant secretary for Mental Health and Substance Abuse. A position we created in the 21st century cures act. New authorities to work with states and federal agencies and help more americans receive the treatment they need. I look forward to hearing about the progress being made to insure more people can receive the help they need and have positive outcomes like sean. Id now like the turn it chairing of this over to senator murphy and then senator cassidy will make a statement. Thank you very much, chairman alexander to both you and Ranking Member murray for holding this important hearing and thank you to senator murray for allowing me to sit in her place and it is indeed fitting were holding this on the oneyear anniversary of president obama signing the legislation that established this new position at the department of health and human services. Dr. Cats is the first in a position long over due. It is also almost five years to the day since the terrible tragedy at Sandy Hook Elementary School when a young man with Mental Illness killed. There is no connection between Mental Illness than violence. We have no more Mental Illness than any other country and and we with people fall through the cracks of our Mental Health care system it can have a tragic impact. Republicans and democrats were able to come together to pass the reform act, it rchts the First Comprehensive authorization of our Mental Health laws. And it couldnt have happened without the bipartisanship of this committee, which is of course a testament to chairman alexander and ranking am ember murray. I think the most important provision is the part that built on the parody and equity act by strengthening enforcement of that law. And there are two recent reports that illustrate how far we need go to illustrate that vision of charity. And the first nation wide charity report which found one out of three respondents had difficulty finding a Mental Health therapy, similarly released a study that found insurers paid primary care providers 20 more for the same care they pay addiction and Mental Health specialists. In many states the disparitities in payment rates were 2 to 3 times greater for people practicing medicine below the neck than those who are practicing medicine above the neck. Fortunately the 21st sevcentury cures law allows on parody. The law also created the role of the assistant secretary to make sure theres one person who is solely focussed on these issues and we codified the role to work closely with you. Other provisions include several Grant Programs to include coordination of Mental Health treatment and the first infant and early child Mental Health grants. And after hearing from consume and we ifcluded new authorization to help patients and clinicians and family members better understand when these disclosures can take place. There are other elements of the bill that will likely come up today. We have to remember none of the programs we authorized in this bill dont matter if it we dont fund them. Congress as an awful habit of talking a really good game on Mental Health and addiction but then never being able to reach our rhetoric. The appropriations bill doesnt yet include funding for programs in the bill we passed last year and even worse the repeal bill would have cut medicaid over time by 800 billion. Medicaid is the nations primary payer for Mental Health treatment. But the legislation we passed is still Ground Breaking and properly funded it will save lives. And so im deeply thankful to the committee for their work in making this bill possible and for calling this hearing and lastly id like to ask unanimous consent that rajing member murrays statement be placed in the record. Without objection. I learned a couple lessons that one when the patient has the power, the system lines up to serve the patient. But what ive also observed is those with serious Mental Illness have no power. Their ability to act upon the resources that are available are lost by it disorder which is in their mind. Now this is not just an experience for a fellow whos worked in a Public Hospital for the uninsured. Its the experience of us all, whether its a family member, an associate. Someone we went to high school with. We all know someone who seemed to have such prommice and that promise was snuffed out by serious Mental Illness and their ability to execute power totally lost because of that. Government has a role and government has a role at its best to help those who are most vulnerable. Theres been a tangle of efforts by government to attempt to help those who have serious Mental Illness. What i was so privileged to work with senator murray and others for the Mental Health bill of 2016 and we created the position that dr. Cats is the first to hold to create the authority to untangle this mess and somehow take this whole mismash of Government Programs and line them up to help those with serious Mental Illness. Were on about it oneyear anniversary of that bill signing. And this is a hearing to look at the effectiveness of this. And let me say sometimes these committees are conon foritative. This is about cooperation. How do we Work Together with this newly created position so that we can better serve those folks who have lost their power for almost anything because of serious Mental Illness . My goal is that when that 24yearold has her first sicaughtic episode, its her last and when shes 50 years old does not look back on that as oo event leading to loss of her family and children and health but rather a distant memory from which she grew and became a better person. That is the goal of all of us. We look forward to your testimony as to how ultimately we restore wholeness and return power to that patient. Now i will make that introduction. Very pleased to welcome dr. Eleanor mccans kats to todays hearing. Shes it assistant secretary for the Mental Health and Substance Abuse administration. The 21st century cures act created the secretary, replacing the role of samsa administrator. She formally served as the chief medical officer for rhode island Behavior Health care in hospitals. Before that served as chief medical officer for samsa. You have five minutes to give your testimony and we shall hear from you now. Thank you so much, senator cassdy, murphy and members of the Health Education, labor and pensions committee. Thank you for inviting me to testify today. One year ago today the Substance Abuse and Mental Health Services Administration has been accurately implementing and for over 25 years ive served people with serious Mental Illness and Substance Abuse disorders. Its such a privilege for me and an honor to serve as the First Assistant secretary for Mental Health. I take my duties seriously. The cures act has asked that assistant secretary look at disseminating research findings, insure grants are subject to performance, consult with stake holders to improve Health Services for those with serious Mental Illness and children with serious emotional disturbance. Part of strengthening leadership and accountability includes a strong clinical perspective at the agency. The cures act codifies the role of chief medical officer and weve tyken that farther to ifclude two additional psychiatrists and a nurse practitioner. A new requirement is the national Mental Health and Substance Use policy laboratory. The policy lab will promote evidencebased practices through models that would benefit through expanding, replicating or scaling evidencebased practices across a wider area. The interdepartmental area was established by the cures act to establish further determination to address the needs of individuals with serious Mental Illness as well as their families. I was pleased to chair the first meeting in august which was attended by key leaders in federal government as well as 14 highly qualified nonfederal members. Its been working within five key areas of focus, strengthening coordination to improve care, strengthening the gap between what works and whats offered and improving care for those involved. Making it easier for developing finance strategies to increase aveilability and affordability of care. As required by the cares act, it will be delivered to Congress Today. We are very pleased to bring it to congress on time and i hope that you will be pleased with it. Ill scratch that question off my list. The cures act reauthorized the community Health Services block grant and the first psychosis set aside. Thats vitally important to insure individuals receiving it, rese receive timely treatment. Theyre better able to live with their illnesses, similar to other Chronic Health conditions. I strongly support assisted out patient treatment or the aot program. Samsa implemented a Grant Program and awarded 17 grants. Theyve partner would the assistant secretary of planning to implement a cross site evaluation which will assess the effectiveness and impact of this program. One very important area it addressed was Suicide Prevention. In 2015 over 44,000 americans died by suicide and there are over 1. 1 million suicide attempts annually in the United States. They activated the prevention lifeline. Its already answered over 1. 6 million calls, surpassing by 100,000 those recorded in all of 2016 and were not done with 2017 yet. Suicide remains the second leading cause of death for those 15 to 23 years old. We memorialized act to reduce Youth Suicide and suicide attempts. At the same time the highest rate is among 45 to 64 years old. Prior to that, there was no program for adults at samssa. Were grateful and for congresss funding of the program in fiscal 2017. As a result we have awarded grants for zero suicide which is a program that implements Suicide Prevention in health systems. It was a key element of the cures act. The National Child Traumatic Stress initiative was reauthorized by the cures act and provided resources to individuals impacted by natural disasters and other traumatic events impacting the health of all americans. Working collaboratively with the office of civil rights on guidance that would clarify permitted uses and disclosures to permit for care givers of adults to facilitate treatment. With the passage of the cures act we continue to recognize the Critical Role of behahiv ill healthpari health parody for all americans. Samp suhas two parody academies in the insurance market, medicaid in the health and insurance program. Its been updated to include information from a public listening system which provides information for individuals who may have experienced a parody violation. Much work has been undertaken to implement the cures act but we know this work is far from over. There are many more individuals and families suffering from substance and mental abuse disorders that need to help. I look forward to help these people and their families and to answer your questions. Thank you. Senator murphy, would you like the go first. Thank you, mr. Chairman. We are very excited you are doing fantastic work in this position. Youve got a lot on your plate but were excited about some of the early deliverables. I wanted to maybe first ask you to talk about this question of integration. Id like you to talk about it work to bring together it rest of our health care system, whether the proper ways to do that are through state governments, new payment mechanisms we could develop through cms to try to marry together these systems. The idea you have one system for your neck down and walk across town to find somebody to treat it rest of your body. Its a slow progression to fix that. In part because of the way that we fund Mental Health and services. So theres at least one Grant Program thats designed to take this on but tell me what youve been doing since youve been on the job to try to promote integration. So thank you for that question. Because i think were doing a fair amount. We have funded programs that there by directional and that was through the cures act. So that Behavioral Health care can be put into primary care settings. We also have a program that again congress brought into being and is in the process of implementation and thats for the certified Behavioral Health centers. They require that both serious Mental Illness, treatment and Substance Use Disorder Treatment as well as physical health care can be in the same setting for individuals primarily diagnosed with mental disorders. So thats very important. We are talking with them about what kind of inovations they might be looking at in terms of ongoing funding. I will personally advocate for the continuation of the ccbhc, the community Behavioral Health program because even though we have an evaluation out, we know that they work very well and work very well because they integrate care and they pay for that care and thats the other thing about the ccbhcs, we have ccms providing payment for services. I think thats going to be very important to establishing these kind of centers. We also work with others providing direct care incloouding a much Larger Organization but we provide a lot of opportunities for training for their providers. Same with indian had health service. And i have also, since i started had my officers make sure these things move forward. Often time they regulate Health Care Centers and their qualified Health Care Centers through different agencies. So when they try to combine they often have simple regulatory hurdles like the number of fire drills are different in the two different locations so when they go on one site, they often are sort of being over regulated and so i hope thats something youll help states try to overcome. One final question on hippau. I mentioned it in my testimony. A lot of confusion as to what clinition kz share with family members and we gave you the ability to develop some new guidance to try to make it clear, i think mostly to survivors when theyre able to share information with a family or care giver. I know youre working within hhs on guidance. But wanted to give you an update on when we might be seeing that come forward. I think it would be really helpful to anybody in the community. So yes, i can definitely comment on that. For one thing today youll get a series of informational documents that further clarify when information can be shared. We spoke i spoke with them actually yesterday. So they told me that would be delivered to Congress Today just as our ismic report is coming today. A few weeks ago the office of civil rights put out a guidance about what can be shared in emergency settings. So one of the big sources of confusion has been when they come in with for example an opioid over dose can that be shared with care givers and loved ones. And often has not been shared because mistakenly they think this is covered by the federal confidentiality statutes. This is not Substance Abuse treatment. This is treatment of a medical emergency and under hippa were able to share that and its also true there are exceptions under 42 cfr and so we have had one guidance go out to track titianers that went out in november. Were working on a further document that will certify in the same document. I like these to be short and easily digested by practitioners. I can tell you last week i was at a National Meeting of Substance Abuse treatment providers and the issue of sharing information was one of their main issues and so i am really grateful to congress for the direction on this. Thank you for taking it so seriously. Thank you. Doctor, im going to ask you to be tight with your answers because i have to lot to ask you. That is great youre coming out with this hipma guidance. Do you have the ability to turn this if to a continuing education credit or a nursing credit because i find those sorts of things can be trees falling in the forest but if you make it a ceu and everybody has to get their credits in, has a little bit more bang. Exactly. And so we have a number of different type of Training Programs at samsa they address a wide variety of topics and the issue of sharing information but will they be specifically be in continuing Education Credits . Absolutely. They offer this add no cost to providers. So we have the providers clinical support system oriented towards physicians, nurse practitioners, pas mainly. But skrou to get your continuing legal credits because its going to be the lawyer theyre calling in the middle of the night saying can i share information and if the lawyer says no theyre not going to do it. Youre right. And i can tell you that they can be a very big barrier to sharing information. Lawyers a problem cant imagine. But anyway. Our chief medical officer one of the things shes working on is developing a network with hospitals and the hospital associations to identify these issues. We have reported requirements. And clearly you got to measure or else its money wasted. How are you measuring compliance by the states concerned with reporting and how well states are performing when they decide to award a grant. So we have a required government reporting system used in the block grant funding. I will tell you that im not satisfied with the data as its currently collected. I think we could do a much better job of getting information and that require as certain set of steps to go through. We have made Good Progress on that and will be approaching to further hone those questions that will be more informative about programs. Let me ask as well because ive actually spoken to colleagues about this. Medicaid is not required to robustly report data. I understand when it comes to Mental Health hits called braiding with medicare doctllar etc. And have has there been any initiative between samsa and cms to perhaps unlock some of what cms holds but samsa can use. What i can tell you is this. Part of the role of the assistant secretary position is to reach out to other divisions, agencies, departments. And so asked for a meeting. They say this is a big hurdle, that they do not know a way we could right now pair those data because i do understand what youre getting at but ill be talking with cms about that and see if we cant bring people together about that. This is about collaboration and cooperation. I suspect senator murphy, but certainly my staff would love to meet with your staff because right now were paying a lot of money and we have pretty poor outcomes in medicaid. When you control for everything you still have poor outcomes and so we need better reporting requirements and if it takes some sort of oversight, sometimes that makes it work better. So they would like to meet with your staff about that. Now i think i go eto senator franken. Thank you, for had chairman. Good to see you again. Doctor. When i meet with people in minnesota struggling with Mental Illness and Substance Use disorders i often hear about the stigma people experience. Mental illnesses are often not regarded as physical conditions, rather sometimes seen as moral failings and we all know thats just not it case. My predecessor made it his lifes work to fight for people of Mental Illness. And championing policies that promote parody. Im proud that Affordable Care act gave protections to those who dont have employersponsored coverages and the cures bill extends these efforts by calling on the federal government and other key stake holders to generate an action plan. In your testimony you referred to listening sessions. Payments, advocates and roviders explain many times people cant find in Network Providers have to fight with Insurance Companies just to get services covered. Stake holders called for more if had forcement, transparency and agency guidance. The actions the administration has taken thus far fall short of these demands. What will you do commit to doing in your new role to improve transparency from Insurance Companies and transform the parody portal into a meaningful resource for consumers . Yes. Thank you, senator franken. And i will tell you that is a work in progress. One of the reasons i agreed to come back to federal service is because i want to advocate for People Living with mental and Substance Use disorders. And so im going to be an advocate for as long as im in this position. One of the things i think is important is for people to get access to care and with they have barriers put in place by arbitrary insurer limits, its unfair. So im working with people around this parody port tool make it something that will be more functional for consumers. Right now it has been updated so people will be shunted to either susio or department of labor depending on what their problem is. But id like to see this be something much greater and something consumer kz use to get information. But it will take time. Im so glad to hear you say that. For years weve heard a growing and urgent cry from help from clinicians and tribal leaders about there Opioid Epidemic and in particular its impact on Indian Country. Thats why in the Indian Affairs committee i asked Indian Health service acting director how the administration could address this issue and the Opioid Epidemic more broadly. He recommended that we first bring tribes to the table and second consider community and structurally specific Treatment Programs, a push for language in the 21st century cures act to insure the leaders consider the unique leads and circumstances of vulnerable subpopulations including native americans in their programs. What are you doing to expand culturally basised treatment frograms for those in indian countries especially those suffering with opioid addiction and other substance disorders . And can you describe how youre engaging with tribal communities and working to develop and implement these culturally specific programs. Yes. So we have an ongoing we can actually have an office of Tribal Affairs at samsa. When i came to samsa i learned one of the Addition Technology transfer centers that was specifically put in place to assist tribal nations was going to end. That has now been funded. Theres a funding announcement out and we will choose a grantee who will work with tribes and meet their cultural needs as well as their Substance Abuse needs. We also worked, as i mention hadded, with the Indian Health service. We have our chief medical officers meeting with theirs and working with them around what kinds of Technical Assistance and Training Needs can do they recognize and that samsa can help them with. We have a lot of Training Programs that really are quite good and thank you. Because i am out of time and before the hearing i spoke to you also about Supportive Housing. I want to continue that conversation with you even as i leave this body because i think tats rr very important that people with Mental Health disorders and addiction get Supportive Housing and wrap around services. So thank you for engaging that conversation for the hearing. Thank you, for chairman. Senator whitehouse. Thank you, chairman. Appreciate it. Welcome, good to see you again before the committee. Thank you. We got an extra half a billion dollars to be spent on opioid treatment. We suspect the second half will come through in the end of this year funding measure whatever that ends up looking like. Were very much counting on that. In the last one the measure by which the funding was distributed to states didnt correlate to the rate of the Opioid Epidemic in that state. Nor did connect to the recently passed kara bill. Im hoping as we move forward youll be in a position to structure the grant process for that second half billion in a way that it more accurately addresses the high impact states and that it better connects to the kara bill. I think you can probably do that in the terms of the Grant Application request that you structure from samsa. The high impact states kind of got treated not so well. So my understanding of this situation is that if we make any kind of changes to the previous funding announcement then all states would have to reapply for it money. I can just tell you that weve been hearing from lots of states about their concerns in having to reapply for the money and the decision was made to not have any substantive changes in the second year of funding for that two years, that billion dollars, 500 million each year. So for the sake of the process convenience for all the high intensity states are going to pay the price . So i would say a couple of things. One, we did find money and put a new funding announcement outthat does prioritize the states that have been hardest hit by the Opioid Epidemic. I will continue to do that. In addition the other thing that ive been able to do is to reallocate funding that will be individualized to every state. So those states hardest hit who have certain types of special needs, we will have local Technical Assistance available to them that we think will be important to helping them implement as efficiently and effectively as possible. Going forward from from that two years of funding, well be very much aware of the kinds of issues youve just raised. And please also be an advocate for additional spending in this area in the kara programs in particular. I think we were able to get 170 million. Yes. In the last funding measure. Thats 2 of the 8. 6 billion it pharmaceutical agency makes just prescribing the prescribed opioids, setting aside the stuff that comes from the border. So 2 up against it devastation that were seeing in the context of a multibillion dollar industry, i would consider a beach head, not victory. Hope you agree. Yes, sir. Last quick thing. This is a rhode island specific thing. The Health Insurance commissioner as you know is taking a look at the parody compliance of the Insurance Companies in rhode island and i know youre looking at that at the national level. Can i make sure you have somebody on your staff coordinating with rhode island to make sure youre supporting their work and everybody is pulling smoothly together on parody disclosure and if forcement. Yeah, so two two things he one, theyve developed a parody tool kit for Insurance Commissioners weve made available to all the states and two, we have an office of around Health Care Reform issues and that we have a person who works individually with the states and with Insurance Commissioners within the states. So well make sure that that happens. Times up. Thank you, appreciate it. Chairman, alexander. Thank you. Welco welcome. If i remember right it was his language we put in the cures act to make sure the money distributed took into account highimpact states. I not correct about that . It problem is it was based, as i understand it, on the number of opioid deaths among other right. But we did put youre obviously going to have a big number but that doesnt mean a big impact. So our intention was to recognize the importance of was to distribute money to high impact states. The if had tension was not accomplished. Youre saying that it would be i could see that but there will be more money coming from opioids. We dont know yet when or where or how much. But is it the language about the difference between high impact states the number of total deaths and the number of per capita deaths . Is that the issue . Or what kind of language would you recommend so we direct money with a particular sensitivity to high impact states. So senator alexander i was not here when the decision was made. However, my guess would be that they were trying to implement as congress directed and i dont know that ing. What would be a better way. Im not trying to criticize them. If youre doing it today, how would you do it . And so for the new funding announcement that we just put out, what we said was we were looking at the rate of opioid over dose death within it state and the rate of increase year over year. That tells you how hard a state is being hit. Is that going to effect the second round of funding . When the second round of funding comes forward, absolutely well be require reapplication by are had the states . If its a new source of funding everybody would have to apply for that funding. But the second round im sorry. The second half half billion what you just described apply to the second half million . So no. But you would recommend what you just said would apply to any new money. Exactly. And would you work with our staff so we write that properly so we recognize the impact states so we do it in a correct way so we dont get surprised by . I absolutely will do that, yes. Now let me ask you this. In 2014, congress required states i remember the discussion with senator whitehouse, and i wanted to see his we tried to implement his intention, and we can keep working on that. Im just so grateful that you followed up that way, chairman. I appreciate it. In 2014, congress required states to set aside 5 of community Mental Health block grant funds for serious Mental Illness. The kurzak increased that to 10. That sounds good, but that reduces what states have to address what might be different in rhode island and california. Whats your opinion about the increase from 5 to 10 . Does that help or hurt the ability of states to respond to the needs of those with serious Mental Illness. The vast majority of payment for the services delivered to people with serious mental ills is not from samsa. The block grant having that increase of 10 cause as focus on something that is extremely important, and that is early identification of First Episode psychosis. We know the longer a person goes without having their psychotic thinking detect and treated, the more refractory their illness becomes over time. So that 10 and that block grant does a tremendous amount of good in terms of raising awareness of this important issue. How does that encourage early u early prevention. The language is just to focus on serious Mental Illness, doesnt it . Or does it Say Something about early . It talks about early identification of serious mental early identification. Yes. Serious Mental Illness. Yes. So its not the serious, its the early thats the key to really effective treatment. But we consider psychosis to indicative of serious Mental Illness. So you think the 10 helps . I absolutely do. Because of the push toward early identification. Yes. Of serious Mental Illness. Yes. And we know that the onset of most psychotic disorders is in adolescence and transitional age youth. So this is really very important to the lives that these folks will be able to live going forward. Thank you, mr. Chairman. Senator hassan . Thank you very much, senator cassidy and mr. Chairman, thank you for holding this hearing. And dr. Mccancekatz, thank you so much for being here and for the work you do. I want to follow up on the conversation we were just having about funding for those of us who are from states have a been incredibly disproportionately impacted by a horrible epidemic that is taking lives obviously across our country. But in new hampshire, our fentanyl, heroin and Opioid Epidemic is referred that way because it is fentanyl that is killing people in my state at one of the highest, if not the highest per capita death rate in the country. And we have been targeted by fentanyl dealers. I was at a funeral saturday where a family buried their second daughter from an overdose. A woman who had been in recovery and had been working really hard at it. And this disease is taking all of our efforts. And i am very, very grateful to everybody on this committee. But i will add my concerns and frustrations to what you heard from senator whitehouse. I have expressed them directly to the secretary. I think the fact that states were uncomfortable about reapplying is not an excuse in terms of the decision that was made with the second round of this funding. Towards that end, senator alexander, senator capito, coons, myself and senator manchin have a bill in called the targeted Opioid Funding act that would change the formula and make clear what kind of priority we should give to per capita death rates. And id love the committees attention and collaboration on the bill. But even if we fix this formula under the cures act, we know that the cures act money right now is only for two years. And we know that there is no quick fix for this epidemic. We desperately need funds to fight this epidemic. We need the administration to tell us what supplemental resources its proposing to turn the tide. And i was appreciative of being at the white house in october when the president declared this a Public Health emergency. But so far we havent seen any follow upton that declaration. And weve seen no proposal from the administration for the funds that we need to tackle this epidemic everywhere in our country, an epidemic that is not only taking lives, but in new hampshire, i think the year was 2014 or 2015. Cost us over 2 billion in our economy. So dr. Mccancekatz, have you had conversations about the need for additional funding with hhs and the white house . Why hasnt this administration called for additional funding or proposed additional funding so we can get the dollars and the resources to the front lines where its so needed . Senator hassan, i think there are many conversations going on what the needs are and lots of efforts to look at the data that is available, the information thats available. Its my understanding that the administration is very interested in working with congress on developing those ideas that might be something that both the president and congress can agree upon to bring more resources to bear. Well, this congress has made very clear that we support additional funding to fight this. But we really need a partner in the administration to stop talking and start funding. And so i would look forward to continuing those conversations. I also wanted to follow up with another question because we know how complex the opioid use disorder is. Its often accompanied by a variety of Mental Health disorders, including for example post Traumatic Stress disorder. This leads to complex and sometimes very dangerous outcomes. Veterans and other populations with ptsd and coor current pain conditions are often prescribed higher doses of opioids. Treating one disorder obviously does not address symptoms of the other. Its imperative that we work to ensure that patients have access to comprehensive treatment to discuss both Substance Abuse disorders and Mental Health needs. Doctor, have the Mental Health helped samsa enhance the availability of programs for duel diagnosis for Mental Health disorders and opioid use disorder . Yes, i believe they have. And specifically, i can speak to the issue around department of defense and veterans affairs, which cures addressed. And which has developed into a very strong relationship where samsa works collaboratively in an ongoing way and we specifically address the issues of mental disorders and Opioid Epidemic, as well as suicide. Those are the big issues that we are working on right now. And we also can use the information that we learn from the v. A. , which also does a lot of research of its own. And we share this, and we promulgate it to communities. Well, i thank you for that. And i thank you for the vision of integrated health care in this area. I am most concerned that we are delaying some of our work that would be made possible with extra funding because of the stigma attached, as many of the other speakers senators have referenced. I appreciate very much your efforts. Thank you. Doctor, good the see you. Good to see you. I read a book some months ago by sebastian younger. Its a small little book called tribe. He discusses in the book the challenges our veterans face as they try and reintegrate back into society. He makes the point from an evolutionary standpoint, were more comfortable in tribal societies like military platoons, embedded in a military structure than we are in the current atomized society where people tend to feel lonely. So there are challenges of reintegration and adaptation. So he turns on its head the challenges our veterans are facing. The problem is not per se with the veteran but it may with the broader society. Its a really interesting read. And when i lay that line of argument, that analysis on top of the study, the deaths of despair study that indicates we see increasing rates of morbidity among middle aged men, white men in this country and the reason for the deaths is heightened suicide, alcohol use, and so forth. I start to think that loneliness is really driving so many of the Mental Health issues in our country. Could you just give me your assessment of that perhaps popular reading of the literature . So i do think i do think that those are important points. And i actually think that there is there is actually Research Data that says that people who are isolated, who will endorse loneliness and feeling ostracized within their communities have die at much younger ages. So that is an important issue. Is this something that is this its a driver, is what im hearing, a driver for some Mental Health challenges. Are there evidencebased approaches to intervening in this problem, if not solving it, mitigating the challenges . And if so, what is that Evidence Base . What interventions work. Yes. So senator young, i think this is a topic in evolution. But i do think there is some accumulating evidence for the value of recovery supports as they relate not only to Substance Use disorders, but to mental disorders. And so one of the things that im work on, and this is one of my priority, actually, to bring psychiatric medicine into closer contact and collaboration with Community Recovery supports. Its not enough. Its not enough to just provide medical care, psychiatric medical care. People need those recovery supports in their communities. They can be veteranbased. They can be faithbased. Right, right. You get where im going with that. And i think that will go a long way towards assisting people to live a long life. It just seems consistent with common sense. There is more needed than medicating these problems away. People need genuine human contact. They need relationships that are meaningful to them. They need to feel like theyre part of a broader community, a meaningful part. So i just have a couple of minutes left. If we could turn to how the federal government incorporates or fails to incorporate feedback loops in terms of addressing Mental Health and the policies we have. There is a recent governing Magazine Article on this written by Health Economics professional at Harvard Med School and a former Obama Administration official. And the authors advocate for including a tiered evidence approach with cures dollars to allow for scaling up of evidencebased approaches while concurrently supporting fieldgenerated innovations. Have you considered including a tiered evidence approach in some of your programs, say the national Mental Health Substance Abuse policy lab . Thank you for that question, senator. And i think we spoke a little bit about this when i was going through the confirmation process. I want to publicly speak about it. But, yes. And so the answer to your question is yes, we are. And im very happy to be able to tell you that the policy lab is being stood up now. Weve hired a director whose i think is a very experienced and knowledgeable person who is going to do exactly that kind of work. Well, great. I continue, of course, to have great interest in this. And well be following up with you and your staff to see how we might be supportive from a legislative standpoint. Thank you, chairman. Senator franken . Thank you, mr. Chairman. I was glad to hear you talk about recovery supports. We had rebecca boss from rhode island. I know youre from rhode island. I used to work for her. And she is doing unbelievable work. In rhode island they talk recovery coaches is what theyre called, who do exactly what youre talk about is getting into the community. One of the things that we put in 21st century in the cures act is more crisis intervention training for police. We talked before the hearing about judge leifman in miamidade who has implemented a system where people with Mental Illness and Substance Abuse who get arrested instead of going to jail, which they used to do, and which costs a tremendous amount of money, were going to Emergency Rooms which also costs a lot of money, is getting them housing and getting them wraparound services. And that is something that i think talking about i know that senator young and i have talked about housing as a way. And weve done this in Hennepin County in minnesota as well. But thats something that i want senator young and others on this committee to keep advocating for and keep thinking about. Ill be bugging you even from outside. I want to i want to talk about Indian Country again. And senator hassan talked about ptsd. You talked about trauma. And we see a tremendous amount of trauma in Indian Country, not just the historical trauma, but the trauma of extreme poverty, of domestic violence, of drugs and of sexual abuse and all of those things. So we see thats why we see such high incidents of opioid deaths in Indian Country. I went to a rehab for teenagers in northern minnesota a couple of years ago. And ive been there to visit a number of rehabs. And i had never seen such kind of hopelessness from these in a rehab. Usually when you go to rehab, there is people feeling hope at a certain point. And what i really got was that these kids, most of them had started with use with their parents. And the hopelessness that i saw was what they were going back to. And they seem to be going back to. And this is true also not in Indian Country. I was in rochester, minnesota, where we had a round table on opioids. And a woman whose daughter had gotten treatment went back, fell in with the old crowd, and is now gone. One of the things that i was thinking of again with housing is a model and maybe piloting this a sober living housing in Indian Country. Where instead of going back to where you where you were living, going to a facility that has people like you, you know, and it can be very close to the reservation or on the reservation. But where youre getting continuous support and youre being tested and you have a fellowship of the people there who are living sober too. Because especially the opioids, this is a long, long, longterm thing. It isnt five days of rehab of detox and then 28 days. Its much longer thing than that. So thats something that i would really like to advocate for and going forward. And one last thing about culturally specific in Indian Country. I think its very important, but i did a round table in minneapolis. And one of the providers there, one of the counselors said to me, what does that mean, culturally specific. She said when an indian woman sees me as her counselor, because im indian, she knows that i know. What she has been through. So i think that culturally specific means more than just a cultural thing. I think it means actually in Indian Country making sure that we train the providers. So thank you. Yes. And i agree with you, yes. Youre quite right. Thank you, doctor. Senator warren . Thank you, mr. Chairman. Dr. Mccancekatz, one of the most important things we did in cures was to create an office of the assistant secretary of Mental Health and Substance Use, which is now what you have been nominated to head up. We need to ramp up our response to the Opioid Epidemic, and that means using every single tool in the tool box. And one tool is to put more resources into Mental Health. So can i ask you to tell us why it is so important that we address Mental Health if we want beat back the Opioid Crisis . Yes, and thank you for that question. Because there is such a very high rate of cooccurring mental disorders with Substance Abuse discords. And they often predate the Substance Abuse disorder itself. And we also know if we do not address both disorders, treating one does not treat both. Good. Thats a very succinct way to put that, and i appreciate that its clear that making progress on the Opioid Crisis means putting resources into treating Mental Health disorders. Medicaid is the largest Funding Source for Mental Health services, but samsa has a number of other programs that help Fund Services that are not covered through public or private insurance. The Mental Health Services Block grant and a group of other block Grant Programs Call National and regional significance are samsas main Mental Health programs for providing funding for supporting the work of Mental Health agencies of local governments and of nonprofits who are working in this area. These programs are absolutely critical to improving Mental Health in this country. And they serve millions of americans. But let me ask you, dr. Mccancekatz, is everyone who needs Mental Health care able to get that help right now . Id say the short answer to that is no. No. And why not . There are a variety of reasons. One thing we know is a lot of people who who we would say need this kind of assistance dont want to it. But then there are also barriers that prevent people from getting the care and treatment they need. It can be very difficult to access care. Do you have an estimate on how many people who need mental care freemont that dont get it . Our data told us somewhere around 12 million, 13 million people. Thats really a stunning, stung number. And now the Mental Health block grant and programs of regional and National Significance are samsas two largest Mental Health problems. Combined, we spend less than a billion dollars a year on those programs. So let me ask you. The White House Council of economic advisers released a report last month estimating the cost of the Opioid Crisis to this country. Do you know what figure they came up with . Im guessing it was pretty high. It was pretty high. 504 billion. So think about that. The cost to this country annually of the Opioid Crisis is more than half a trillion dollars. Thats in 2015 alone. Thats where we have the most recent data. And we are investing only 1 5 of 1 of that amount in helping samsa tackle the Mental Health piece of this problem. I think we need to do more. And thats why ive called for an additional billion of funding in next years budget that would double the samsas budget and let them double what they put into the two largest Mental Health programs. Yesterday, the national council, which represents 2900 Mental Illness and addiction organizations wrote me a letter. And i just want to quote what they said. They said now is the time to support the highest possible levels of funding for Health Care Programs in the federal budget. And today, this morning, the Massachusetts Association for Behavioral Health care sent me a separate letter requesting that congress double these funds. I could not agree more. That doubling the funds for these Mental Health problems would give millions more americans access to the treatments that they need. And it would start making a dent in the astronomical cost that the Opioid Crisis is imposing on our country. Thank you. Thank you for being here. Thank you, mr. Chairman. Senator kaine . Thank you, mr. Chair. And its good to have you with us, dr. Mccancekatz. I want to ask about the issue that i hear about all the time in virginia from my Law Enforcement community. And thats the intersection between Mental Health and people who are in jails and prisons who shouldnt be. I have a lot of tough sheriffs, tough Law Enforcement sheriffs and Police Chiefs who lament the fact that their jails are filled with people who have diagnosed but untreated or sometimes never diagnosed Mental Health conditions. And they feel these people shouldnt even be in jail. But if theyre not treated, theyre going to do something to harm themselves or others, theyll end up in jail. They feel like theyre being asked to be the Mental Health provider for society that doesnt fundaMental Health services. And they feel both sort of a compassionate anger about that, but also a resource challenge that makes it harder for them to do their job. And soy really want to ask about this. I also talked to Police Chiefs sometimes after high profile incidents of a Police Shooting of somebody, for example. Theyll say you know, at bottom, some of this was the police approached somebody who had a Mental Health need, and were not completely trained on that. And then it spiraled into something worse. And then that can often become a flash point for community anger. But at the bottom of it, there was an untreated Mental Health issue. So thats what i want to talk to you about. The 21st century cures act had some important provisions around Mental Health in the criminal Justice System including an serious Mental Illness coordinating committee. Thats a long anachronism and a Pilot Program to determine the effectiveness of diverting federal courts and prisons into drug and Mental Health courts. You tell us a little bit about work the coordinating committee is doing in conjunction with the criminal Justice System, and has the attorney general and the department of justice been supportive in these efforts . So a lot of questions there. But yes. So the ismic, the interdepartment coordinating committee includes the department of justice. They have been good partners with us, and we expect that to continue. As you know, this is a fiveyear process. You will be getting that report from the committee today. Right. And the issues around the interface between serious Mental Illness and the Justice System is one of the primary areas of focus within that report. And so and i will just tell you also that we have programs at samsa that are dedicated to diversion, Mental Health courts. We have programs for offender reentry so they dont get lost through the cracks. Because my own experience, having run the State Hospital system in rhode island where we worked with the department of corrections was that we would frequently get folks back because they didnt get into appropriate Outpatient Care at the time they were leaving. And even though we might provide treatment to them while they were incarcerated, that stopped. So ismic has addressed this. I hope youll be pleased with some of the recommendations that we will be working on. I very much look forward to reading it. The thing that im sort of most familiar with at the state level was the use of Mental Health courts which are significant. Can you talk a little bit about how the Mental Health court system is working at the federal level, some of the things we might be reading in the ismic report about that . Well, what youll be reading is that we need more, more of these types of programs. And these programs can be very effect they are very effective in diverting people away from incarceration and into treatment, appropriate care, including medication. Because a loft these individuals need medication and have not gotten it and dont continue to get it. Thats also part of what the ismic committee has recommended, that the issues around civil commitment laws be looked at to try to maintain a person in care once they leave. Also, the other thing that we talk about in the report is the Crisis Center. The use of a Crisis Center that is specifically geared to the treatment of people who have Substance Use and mental disorders, rather than going to an emergency department, which is not an appropriate placement and where Law Enforcement often get stuck. And so these kinds of interventions can be very helpful in freeing up Law Enforcement and getting people the care they need. Mr. Chair, have i one more question, if i could ask. Im near the end of my time. But if others want to jump ahead for a second round, should i just go ahead . I want to ask about coprescription of naloxone. I know many of the questions you have been asked have been about opioid. It was incorporated partially into cara. I was pleased to see that that was a very bipartisan effort. How much progress has been made in terms of making naloxone more available to atrisk populations . And can you speak to the availability of prescribing guidelines . So so prescribing guidelines, we have at samsa an opioid prevention tool kit that speaks to the use of all of the available formulations of naloxone. Its in the process of being updated right now because there have been some recent fdaapproved formulations. So that is available. We also encourage coprescribing. We train on coprescribing. And we have through cara and through cures we have programs that train first responders, and also provide for funding for purchase of naloxone and distribution of naloxone. Thank you, mr. Chairman. Yes, dr. Mccancekatz, kind of a followup. And its a followup not only to what i asked earlier, but actually to a previous hearing where you were talking about opioids. In my previous line of questioning i was asking about how do we monitor outcomes. Last committee hearing, i asked how do we monitor a specific program if we have Treatment Program a and Treatment Program b and Treatment Program a has a high recidivism rate with a lot of folks being perhaps overdosing in an emergency room two weeks after discharge, and we have program b where they have a more effective approach. And we dont see that sort of thing on billing data or however. And i asked you last time if samsa was instituting those kind of review processes. And i think the answer i goth got, great idea but probably not at this point. In relation to what i asked earlier, it possible for samsa to do that without a cooperative agreement with cms to look at billing data, to see if there is some marker of recidivism, for example, billing for an emergency room visit a week after discharge. You follow what im saying . What aye im really trying to get, how do we effectively look at programs who are treating folks for addictions to know whether or not those programs are effective. And the taxpayer gets the best deal for her dollar. But as importantly, the patient gets the best outcome relative to recovering from their addiction. Thoughts . So the issue around cms and their billing data is one that we have to work on. But we are so, yes, i am reviewing all of samsas Data Collection programs right now. And we are going to be making that data more available publicly. So its not just a matter of and these would be our programs that were funding. But its not just a matter of collecting that data so that we can see whether the programs are good, but making it available to the public. And so we are working with our center for Behavioral Health statistics and quality to look at means by which we can make that data more available. The other thing that we do is i will tell you that for the str program, im a clinician. Sdr . Sdr is the state targeted its the 500 million a year for each of two years. So im a clinician. And i love clinical work. I am meeting with my staff about every single grantee. Were looking at every Single Program to see how the states are using their money. Theyre all doing it differently. So let me ask. Yes. In followup, if states are doing it differently, is there a common way you can say this is how we wish you to evaluate . Really, absent billing data that is only available from cms, it seems like it would be very difficult to evaluate recidivism rates. Many of the Treatment Programs are at a geographic distance from if place where the patient begins, right . So if there is a way to evaluate without billing data, one, does it exist . And two, is cms promulgating this as listen, we want you to evaluate, and this is how we wish you to do so. Yes. And so the answer to your question is we have several evaluations of this program ongoing. And we are monitoring the states to make sure that theyre using evidencebased practices. We have one evaluation that is being done by cdc. We have another being done by a contractor. And that data will be made available publicly. So that is an ongoing that is an ongoing project for samsa. And by the way, i dont think personally the data should be used punitively. It could be used total quality management. And the other thing that we do, because were working so closely with the state, and because we have a new program of Technical Assistance, we will also be asking the states to bring forward data on their programs. Because they have abilities to see whether their programs are working. Available for the general public or for congress to review, the first set of it . So i dont know the exact answer to that. But i will find out and get to you about that. Fantastic. Senator murphy . Thank you very much for your followup questions. I wanted to ask two on the challenge of broadening our Mental Health workforce. Senator kaine accurately talked about diverting individuals out of the criminal Justice System. Often your first interaction with the criminal Justice System happens at school. Many kids with Mental Illness will misbehave at school, will run into a Police Officer and be sucked into the criminal Justice System, never to emerge. We talk a lot about Mental Health first aid training. Shouldnt to the extent that schools have Police Officers onsite, shouldnt every single schoolbased resource officer have some basic training in identifying Mental Illness so that they can divert kids away from jails and into treatment if they present with symptoms . Yes. And without endorsing a particular program, yes. Right. Yes, i believe that that is the best way to approach that issue, absolutely. And then tell me about samsas work to develop more peer capacity. Peers occupy a very specific and useful role in treatment. Lots of emerging data telling us that for many people in recovery, that peer connection is what matters most. What is give me an initiative that samsa is working on now to try to broaden and improve the quality of peers in our system today. So samsa has had a pretty substantial role in the development of the peer workforce. However, its my view that samsa no Government Agency should be in the business of trying to figure out how to accredit a particular type of workforce. And so what we are doing is we have an office for consumers and families that is working with some National Organizations on developing criteria for accreditation of peers. The states are all different. They do it differently. But were working with states and with the stakeholders to move that process along. I believe that peers need to be integrated into the Health Care Team because its so important to not just give medical care, be also the recovery services. And so thats what were working toward. One last question to follow up on, the questiconversation ye having with senator cassidy. You mentioned you were not satisfied with the data that youre receiving from states. I think thats in relation to the block grants. Can you just tell us why youre not satisfied with the data that youre getting . Is it is the amount of data or the quality of data . Whats the problem that youre seeing . Because the data does not tell us anything about diagnoses. And it doesnt tell us anything about really basic standard of care issues like did a person get medicationassisted treatment. How do i know if a program is working if i dont even know they got the standard of care. Were changing that. So what are you getting right now . We get number of people served. We get things that approximate certain types of diagnoses. Did you feel sad . Do you use certain substances . But that is not enough to tell us what these programs are doing for who and what does and doesnt work. Thank you for your focus on data. I agree with senator cassidy that to the extent we can avoid duplication in requirements to states on this, its something we should Work Together on. And i would echo that. And i thank the administration for appointing you because you seem as irritated about some things that i am as irritated about and i suspect you. And there are good things to be irritated about. I want to finish by thanking senators Alexander Murray and murphy for calling, convening and participating in this. And also thank you, dr. Mccancekatz for excellent testimony. The hearing record will remain open for ten days. Members may submit Additional Information for the record within that time if they would like. Thank you for being here today. The committee stands adjourned. Thank you. Coming up here on cspan3, the impact of u. S. Investments in developing countries. Thats followed by discussions of cybersecurity threats to elections across the world and defense cooperation between the u. S. And south korea. The federal Communications Commission meets thursday to consider its plan to change Net Neutrality rules. Fcc chair ajit pai is proposing to give internet providers control over how broad band content is distributed. Live public coverage thursday at 10 30 a. M. Eastern on cspan3. This weekend on American History tv on cspan3, saturday at 6 00 p. M. Eastern on the civil war, generals we love to hate with author craig simons on confederate general joseph johnston. Johnstons critics argued that his timidity with the enemy and his combativeness with the confederate government in richmond so undermined the southern war effort as to make him a contributing factor in confederate defeat. To these critics, johnston was the real mcclellan of the west. A man who lacked the moral will to commit troops to battle unless he could be absolutely certain of victory. And since those circumstances never obtained, he seldom if ever sought battle at all. Sunday at 4 00 p. M. Eastern on real america. The white house naval photographic units monthly reports on president lyndon johnson. Two days 56 his return from new york, the president s oldest daughter, linda bird johnson became the bride of captain charles robb of the United States marine corps. Historically, it was the First White House wedding in 53 years. And at 6 00 on american artifacts, the 200year history of the Willard Hotel in washington, d. C. Whose guests include abraham lincoln, world war ii soldiers, and the first japanese delegation to the United States in 1860. Abraham lincoln conducted quite a bit of business while he was here. He stayed for ten days. And in fact, the First White House levee was held not at the white house, it was at the Willard Hotel. When he introduced himself and his wife was quite a bit shorter than him. He said i want to introduce you to the of the new presidency. American history tv, all weekend, every weekend, only on cspan3. The center for strategic and International Studies hosted a discussion about u. S. Investments in developing countries. Speakers included the Egyptian American Enterprise Fund chair james harmon and tunisian American Enterprise fund bowman cutter. They support Economic Development and generating financial returns. This is nearly two hours