Transcripts For CSPAN2 Surgeon General Jerome Adams Testifies On Substance Abuse 20240713

Recent high profile case involving treatment scams in ohio, and investigations and partnership with the fbi and Law Enforcement generally, leading to the indictment of six people this year, all six pled guilty to medicaid fraud. Some have called for developing more by which the public could evaluate the effect in the Treatment Programs. Our last witness, has gone a step further not only identifying it core standards, he believes are key to any successful program, but also launching quality rating systems. This is uncharted area treatment sector, and we look forward to hearing from him, the progress thats been made there, with his Non Profit Organization. We are here today because two Many Americans have lost too many loved ones to addiction. Americas Opioid Crisis has left a trail of broken hearts and homes across our country. We are here to help communities get on a path towards health and wellness. Millions of americans are desperately seeking a path forward. Working together, we can save tax dollars and save lives. Senator . Mister chairman, i want to thank you because this is an exceptionally important issue, and i think we do need to have our committee tackle it in a bipartisan way. And i also want to thank you for moving this mornings start time to 9 am, because we both know there are members who want to attend the Memorial Service to chairman cummings. Todays hearing is going to spotlight the pitfalls americans face when they try to find quality treatment for a Substance Use disorder. An american battling this disease is often jostled and pushed around from one end of the Health Care System to the other. The last thing you need when you are suffering from this disease is yet more obstacles. Rip off artists, empty promises, or just out and out abuse. The last thing you need is that, when all you want to do is get better. Too often, people travel across the country expecting to arrive at a legitimate Treatment Facility only to find that they have fallen prey to a scheme. The goal of which is to train their bank account and just milk their insurance for every thing it is worth, in some instances, on scrupulous operators are working to lure patients by paying a for plane tickets and promising free rent. Once the patients arrive, what they end up getting is lousy care or no care at all and then the fraud stirs just go out and build the Insurance Companies for Health Care Companies that may never been performed. One of the biggest problems involves facilities that treat Substance Abuse disorders but are actually set up to rip off taxpayers, they illegally recruit patients using bribes and kickbacks and then they milk the taxpayer by building the Patients Health plan for medically unnecessary drug tests, schemes like this, im very pleased to have this terrific group of witnesses today, they are going to outline in these schemes in detail and of course these schemes as well medicare, medicaid, cost them hundreds of millions of dollars a, rare justice on six people operating fragile and Treatment Centers pled guilty to submitting 130,000 medicaid claims that totaled more than 48 Million Dollars for medically assisted treatment and other services i would never legitimately provide, part of the reason this is so common is there is no way for a patient or family to learn about the quality of a Treatment Facility before they enroll. So today we are going to hear from an organization that is saying hey, wake up everybody, this has to change, shatter proof is currently developing public databases in multiple states that if successful will allow the public to identify, evaluate, and compare value substance Treatment Programs. This kinds of transparency is the type of information that American Families deserve to have and they deserve to have it now because itll be a key tool to find quality treatment and avoid sham operators trying to make a quick buck. One other point that occurred to me is that we were preparing for this preparing hearing, is that it is particularly important now to set in place a kind of concrete policies to rip off, to make sure that these programs are not ripped off and that the patients are not taken advantage of because when you read in the morning newspaper, the fact is that states and communities may now be on the cusp of receiving tens of billions of dollars from the companies that help seed the epidemic, i can just look down the road because i have heard about this from virtually all of my colleagues, so if youre talking about a fund of tens of billions of dollars, a some of that size is going to be a magnet for the fraudster and rip off artists, so this will highlight the need to make sure that there are rules of the road so that those dollars actually go to help patients get proper care and all that new money doesnt just find its way into the roof off artists, i think the witnesses and miss chairman again we will work on this in a bipartisan way, and i look forward to the witnesses and colleagues hearings. Thank you mister chairman, thank you for giving me this courtesy, its a real pleasure to welcome all of our witnesses today, particularly welcome the syrian general doctor jerome adams, he hails from maryland, a proud son of maryland and had a glowing career, first winning the prestigious scholarship to county where he received both in a bachelor of science and biochemistry and a bio of bachelor of arts, i say it is because we had conversation before with doctor freemen at you nbc, he calls doctor adams is most accessible failure, thats because the Scholarship Program is a program that has been extremely successful and African Americans obtaining their phds and going on a two extraordinary successful lives, well doctor adams does not have a ph. D. But he does have a masters degree and an empty degree and of course is had very successful career, i want to congratulate him for his leadership in our country, the service to our nation, he attended Indiana University school of medicine and was a Company Scholar before serving as the United States Surgeon General, he was appointed by the Indiana State Health commissioner, he has found his time focusing on combatting the Opioid Epidemic, he has been an advocate of behalf of Public Health in our country and we are very proud of his service and very proud to have him hail from our state of maryland. Well the three of you if i can just go to the testimony on it. I have talked to all of you in my Opening Statement because of the time constrains, i want to start with the Surgeon General, will you start and then what we will do is, go in the order that you are sitting there in the table and then we will have questions after you all get done. Fantastical, good morning chairman, my wife says to tell barbara i and we cant wait to bring the kids out to the farm, i hope she told you about that. Everybody knows a bow my wife, does anybody know about me . Ranking member wide in and swedish members of the committee, will you give me a few minutes to acknowledge the flags flying at half mast and lift up the examples of representative cummings, his life was the very definition of Public Service and my condolences go to his family that are all blessed to know him. For my testimony today i would like to begin by thanking all of you mister chairman for passing the support act, which has enabled our country to make progress in the fight against the Opioid Epidemic, i am pleased to be here today on the one year anniversary, americas overdose an addiction crisis is one of our most daunting Public Health challenges, recognizing its scale and scope it launched the five point strategy in 2017 and under that strategy we are achieving better addiction, prevention and Treatment Services, better data, better paid management, better targeting of overdose drugs and Better Research. Ive been engaged on this policy, and as you heard from senator nick cardin, dealing with an unprecedented hiv outbreak, but my work on the Opioid Epidemic is very personally. Younger brother philippe struggled with the addiction, he struggled again with untreated depression, getting to self medication and opioid use. And like many with Health Issues he has support in and out of course ration, he is currently serving a tenyear mark this guy can happen to anyone even in the brother of the United States Surgeon General and when stigma keeps people and shadow, it mps our collective recovery. To address this epidemic, my Office Released a spotlight on huawei its, a digital postcard which you can find at Surgeon General dog in which you have in front of me janet senators, and an advisory on opioids, i want to leave you with five key messages at a detail on these publications. Number one Early Intervention is critical, evidence based prevention screening programs work but they need to be initiated early in life, we can wait until someone is in a high school or college to talk about the dangers of opioid issues. Number two must be integrated into mainstream health, care as an example medicare assistant treatment is the Gold Standard but in the course of the year only one in four people with opioid use disorder receive special treatment. Number three having the bloc zone, can save a life and me i hope you know about, this i carry this wherever i, go its literally that easy to save a life. Since it was published, almost 3 million to davos units have been distributed, but too many needlessly die. Fourth comprehensive Communities Support Services are essential, and i saw this firsthand when we visited the industries and indiana, they came up with pathways to recovery, and where failed drug test offer drug counseling and participants that state have assured jobs, and this is also vital to the degree in new york that provides Employment Services for out judgment, no, resume no work history, no background check is required, at the bakeries model which i love is, we dont hire people to bake brownies we bake brownies to hire people. And when it comes to opioid uses, this inside he must to continue u. S. Front can criminal justice used to a Partnership Based run, stigma and judgment are keeping people from disease of, addiction people like my brother from getting the help they need and is in my opinion is killing more people than overdoses. In conclusion, under this administration and through your support, a historic investment has been made in combatting the Opioid Crisis, by the end of 2019, hhs will have awarded nine billion dollars to states and tribes and local communities to combat addiction. This includes nearly one billion across 375 projects and 41 states as part of their and for ending addiction long term hell initiative. And if these funds expand access to agreement, and surveillance, insist artisan ministration, we have seen the amount of opioids nationally drop in terms of prescriptions, we have seen a number of americans receiving treatment grow, now nearly 1. 2 7 million americans are receiving treatment and we have doubled the number of providers who have their data waiver. And the drug quo provisional death drop by 5 , our first draw wage many, years we are making progress, but challenges remain including the resurgence of meth amphetamines, we need to increase support for comprehensive support programs and to support assisted Treatment Programs with warm me and in, care we also must expand the behave real workforce and we talk about that before the hearing, i promised you, i promise you that hhs in my office will continue to focus on this critical Public Health issue and i thank you for the opportunity to testify and i look forward to your questions. Doctor before you began, with a lawyer background and animal science, how did you end up doing this . As you probably are aware there is a nexus between Animal Health and Public Health and i think they recognize that. Well i needed that explanation. Sure. Proceeds these. And chairman grassley and members of the committee, i am pleased to discuss on the oversight of recovering homes, Substance Abuse and drug use is a problem that is ruined families and take analyze the da reports that since 2011 Drug Overdose has allowed alone ive been leading cause of death in the United States, outnumbering deaths by, guns car crashes, suicide, and homicide, recovering homes can offer safe and supporting houses, unfortunately bad actors have use these homes to take advantage of individuals during the time of need. Today i would like to highlight two key findings from our report, first g eight oh found that all five states have received complaints of fraud related to recovery homes, four of the five, florida, massachusetts, ohio, and utah had or were in the process of conducting investigations. For example, officials told gao, that fraud was extensive in southeastern florida, a Task Force Found that operators were lowering individuals using deceptive marketing techniques, such as promising of free airfare and rent. Recruiters then broker these individuals to providers who builds their and sirens for hundreds and thousands of dollars for unnecessary drug testing, home operators were then paid 300 or more per week for every patient they referred. At the time of our arm hurt some arrests had been made, and mass since two since they found that some owned recovery homes and referred patients to, labs other labs are paying kickbacks to home for a patient referral for testing that was not medically necessary and between 2007 and 15 they settled with an iron labs in 4 Million Dollars of restitution, and the time of our report ohio was investigating fraud at the recovery center, this monday reported that six people planning guilty on for building medicaid more than 40 Million Dollars in drug and Alcohol Recovery Services that were not provided or not medically necessary. To increase over saint, florida, massachusetts, and utah establish either a licensed or or a voluntary Certification Program that included incentives for recovery homes to participate. Our other two states, ohio and texas, do not have similar programs but we are providing programs and resources such as training to recovery homes. Despite such efforts fraud continues, for example the Pennsylvania Attorney officers recently completed an 18 month investigation looking into Insurance Fraud Treatment Centers, charges included kickbacks for unnecessary drug testing and billing Insurance Companies at exorbitant rates. Those charges actually got them working in unlicensed recovery homes where the houses were sometimes unsafe, employees and patients were engaged in sexual relationships and there are opportunities to realize, this is the case of the bad guys getting caught and that is what raised me to my second point. We do not know the total number of recovery homes and therefore we dont know the extent to which this is happening. In addition no federal agency oversees the operations of these homes to provide a nationwide perspective, in closing when run properly recovery homes are an important part two nations path to serve right in combatting the Opioid Crisis. Our work on recovery homes as part of the gao broader work on drug misuse, we have explored federal oversight in medicare, we also have ongoing work on identifying accessing important overweight misuse, much of our work is as a result of mandates from the support act which was signed one year ago from, today we highlight this another work in our latest highrisk report where we identified as federal efforts to prevent drug misuse as an issue requiring very close attention. Thank you chairman and grassley, Ranking Member widen, and members of the committee for holding this committee, this concludes my remarks, im happy to answer any questions you may have. Good morning chairman grassley and member widen and other distinguished members of the committee, i am the deputy neill or i appreciate you coming here for you to combat the Opioid Crisis, our ongoing work is taking a multi faceted, approach looking at a variety of issues for prescribing and treatment to this crisis, they are addressing it through expanded Law Enforcement activities, audience, and data briefs, our efforts to combat this wall ensuring both substance and treatment and continuity of care continue in our top priority, we have expanded enforcement efforts the, resulting in an increase of over 100 percent of open investigations at our office from 2015 to 2019, just this year the newly launched appalachian regional strikeforce, a joint initiative between do i jay, oig, and fbi and, partners took down 73 individuals. 64 of them medical professionals, for participation and illegal prescribing of opioids and related to Health Care Fraud schemes. Opioid fraud comes from a broad range of criminal activity and addiction Treatment Services and billing schemes, our growing concern is fraud and medication, sober homes and ancillary services such as counseling and drug test screening, and sober homes continue to increase in conjunction with increased demand and availability of federal funds to support the services we have seen in the commensurate increase in illicit schemes, as our enforcement in oversight efforts to address this crisis have expanded we have also come to understand the impact of that are enforcement where we can have on the patients that we served. We recognize that when i clinic whose patients are was just prescribed avoids, are shut down, access to care can and will be disrupted. Rather than leaving these patients to potentially turn into another fraudulent provided or stream drug, we want them to have access to quality treatment and Pain Management services with minimal disruption to conduct, but this is not something that Law Enforcement can do alone. Ensuring these patients have care requires a collaboration with our federal state and local Public Health service officials. As part of the appalachian takedown, the Law Enforcement partners in us work with age ages offices for secretary of health and the center of Disease Control and prevention, and state Public Health agencies, to prove or state and federal Level Strategies and resources to provide assistance to patients. Oig will continue to work hand in hand to help ensure access to treatment and continuity of care for patients impacted by our efforts. Beyond our enforcement efforts we grow our roast best performance of work related to the crisis, ongoing work that identifies opportunity to strengthen the Program Integrity and protect on patients across the treatment i mention of this crisis, we have treatment related audience and evaluations underway, examining issues such as access to medications, and employment an oversight of state treatment grants, we look forward to sharing the results of this work with the committee when it is complete. Oh i jeez reason did a brief shows significant declines and opioid prescribing, at the same time in show that the number of patients receiving medicare is increasing, this is a very positive sign, however there is still much work to be done to reduce illegal prescribing of opioids, was only to track from the efforts to provide these that the visions truly need. Thank you for allowing me to discuss this important topic what, do i look forward to any questions you may have. I realize a little bit i said about you in our Opening Statement, i need to recognize your success in the private sector and now bringing that to the Non Profit Organization jar to help us accomplish this goal, as you have said that and so proceed. Chairman grassley, Ranking Member wide, and members of the committee, thank you for holding this hearing, lie name is gary vandal and im the founder and chief executive officer of shadow proof, a National Nonprofit organization dedicated to review forcing the addiction crisis in america. For nearly a decade my son brian struggled with Substance Abuse disorder, despite as working tirelessly to find the best possible care, on october 20th 2011 we lost my son to the disease of addiction, in the months that followed i was destroyed all over again when i learned that research existed, proving the type of interventions that would significantly improve the outcome of brian and millions of others who were in treatment for addiction. If only we had known what to look for, that is why i found it shadow proof, the first Non Profit Organization dedicated to reversing the induction crisis in america, to accomplish this we developed a five point planned to transform the Addiction Treatment in the United States, never won a core set of science base principles for care and treating addiction, number two quality Measurement System, number three payment reform, number for treatment capacity, and number five ending stigma. My remarks today will focus on the second of these five, treatment quality measurement, addiction is a chronic brain disease and despite the fact that there are clear best practices the use of these practices various widely, across the treatment field and some facilities are still employing tactics based on and effective and outdated methodologies and unlike other Health Care Services comprehensive and standardize data on the quality of Addiction Treatment does not exist, even worse because consumers, payers, and state regulators do not have access to quality measures, Market Forces have not been aligned to support these best practices. In 2006, in a landmark report by the institute of medicine, it calls for a development and dissemination of a common, continuously improving set of measures for the treatment of Substance Abuse disorder to drive quality improvement, seizing, on along this recommendation to develop a platform for three aims, number one providing patients and family members the information they need, to identify treatment for their loved, ones number two equipping providers with data to advance the use of Evidence Based Practices, and number three injuring policy and payment decisions are data driven, a tool builds upon our a National Principles of care that were developed with experts in the field to establish addiction should be treated like any other chronic is illness we are currently in phase one of that and i were in Treatment Facilities and other stake holders in six states, delaware, louisiana, north carolina, west virginia, massachusetts and new york, thus far this phase has included identification and refinement for the expert panel strategy sections and Public Comment period, and claims measures and a pilot of Patient Experience survey across different Treatment Facility in the state of new york, quality data will be collected and triangulated from three sources. Claims data, Patient Experience survey and Treatment Facility survey, and reported through our analysts saying back to providers, to the public, to paris, and to states you. When i say the public, the families, following Evaluation Phase one, shatter proof will work with other states to bring the resource to serve more than 21 million americans with Substance Abuse disorder. Alice is part of the strategic goal to transform the Addiction Treatment in the United States to reverse the addiction crisis that is had such a severe and tragic toll on far too many and to which the impact can absolutely be avoided for so many others, thank you for the opportunity for testifying today and i look for is your questions on. We will have fiveminute round of questioning, we will start with the Surgeon General, first of all i know and thank you for the top priority we have with Surgeon General and even probably as an individual to making and addressing addiction as a top priority, i also think the efforts to prioritize and carrying out the enactment of this legislation. Section 70 31 of the new law calls for the best practices, has the administration appointed members to develop such best practices or identify the factors that could identify fraudulent recovering operators by support and if not could you give us a timetable when that might happen . Thank you for that question sir and i want to recognize that iowa has led the way a 14. 7 decrease in overdose raids in the past year, it has been reported so we need to share more of what is working in iowa with the rest of the country including connecting people treatment and Recovery Services, i will tell you very specifically, in the spotlight on addiction which i highlighted, this came out last year, there wasnt much fanfare and theres a lot going on in d. C. Nowadays in folks dont always notice, but i highlighted what to look for in his Substance Abuse Treatment Program. Personalize diagnosis set cement, long term disease management, its not just Substance Use disorder, or its hiv, hepatitis is, for Mental Illness, and effective behavioral interventions, coordinated care for other diseases and diagnosis and Recovery Support services. So my role is to help give the Public Information they need to have informed decisions, we put that out, we also have the treatment finder, and beyond that in terms of bending good from bad i will turn over to my friend from oig. Unfortunately we only encounter the that, bc institutions that are not providing the institutions that they are willing for, they do not receive the type of counseling theyre supposed to receive, sometimes we see prescription pads just left behind for staff, not qualified staff at the facility right prescriptions as people walk through the door, there is zero and most of these occasions, we are involved in actual care for the treatment so they are not getting the services that they need and deserve and oftentimes are paying for. I wanted to ask you a question here for it in your testimony about not knowing how many homes or where those recovery homes are, do you have any way of telling us what obstacles exist to obtaining this information . It seems like we need this information. Yes it is difficult to obtain the information, as i mentioned there is no federal oversight of these homes, it is a left of to the states and states of varying practices, for example some license, some require certification, some of it is voluntary and some of them just lie under the radar, so there are many obstacles to identify these homes that we have. Sir i would highlight and this ties into your question, today medicare will be releasing a Substance Abuse disorder data book, that is a direct request from the support act then you supported a year ago, this will highlight the people in the state that are getting recovery and Treatment Services through medicaid, that will be an important step to figuring out who is getting what and where they are getting it and will better allow us to assess the good from the bad. Obviously, i didnt recognize that you lost your son and obviously that is a terrible loss for you and i hope you know that is not only your son but everyone also we are trying to help in this regard, so that and we really appreciate yours, and it is my last question, what helped you develop a National Standard of care . Sure, is this on, and yes, yes, what i saw in the industry was literally about 45 Evidence Based Practice is that Treatment Programs should be following, each with multiple published articles, Clinical Trials showing that they worked, if you do x the patient does better, if you do abc the patient does better, but there are four to five of these approximately and they were not all in one place, they were all in pure viewed medical journals. There is not a business that has things, most businesses that are successful narrowed down to the less than ten core things that removed for success so i knew what we needed was less than ten Core Principles of care, number one of that could be readily understood, the general just mentioned many of those and lesson ten principles of, care number one i can be easily understood, number two most importantly, that can be measured, you can measure 45 things but you can measure less than ten, and we purposefully selected working with the leaner researchers, many that drafted the 2006 sergeant generals report that was followed up in the spotlight, working with them to draft eight principles of care that can be easily law measured, whether i was opioids, adolescents, or adults on. Thank you this has been an excellent panel and we thank you all for your commitment and compassion to the patients, let me tell you what is foremost on my mind this morning, every morning now we wake up to these news reports that there is this effort with this states and communities to work with the pharmaceutical companies and come up with a settlement that deals with the opioid drug addiction and the an epidemic that then Drug Companies contributed mightily to facing in this country, law it is almost turn that a significant portion of that money is going to go to Substance Use them treatment, it out to vote based on fraud and rip offs that you are already describing to us today, it seems to me that this lack of oversight could mean that with a potential influence of more money we are creating a perfect storm for more fraud. In through the colors we like you to do doctor, Going Forward what should the federal government working with these states and private sector due to make sure that if that settlement takes place and there are billions of dollars coming in for Substance Use on, what should they do to make sure they in dollars on go reputable operators and not more fraud. Its a good question, although our work will show that the certification, process the license process, the charter houses, have oversight so we would be good if we can ensure the funds can at least go to those homes that have some form what are the gaps in those areas . My understanding is that you already identified some gaps today in the oversights in those key areas. In the gaps are numerous, as i mentioned there is not one federal oversight to help us with this program, as you mentioned there were so he would you make the point person on the federal side . What is being the center of medicare, would it be the point person given the fact that there is nobody coordinating this. We did not look at that directly however we do know that samsung is providing grand money so that is one way to tie into what the states are doing. Would that be the most costeffective . Based on your work what would be the most Cost Effective ways turning on the federal side to fill the gaps so samsung would be better than . Unfortunately we havent looked for me to say which is better, however clearly seeing how us and others are involved. What are the other gaps . The other gaps is that we really dont have an understanding and the states are hearing very little theres not one program, this is a Grassroots Level some dont want to have federal regulations because theyre afraid that they would have loss of these recovery homes. What would be the two most serious gaps . In other words after this somewhere, and if you have a federal level reordering, and what are the two most serious gaps and if you dont deal with that more money will get ripped off . I wish i could answer that on. Who would be able to answer, that who can tell us with all this money coming in what the biggest gaps are . I think that is an excellent question because when you look at the number of individuals that we have interviewed just to get an understanding of the oversight of these homes. Lets go to mr. Mandel, you guys have already started us on the way to answering this because you found some problems with the accrediting organizations and the like, i gather you said that. I suspect many in this room would agree that it is difficult for the federal government to get down to regulating to the local level but with the federal government can do is condition all the grants it is coming to states on states doing Evidence Based Practices, so for example, sam said will be giving out billions of dollars to states, it could on condition that money if states did the following five or six things. My point is, number one the senator has been a leader in working on these kinds of behavioural issues right now, we are not talking about the federal government taking this over, we are talking about the fact that the federal government, ever talking about Substance Abuse, their significant amounts of dollars that the federal government has been involved with and the federal government being a partner with the accrediting organizations and with the states and the private sector and the light, will hold the record that durant has had, i would be very interested in hearing from each of you, what you think the biggest gaps are right now and you are ideas for helping to fill them and i also like to throw a bouquet to my seat made frittering good work on this and being part of the Bipartisan Coalition that is coming up with an actual plan to deal with it. Senator why did you ask for two things, 20 seconds, to big, things the hhs fillers is better data, i used to run his state health department, against the substance of your status book is a big deal because it will give states better information about what is going on where so that they can make better choices about who to lift up and who needs to be investigated. So better data is one, and number two i get anne as mr. Middle mentioned, we need to let consumers know what to look for and a good Treatment Center so please look at what shadow proof has put out and look at what we put out and use your positions to put that information out to people and dont have a checklist to tell good from bad, we have the checklist available and we need to help us push it out. We will keep the record opened, chairman wants to move quickly within the next ten days we would like to have recommendations to make sure that if we see this influx of money we are not gonna see it used for more fraud. We will get a senator daines and id like to recognize this is exactly why were having this hearing and it is a very constructive conversation. Thank you mister chairman Drug Overdose is now the leading cause of death through those under the age of 50 in the United States and let me let that sink in for a moment its a sobering fact. No doubt our country is in a major Opioid Crisis and we absolutely must do more into combat this drug epidemic, in fact in my home state of montana it is a matte that is destroying families and communities and in fact from she doesnt 11 to cheer dozens of teen there was a 415 increase in math cases in montana with matt related deaths rising 375 during that those years. Unfortunately in and my state of montana the matt graces is diverse proportionally impacting native american tribes, thats why it made up here included the mitigating matte act, and helped strengthen Indian Tribes ability to combat drug use and the support act that was signed by law last, year it was a good first step, but we solve a lot more to do. On the need to put an end to the tragic stories we are putting in the news, no more babies being born addicted to, know more stories of individuals taking advantage of who are seeking Substance Abuse treatment, i know i can speak on behalf of montana, we have enough. Doctor adams things were being, here first i like to invite you another hhs Administration Officials to come to montana to see this on matt crisis, its Mexican Cartel matte that is affecting it. Although the Opioid Crisis is in affecting it, matt is the biggest news, you can you speak to how matt is the big wave of the Opioid Crisis. Thank you for that and you are right and in montana the overdose rates have gone up 26 in the last year, we know that well we have seen a 5 decrease and opioid on, we have seen a 23 due to meth and stimulant, you are exactly right. I want to go back to the hhs strategy, better provision treatment and recovery, and number to Better Research on addiction. I want to say that a third of my officers work at the health facilities, we see this firsthand, i have visited tribes and reservations over the nation, and what i want you to know it is, this crisis is not a problem as much it is the failure to the system, to treat health is used, to build resilience into communities, its a failure to recognize that there is massive untreated pain in our country both emotional, mental, and physical. So we really need to lean and to truly better provision treatment and Recovery Services that include all those things, otherwise we are just going to keep playing whackamole over and over again and it will put out the opioid fire but the math fire will pop up again, in our country we are seeing this in montana in the west coast. If you look at the meth crisis in montana, the homegrown on meth that used to be the source, and purity levels of about 25 , today the Mexican Cartel anne meth have purity levels in north of 95 , so it is much more profit, into the prices have come down because theres so much more being produced, and the distribution has become much more sophisticated, we are literally takes a couple of days from the time across the southern border to reach a reservation in montana. We actually work to bring together Public Safety and Public Health, we need to work on the supply side and you talk a lot about the supply side, but i will tell you if we dont deal with demand, if we dont deal with people self medicating away their pain and mental Health Issues, there is always gonna be a supply, someone will find a way. I completely agree with you as well, lastly, i do believe we need this multifaceted approach, anne thats why ive been pressing the and i80 to treat meth an well it exists for opioids on, there is no mats for an are you familiar to do this for matt. Yes i had it too many conversation about this and i will tell you what i was told, the research is not an promising, they have spent millions of dollars and they will try to spend more to develop, it but our best solution right now is prevention, trying to get upstream trying to deal with these problems before they turn into the next wave of a meth, but we will devote research to try to find solutions for people who need recovery. Last statement would you commit to working with me to demands these reference to this montana overcoming the meth epidemic. Absolutely, certain parts of our country where native American Tribal folks reside are very, very personal to me and it is where i have tried to make a point of getting up to and visiting and i commit to you that we will not forget about those individuals their, citizens of our country and they should not be forgotten. Thank you dr. Adams. I ask you not to answer her letters from the federal Law Enforcement association and others into the record, these folks see the devastating effect on Substance Abuse of our local communities without objection, so senator stamina. So thank you so much for holding this hearing, to me on the panel, thank you very, much this is a very important topic that affects all of us in some way and im so sorry to hear about your son ryan, and im sure that he is part of the effort you put into moving this effort forward and making a meaningful difference for so many other families. I have heard like other people so many horrifying stories, individuals in the family struggling to get Substance Abuse help, as well as Mental Health, we know those are very much together, Mental Illness people are self medicating with alcohol and drugs when underneath there is Mental Illness as well so these are very much tied to the other, people are trying to do the right, thing get the best possible treatment, families, ultimately have as you have shown people can be taken advantage. Of unfortunately i believe this is happening in part because structurally on retreat Behavioural Health differently for reimbursement, its quality standards, its evidence based but its also, we predominantly do this through grants rather than reimbursement likely due for health care, so we have federally qualified health standards, we set high standards, and you get full reimbursement if youre physician or nurse at the health center, we dont have that on Behavioural Health which we are working very hard on right now. So we know on right now there is a right way to do things and we can spend federal dollars much more wisely with high standards, in fact a couple of years ago, im so grateful for the senator leadership on this as well, but on this table we have oklahoma, oregon, in pennsylvania, nevada, new jersey where we now have two years of data of what happens when you set quality standards, and Addiction Treatment and Mental Health and see how it plays out from people going to jail for people getting the treatment that they need and i want to thank the chairman and the members and so many people here for giving us the opportunity to take the next step to more services, more states, to actually be able to put this in place. So we have seen in a short amount of time, this has been and samhsa has been a league in making sure that we set up these structures, so general atoms can you provide an update on the administrations work on an implementation for the excellence of mount health and Addiction Treatment act as well as the Certified Community for the transit are moving forward. Thank you for that question, and this is very personal to me, my brother as i mentioned sits in jail due to crimes he did to support his addiction, he hadnt recognized and untreated anxiety and depression. We know that many of these Substance Abuse disorders or coherent with behavioural issues and it is a priority for us to make sure that folks who are being treated for Substance Abuse disorder are having their behavioural Health Issues taken into account but we recognize that before they turn into Substance Abuse issues and self medication. You asked for an update, i know you spoke with the secretary and he shares with on your excitement about what is, happening i will tell you the 50 million in twenties even teen, Mental Health Substance Abuse disorder over 550 Million Dollars dissipated to 1200 Health Centers throughout our country and then the pilot granted you mentioned, so far there is also, good so i just want to say succinctly that we share your concerns, i want to thank you for your sapphire for this in michigan, youve all seen a 10 decrease and i think it is because you looked at this is both a mental and Behavioral Health issue and a Substance Abuse disorder is you are not separated out the two. I want to say quickly, i often tell folks a long time ago we caught off the head from the rest of the body, what i mean by that, we said everything that happens from here off, or a, welt vision, all Mental Health heres acquired go see someone and the block, anything happened from here down we will take care as your primary care, im telling you we need to encourage integrating Behavioural Health back into primary care. We know that its a brain disease, its a very important part of the body and we should treat it as we treat every other part of the body, i know my time is up so ill just indicate in the areas where we have Certified Community behavioural services, we actually have medication assistant treatment, we have specialists, real trained people with evidence based Treatment Options that are working with people and in each of these centers there is also a 24 hour, seven day a week access to crisis services, so folks arent going to jail or an emergency room, theyre actually able to talk to someone that is trained to help them. Thank you mister, chairman i think all of our panelists, a certainly agree with the points that have been made by a senator wyden and others, we need more information by consumers, more transparency in order to prevent fraud and i also agree that we have to get the matrix for that and that is not as easy, we have to narrow it to consumers can use that information most effectively and making decisions, i do think it does provide us some ability to look at a group that has a locked into these issues, i want to go on to a point that doctor items made when you talked about the five key messages we are addressing, Opioid Crisis, specifically messaging mentioning Recovery Support services, and maryland we found that support has worked well in our community, i included provisions in support at that dealt with on studying in the medicare pays support, and in gary county theyre working to increase the capacity for peer support in Emergency Rooms, in the county they are looking at nine traditional hours to make sure we have pierce support, programs in georgia Chester County there is one call peer support programs that are available, i would like to get youre here and how effective do you think the programs have been, and what we can do to try and encourage more opportunity for peer support, particularly in non conventional and non traditional hours and Emergency Rooms and things like that. Ive been all over the country, the communities i have seen that have turned around through overdose raids have done four key things, number one they saturated their communities, you cant get someone into treatment and recovery if theyre dead, number two they have had a warm handoff, usually through some sort of recovering time program, number three they provided mitigation assistant treatment because it is the Gold Standard, number four and a strong Public Safety and Public Health cooperation, so weak in that applies the, problem and you asked what we can do, i will tell you that i am very proud of the fact that during this administration we have increased a number of medicaid 11 15 waivers substantially, 22 have been approved during this administration, that has given states the flexibility to pay for things they feel are appropriate to improve success rates and treatment and recovery, including pierre uncovering, including housing, including childcare and transportation, we need to provide those Wraparound Services but you are right, peter recovery is one of the key tenants and making sure you can stop the overdose and making sure people can become productive again. Some states have implemented under the Medicaid Program peer, support you have any information about the effectiveness of the peer support programs under the Medicaid Program . Its good to see you mention the support act because theyre getting ready to begin a review that is going to look at medicaids use of the peer support in various states, i dont have an answer for you now but we do have work that is beginning that will provide those answers. Im pleased to see that, if you can keep us informed i would very much appreciate it. I would like to get to one other, issue in maryland we are looking at Stabilization Centers, to get that out of the emergency room, i certainly agree that we want them alive, so the medication is important, to the Emergency Services are important but Emergency Rooms are not in places for people in eating care. So the current Reimbursement Structure works against a stabilization, center with emergency room snowfall costs its usually, covered what can we do to encourage that type of care that a person who is stressed needs, . Usually non conventional hours or during the middle of the night and allow for the funding of programs such as Stabilization Centers and communities. Well again i would highlight giving states the flexibility to find these types of programs, such as we have done through the 11 15, waivers this is a good one to pick to mr. Amanda, you can speak from personal experience about the struggle about bringing your son in over and over and not having a place for him to go that would help him. Absolutely, and then you comes back to quality measures as far as, defining through science where the most effective methods to treat people and having a transparent set of quality measures where the information is published on a regular basis, where we talked about consumers seeing the information where they can learn where to send their family members but its also prepares, for paris to understand which providers are most appropriate in their networks and which ones are not. Its also four state regulators and its also information that providers can learn from each other. We have talked about the unscrupulous providers out there but there is a lot of good things in the Provider Community that are not unscrupulous they dont have the information about what programs are mos what tactics are most effective and if we have transferring qualityt information without having to regulate they will learn from each other and have information they need to improve. H it is not ratings the quality measurement, quality improvement. You brought up doctor adams, my wife, your wife beside my wife at the international club. At the Indian Museum and hostess at the meeting, at the childrens in at nih. Is your wife reading that . She shared your story. At the National Institutes of health, cancer free, she shared your story but that was incredibly kind, she was nervous telling the story. She did a great job and i appreciated the support. My wife is a 33 year survivor of breast cancer. I just got a promotion. Thank you for holding the hearing. I want to thank you both, in doing that you do help combat the stigma which is part of the disease and undermines capacity, so thank you. And when it is signed into law the passage of this legislation was a critical step in addressing the Opioid Crisis. The crisis didnt happen overnight. We know that it will take a continuous and sustained investment at the federal level to curb and ultimately reverse the tide of a horrible epidemic. An i look forward to continuing to work on a bipartisan basis to adequately fund the support act, build on the support act and expand access for prevention treatment and Recovery Services. I want to start with a question toco doctor adams and doctor mccauley about services and access for women in particular. The office on Womens Health estimates 70 of women entering Substance Abuse Disorder Treatment have children and many residential Treatment Programs dont allow children to be present when their mother is receiving treatment. This is a real barrier. We have some examples what in works. Residential recovery homes, hope on haven hill in New Hampshire have proven to be effective. And evidencebased treatment, and recovery homes like hope on haven hill are few and far s between. Moreover reporting for news outlets as well as the gao report have shown recovery homes are scamming patients and not using the evidence to use. S the best means to recovery for any women, and evidencebased reform model that addresses addiction. 29 oxford houses provide Recovery Housing for women. What is hhs doing to expand access to evidencebased, allows them to remain with their children on a safe environment and how can that and doctor mccauley after doctor adams, how do we ensure we are providing access for the increasing number of women in need of Recovery Services given limited number of highquality recovery homes. A few places suffered as much. And 10 persons, the hospitals in New Hampshire, learned about the work they are doing. B what are we doing. Acl, and lifting up best a practices including keeping mom and baby together. I partnered to write an article calling on more ob gyn providers so we are not paying hot potato with a mom who has Substance Abuse disorder and we can take care of her and two other models i mentioned, the maternal opioid misuse model will increase access to Substance Abuse Disorder Treatment focusing on improving quality of care for pregnant and postpartum patients and integrated care for kids models. And emphasizes provided supports. Couldnt agree with you more and we are tryinger to do all we can to provide the flex ability. New hampshire has 1115 waiver which provides more flexibility. Thank you. Doctor mccauley. Gao is similarly concerned and we look at neonatal syndrome and ongoing work on mortality which relates to the Opioid Crisis. And Disorder Services for pregnant and postpartum women as part of the report act is being released today. There will be more information there. , i know i am running out of time. I will follow up with you. We have a bill to help remove the waiver necessary for positions physicians to do medicaid treatment. Im concerned people dont understand the Gold Standard and how important it is. Im concerned about the stigma attached so i have a question for the record. Happy to follow up. I apologized for passing over you. I forgot. Thanknk you for the importa hearing on a major health crisis. I spoke with a constituent whose son is grappling with a substance problem and she mentioned theree was a disconnect between what she has been told by experts is the appropriate time for her son to be in a Treatment Center and what her insurance will cover so he cycled through treatment a couple times and this is not the first time i heard this. Do you think there is a disconnect between what evidencebased best practices for Substance Abuse Disorder Treatment and coverage of such programs . I cant say it plainer than that. Someone in a Treatment Program and in four to six weeks they will be magically cured. Recovery is a lifetime and hhs is focusing on treatment and recovery and provide flexibility for states to provide those Wraparound Services the transition the recovery moving forward. What would you recommend to close the gap between what is paid for and recommended . I can only speak on best practices, not regulation but it is important folks look at the fact we are not going to solve this problem with a short, four week, six weeks treatment and we need to fund that spectrum and use the waivers to get states the ability to do that. This is more consequential the way it is operating now, more consequential when we rotate people and they get paid for different segments. E when an outcome based Payment System would insure best practices to follow . Outcome based payment is something we are pushing towards. The fee for Service World needs to get looked at very closely. We need to make sure we are paying people to create health and wellness and not paying people to do procedures or keep someone is in inpatient when their funding runs out. Hhs is committed to providing the flexibility and incentivize new payment models and help states and local entities figure out what helps, show proof of concept to scale it up. Te mister mindel, you have my o deepest sympathies for the loss of your son, previously stated you did not support federal regulation but they are tied to speed limit changes. The federal government tied funds in the addiction space. What laws should all state have in the books and what if any laws should the federal government lead on for National Uniformity and protect individuals in recovery. Let me add there is one federal law that is very important which many members of congress are working on which is to require part of their dea license, all doctors in the field and psychiatrist as part of their dea license for controlled substances. Doctors can prescribe oxycontin, vicodin, opioids, without having any training and as part of their license to do so to be basic treatment of prediction. A huge lift to this country. Number one what the federal government can do. O. What leverage the government can do with a 55 mile speed limit. Conformance, medical societies conforming to cdc prescribing guidelines would be a huge co list, to follow the quality Measurement System. Ours is the only one out there but there could be others, not specific to us. Tying it to the state only going, state funding from the government only going to evidencebased Treatment Programs with evidencebased practices. Relates to the quality Measurement System to determine which Treatment Programs are following evidencebased practices. Requiring medical schools in their state to have basic training prevention and treatment of addiction. There are 3 right there that would be significantly significant improvements to the system. If i could add one more t tnigl legislation to eliminate data 2000 which requires any doctor in this country who wants to provide that to go through a significant process, licensing hours of training, oversight by the dea, doctors prescribe oxycontin without additional training. Why do they go through the process . It is less than 5 of doctors in the country can prescribe up an orphan. 50 of counties in the United States have one doctor who can prescribe it. There is legislation in congress to eliminate that in 2000 and i highly recommend that. Chair menendez, senator young. Doctor adams and other witnesses, welcome. We are proud of you in the state of indiana and think you are doing the country proud in your current capacity. I was proud to see you highlight the important work in richmond, indiana, in your testimony, making a difference as well. Doctor todd graham, south bend physician with over three decades of service was senselessly killedi on july 2 2017, for refusing to prescribe an opioid to a patient. Tragic. In his memory, i worked with then senator donnelly to pass a provision in the support act reduce the oto overprescribing of opioids by examining ways to expand the use of nonopioids in the medicare program. How does this work on the utilization of approaches. This is a major deck of emphasis for us, part of a 5 point strategy, pain and addiction and cant happen fast enough. When i was in medical school and they told me pain was a vital sign it came from a good place. We did and still do have an epidemic of untreated and undertreated pain in this country. We through opioids of the problem foolishly and now we are pulling them back, and a decrease in opioid prescribing and what we are substituting for pain and folks are going to continue to self medicate, they will be angry when they dont get their pain treated and we will chase our tales. The nih Heel Initiative awarded 945 million in the form of grants, and agreements across 41 states, to increase research and practice in terms of pain and addiction and lifted up the different payment mechanisms and to make sure we are paying for the right thing. We put a lot on cms and got to remember the other gorilla in the room, the employerbased insurers and the first drug dealer, many of them wont pay for one of the alternatives for their covered lives. Thank you. There is a lot on the increasing access to treatment. I know you agree with this, to make sure people are in Treatment Services that are there, i place great emphasis during the help Committee Hearings pertaining to the Opioid Crisis last congress. In your testimony you say we have amassed massive evidence for prevention, Early Intervention, can you elaborate on the evidence you are referring tove especially in terms of treatment. As i travel around the great state of indiana t and talk to Different Service providers, doctors, and others, i have to say there is heterogeneity and varying perspectives on what works and what doesnt work. I highlighted we need to make sure when someone is done with treatment they can be reintegrated into society. The stigma is killing more people than overdoses and it causes people to relapse when they cant find a job or be reintegrated into society. Work is an important part, training and taking a look at the Scarlet Letter when they come out of a Treatment Center that prevents them getting a ta job. As far as Substance Abuse Treatment Center there is too much heterogeneity and i would turn it over to mister mindel to highlight key aspects of what to look for. In the Treatment Center we have identified 27 principles every Treatment Program should have. A fool and complete assessment not just of addiction issues but also mental Health Issues and physical issues need to be complete with all three with evidencebased instrument that has proven reliable and valid delivered by someone with the credentials to ask questions in the right way and understand. Once you have that assessment, to be continually reassessed in your care adjusted, at the hospital they will not tell me based on the first 15 minutes of questions heres what your treatment will look like for the next 28 days. They will tell me what my treatment will look like for the next two days or one day and then test me again and oaa adjust on the way. Many Treatment Programs dont do that. Can you reassess . Number 3, evidence to evidencebased medications, not just for opioids but also alcohol. Number 4, access to behavioral therapies there evidencebased. There are only six, or twee 7 in the Surgeon Generals report both originally in 2016 and highlighted in the spotlight with randomly controlled trials tested and proven to work that have to have them. I can go on and on but it is on our website but they exist and easily measured. Ey i also noted it takes 17 years on average for evidence to reach the field. I would welcome future dialogue about things we could do at the federal level to compress the timeframe. Use your bully pulpit to share the spotlight on opioids which lifts the criteria to look for in evaluating a Treatment Center. We need you to share that. Senator cassidy will be the last one and will you close the meeting . I have to go to a meeting in my office so i thank all the panel and the chairman of thisl committee for this fruitful meeting. Senator cassidy . The office of the chair will grant himself as much time as needed. Thank you for being here. First let me highlight something doctor adams at hhs has done, you had aig task for on Pain Management which is really good. Your statement so there is untreated pain and yet we have people dying from addiction and they differentiate between the patient with chronic pain unstable dose for many years, and ever escalating, working in society from the person breaking into a car to steal a purse to buy drugs. It is distinction we have to make as a physician. Lets now turn our backs on the person who has that stable dose who is contributing to society which includes people in this room and differentiate that person from those. Secondly, by two gao folks in the middle who have been ignored but im thinking about you. I look at, i hear private Insurance Companies are capable of looking at Pain Management, looking longitudinally at the outcomes. Who is released and goes back into a situation requiring more care for addiction versus those with a sustained system response . We continue to hear medicaid does a poor job of that. It seems this would be something that could be done with a supercomputer in terms of if you look at diagnostic codes. If someone has billing for admission to Pain Management center and readmission for something which is plausibly related to drugs overdose within appear go of time and you compare everybody against anybody and sort out who is doing a good job and improve their work and who should be kicked out. What is the obstacle to doing so . Either off you . From oigs perspective we do analysis similar to what you described in the medicare space. We have great access to medicare claims but on the medicaid side we dont have the same level. We do have the transform Medicaid Information system, is not ready for prime time. Not quite ready for prime time. Improving but not quite ready. It is readily improving which makes you think some states are ahead of the curve and some still coming on. 48 are currently participatingv can we take those as proof of concept already submitting adequate data and then create a system of scales as other states come on board . . That is something we could explore. Why not something we do . I work with investigations and dont want to commit rk auditors or evaluators yet but it is something we are interested in and follow up with you. The work we have done that im familiar with is related to medicare because the data is there and we previously reported. Can i answer one think you i spoke with people who work for clearinghouses so that someone changes the medicaid plan they have to do data and these clearing houses are better because they have got it all and it has to be with an identifier because it is transmitting bill cassidys claims to plan b so these folko as a point of information. As gao we work for you and we welcome a conversation about what we can do in this area. Gao does a wonderful job but in the time it takes to complete a study an elephant is born. It takes a little while. Is it possible for hhs to stand up something realtime doing this analysis, maybe getting a system from one of these two folks so we dont have to wait a year and a half for an excellent study but the situation on the ground has changed . It is something i will take back and you know i will follow up with you and i appreciate your leadership in one of the positions in congress that you bring up an important question and issue. I have done a lot of work in jail. You mentioned your brother and thank you for your openness in that. 15 d o of males entering a jai have a Mental Health issue, 30 of females. If you had addiction you will be even higher. Current law is if you are in jail even before you are adjudicated you lose your va and medicaid benefits so i have been arrested but i have three months, sometimes 6 months in jail before you go to court and i am mentally ill but lost my benefits even though subsequently i am declared not guilty. A fairly common scenario, not making things up. There is a Score Associated with this but as a physician, i know if the formulary in the jail doesnt include psychotropics, the care is disruptive and my condition may decline. Im begging the question can you give your thoughts. Whatever the score the wisdom of allowing medicaid and va benefits, incarcerated in jail at least prior to the point of being declared guilty or not guilty. Two important points, our jails and prisons become our Mental Health and Substance Abuse disorder provided in the country and we need to flip the script if we are going to get out of this. I saw this firsthand in scott s county, we had to solve our hiv outbreak for prescription opioid misuse because so many folks would cycle on or off, it is a significant problem. You are telling me they would be admitted for hiv and progression is disrupted because they are getting off the one that controlled it and whatever trained it is not optimal care and we need to look at how to transition the system but we didnt know how to have a lot of flexible the at the state level. Some of that is because of the law as written. We need to look at that, take care of the person and patient because it is beyond the individual and society. Senator brown is here from ohio. The score is 10 billion over ten years. It is put in jail, they are adjudicated. I i would like to add something, the components of the Opioid Epidemic and solutions, we talked about how to remedy each of these individually but it would be helpful to go back to it. Surgeon general adams mentioned three times in the last hour Something Else but hasntt gotten airtime which is stigma. The Surgeon General called the biggest killer out there. We havent talked about these specific issues being the biggest killer, it is stigma. Why has he said that . He said that because stigma reaches everything we have been talking about in the last hour. If there were policies in jails where people lose their insurance why is that . Most people in america think it is bad people doing bad things who cant make good decisions when science shows that is not the case. Why isnt our payment policies we have grown up in a Healthcare Industry that believes it is their false, that we shouldnt pay for treatment. In the state of massachusetts in the state we did. It is relative to the rest of the country. Dont want people in their waiting rooms, it might affect their practice. 80 of americans in a recent poll said there uncomfortable for prescription opioids. My friend, coworker or neighbor. Lets say we get through all the hurdles we have been talking about in the last hour and someone gets the treatment evenenl though 20 of american one of the key reasons they dont go to treatment is they dont want anybody to know but lets say they get past that hurdle and their parents for some in and they get the treatment. They find a provider even though there are few providers who treat it for the reasons provided and they get to a provider who delivers quality care throughout the hurdles we heard about today and they are successfully treated and enter a society where 80 of americans dont want you living in their neighborhood or working next to the more be their friend or dating their daughter. I am sure my son didnt see those statistics or the 20 million americans, not just opioids, 20 million americans addicted to drugs or alcohol see that survey, but they feel it every day. I think you and doctor adams for being so honest because that helps fight that stigma. Senator brown. Thank you all for being here. Thank you for coming to my office several months ago. A lot of pain on this panel and a lot of us who had deaths in our family we think shouldnt have happened or a difficult time. Thanks for making it a mission of your lives to step up, to experience the pain some of you and many of us in this room have had. I want to start with doctor mccauley, a couple questions for you first. In the course of gaos work on this report, how many instances of Substance Abuse disorder, medicare, medicaid, fraud, did you investigate across 5 states and of that total, what percentage where a patient was the perpetrator . Thank you for the question. We are different from the ig, we dont do investigation of the case, it would be a better question for mister cantrell. We took a selection of 5 states and found all 5 states have reported fraud and we spoke to various actors involved in thaw including medicaid fraud unit and to our knowledge, we dont go into the case but in florida, they were lured there and unknowingly brokered and sent to other places without their knowledge. I want to ask you and you can respond, based on your work is it your opinion individuals with a Substance Abuse disorder diagnosis seeking treatment are generally called a fraud or more likely the victims . In the cases we see the victims. Overwhelmingly . Overwhelmingly. In our fraud schemes we have some participated patients who are a patient broker trying to solicit other individuals to come into a fraud speak but generally speaking they are the victims of these crimes. The two of you believe states are doing a good job addressing fraud when they maintain the tools they have at the forefront, the tools necessary to police this fraudulent behavior committed much less often by the victim and the perpetrator . On the Health Care Fraud space they are very active in this space. Our office is active but where there have been a need for additional oversights, not in Law Enforcement but oversight of these Treatment Facilities and quality standards as we discussed here today, and the product and treatment. Florida, massachusetts and utah started certification or licensure programs and they didnt have these programs providing training and other av services to the operators of the homes. They were very concerned. I start with doctor adams, i preface it with every one of us think we are not doing enough with prevention education, upscale treatment and all that. I applaud doctor cassidy for his interest and senator marky and others on the pretrial incarcerated to keep them on medicaid. It is upside down thinking to a take away their medicaid when they need it at that point. We are clearly not doing enough to provide the Treatment Options to everyone who needs them but the overall number of not only adults with a Substance Abuse disorder who receive treatment as well, we know those with medicaid are more likely to receive treatment than those with private coverage, thousands of ohioans, because of medicaid Substance Abuse clinic in cincinnati. And to work for medicaid, those statistics, nice question, and answer as close as you can to yes or no, putting additional burdens on beneficiaries, make it harder to access and maintain coverage that could compromise efforts to address and limit access to Substance Abuse disorder and those burdens are you talking about medicaid . We want to make medicaid effective and is easy to access as we can. You frame it as a burden. I dont knowow what provisions you are referring to but we should make medicaid more available and we have tried to give states flexibility through Record Number of 1115 waivers to craft Medicaid Programs in a way that works for their citizens and constituents. S. We have worked for beneficiaries of medicaid and access to medicaid assistance. We have worked on Medicaid Eligibility but i dont im not an expert in that so we have to get back to you on that. I would completely agree with the comments earlier, the Surgeon General specifically. Any barriers for those who dont have insurance to get medicaid would absolutely create more loss of life and cost to our system so people going to er rooms or prisons etc. Etc. We need to keep the few barriers as possible so more people can be on medicaid, and 100 . I will close, senator cassidy, with this. The imposition of work requirements, state Medicaid Programs will have a Chilling Effect on access to treatment. This hearing underscores the ludicrousness if that is a word and the hard heartedness of far too many people in this body and the Trump Administration who are trying to repeal the Affordable Care act, they couldnt do it here, they tried hard, they couldnt do it here, they want to do it through the courts. It is hardhearted, it is stupid h and it will mean a lot more people die. 900,000 people in my state have insurance they didnt have it before the Affordable Care act, we know what it means to young people on their parents plan, we know what it means for the expansion, we had a republican showed more coverage in ohio than most of his Party Members around the country and expanded medicaid and saved thousands of lives and it is absolutely cool and stupid policy to think repealing the Affordable Care act can be good for the country. Thank you. Senator cassidy, can i make one quick comment. Un i would quickly say iran the state department of health in indiana when we expanded coverage to several hundred thousand citizens. As Surgeon General i want everyone to hear me say that access to quality affordable healthcare is critically important. Ev this administration believes we should give states the flex ability and opportunity to do it the way it works best for them as occurred in indiana. The Record Number of 1115 waivers show commitment that flexibility in given states, that flexibility and in my opening state but i talked about industry and bakeries and indiana and new york and i think it is important when we talk about work we understand that one of the biggest predictors of whether someone will be successful in longterm recovery is whether or not they can get back to work. I will be the first to admit the idea of work requirement is a hot button political topic but i dont want usa to lose te strong data that says we need to think about ways we can help people reintegrate back into society and get a job. That is what i am focused on. How do we lower barriers to people getting back to work and how can we bring people together so folks can truly recover and thank you so much for the opportunity to testify today. This is a critically important hearing and i want to give a shout out to senator brown for the work you are doing in ohio. You have been able to drive down your overdose rates by 10 and it is because of a partnership. It is in large part because we expanded medicaid and the president of the United Statesc wants to take it away. I appreciate who appointed you. I appreciate your comments on work requirements but the fact is the president of the United States wants to wipe off the books the Affordable Care act s with no replacement on medicaid and the fact that we have driven down, not very far yet but driven down the death rate in ohio and addiction rate in ohio is because we have that very important Public Health tool. That will be the final rule. The chair will thank you for your testimony. We leave the record open for submissions of questions for the record. The hearing is now adjourned. Te [inaudible conversations] [inaudible conversations] live friday on the season networks, a ceremony for the smithsonian secretary at 3 00 pm on cspan. At 7 30 p. M. The democratic president ial candidates in des moines for the Iowa Democratic Party Liberty and justice celebration. On cspan2 at 9 am the Atlantic Council hosts a discussion in iraqs political and energy outlook. At 8 00, donald trump is holding a campaign rally. On cspan3, ways to adapt the effects of climate change. We are making it easy